Goal 2: Reduce Human Disease

Need for objective measures of dietary intake

How can we build on previous research to develop new methods for objective assessment of usual dietary intake?

Submitted by (@nhlbiforumadministrator1)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

Improved assessment methods for dietary intake is would lead to a better understanding of the role of diet in heart, lung, blood, sleep.

Feasibility and challenges of addressing this CQ or CC :

Can build on newer methods utilizing technology .

 

Methods must be objective instead of self-reported

Name of idea submitter and other team members who worked on this idea : NHLBI Staff

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Goal 2: Reduce Human Disease

Is heart failure reversible by diet and lifestyle changes?

Once heart failure has developed, can diet and exercise measures work to reverse it?

 

Well-designed clinical trials are needed to answer this question.

Submitted by (@nhlbiforumadministrator1)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

There is no known therapy that can reverse heart failure. Drug and device treatments may slow progress but not a cure. If diet and lifestyle changes could reverse heart failure, even if just in segments of the heart failure population, it would be a tremendous impact in saving lives and would have a great fiscal impact as well.

Feasibility and challenges of addressing this CQ or CC :

Innovative dietary and lifestyle intervention studies could be done cheaply and efficiently.

There is low impact, mostly anecdotal evidence that heart failure (HF) is reversible through diet and exercise, but no higher level research has investigated this question. It is an accepted notion that healthy diet and exercise can prevent cardiovascular diseases. Obesity, diabetes and coronary artery disease are strong risk factors for HF. Accordingly, a high portion of HF patients has ischemic etiology, is obese and/or diabetic. Diet and lifestyle interventions could beneficially influence these comorbidities and might reverse HF.

Name of idea submitter and other team members who worked on this idea : NHLBI Staff

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Goal 2: Reduce Human Disease

The missing ingredient in diet and cardiovascular disease prevention research

Determining the dietary patterns and dietary constituents that are most effective in preventing cardiovascular disease events. In addition to the obvious challenge of limited resources, the challenge is overcoming the tension between desire for comparable data produced from low-cost tools and need for higher quality data. Many studies continue using low-cost self-reported diet assessment instruments that produce data ...more »

Submitted by (@nhlbiforumadministrator1)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Addressing the challenge of a dietary assessment method that harnesses recent technological advances in novel biomarker assessments and in metabolomics and microbiome research with best practices in self-reported assessment instruments would enable a giant leap forward in nutrition and cardiovascular disease prevention research. Self-reported instruments require repeated measurements which are expensive or are instruments hampered by measurement error that attenuates estimates of the diet-disease association. Progress on this critical challenge would enable research questions to be addressed using more accurate methods, including questions that ask about best overall diet pattern to prevent cardiovascular disease as well as questions targeted to specific nutrients or diet constituents. Overcoming this obstacle would enable research to move forward in population science research where knowledge of the diet of free-living individuals or community populations is needed as well as among patients in clinical research (other than expensive feeding trials where exact diet is known). There is great potential in stored specimens from epidemiology cohorts and clinical trials to be used with new biomarker assessments to associate earlier diet with hard outcomes accrued in these studies.

Feasibility and challenges of addressing this CQ or CC :

Advances in microbiome research and metabolomics technologies illustrate that progress in the field of biomarker assessments of dietary status is not only feasible but may sharpen our understanding of the relationship of dietary constituents with HLB disease pathologies. In the field of energy balance measurement there are calls for movement away from self-reported diet measures and for researchers and sponsors to focus development on objective measures (http://www.nature.com/ijo/journal/vaop/naam/abs/ijo2014199a.html ). Leadership from NHLBI in this area can move the field forward in validating tools and making them more cost effective.

“You are what you eat” is a familiar aphorism, but research progress on what dietary patterns and dietary constituents are most effective in preventing cardiovascular disease events is impeded by inadequate dietary assessment tools. This critical challenge calls for a major effort, in collaboration with other ICs, to develop methods and innovations in measures using blood, urine, feces, saliva, or other bodily fluids or tissues. These tools eventually need to be cost effective, valid, and reproducible.

Name of idea submitter and other team members who worked on this idea : NHLBI Staff

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Goal 2: Reduce Human Disease

Randomized trial of low carbohydrate high fat dietary pattern

There is a need for a large, simple, hard outcome trial of dietary advice to measure the effects of lowering simple carbohydrates versus lowering unhealthy fats. The main challenge will be to overcome bias favoring the more conventional dietary approach.

Submitted by (@nhlbiforumadministrator)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Substantial numbers are moving towards low carbohydrate/high fat diets to the extent that since 2000 the macronutrient composition of the US diet has changed towards lower carbohydrate and higher fat intakes; however, CV mortality rates continue to decline. The outcome of the trial will help frame future guidelines for healthy diets.

Feasibility and challenges of addressing this CQ or CC :

Yes, since computer or smartphone based intervention materials and passive outcome collections (CMS, NDI, health care organizations) are increasingly being utilized.

Low carbohydrate high fat (LCHF) diets first popularized for weight reduction are increasingly being promoted to prevent diabetes and cardiovascular disease. All trials to date have been small and short term. Compared to more traditional high carbohydrate low fat diets, LCHF diets may be somewhat more beneficial for weight control, glucose homeostasis, and dyslipidemia, but less beneficial for LDL reduction.

Name of idea submitter and other team members who worked on this idea : NHLBI Staff

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Goal 2: Reduce Human Disease

Dietary nitrates and the enterosalivary nitrate cycle

Are dietary fruits and vegetables, particularly leafy greens, protective against cardiovascular disease due to their ability to increase bioavailability of nitric oxide?

Submitted by (@nhlbiforumadministrator1)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

Understanding the biological rationale behind the benefit of a particular dietary component that promotes CV health will substantiate public health recommendations about diet.

Feasibility and challenges of addressing this CQ or CC :

Our understanding of the nitrate/nitrite cycle and of cardiovascular activity of nitric oxide has advanced rapidly in the past 10-15 years. The time is ripe for linking these advances in the science of nitrates to the consequences of dietary nitrate.

The role of dietary fruits and vegetables in the protection against cardiovascular disease is supported by many studies, especially leafy green vegetables. However, identification of the component of fruits and vegetables affording this protection has been elusive. Recent discoveries about the ability of the body to cycle dietary nitrates to produce bioactive nitric oxide via the enterosalivary cycle and lingual microbiome lends strength to the argument that leafy green vegetables may be protective due to their high nitrate content. This possibility should be examined in both large cohort studies and in clinical series. Would be helpful for the USDA to add nitrates to their standard database of food nutrients. NHLBI needs to partner with NCI to coordinate with ongoing research about the potential nitrosylation of dietary nitrites to carcinogenic n-nitrosamines in the setting of low antioxidant intake.

Name of idea submitter and other team members who worked on this idea : NHLBI Staff

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Goal 1: Promote Human Health

Prevention of Obesity

What are the behavioral factors that predispose to excessive weight gain and development of obesity? And, which intervention strategies can effectively prevent excessive weight gain and obesity? NHLBI, other NIH institutes and the society at-large have invested heavily in research and clinical practice aimed at treatment of obesity (i.e, weight loss in those who are already overweight). However, much less research ...more »

Submitted by (@rpate0)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Reducing the prevalence of obesity is one of the great public health challenges of the 21st century. Research should be focused, first and foremost, on prevention, not treatment, of this problem. It seems highly likely that improving the behaviors that can prevent obesity would produce a wide range of important public health benefits.

Feasibility and challenges of addressing this CQ or CC :

Two generations ago the prevalence of obesity was much lower than it is today. The prevalence was lower then, not because overweight people were better at losing weight; rather rates were lower because far fewer people became overweight in the first place. It is high time that the scientific community, clinicians, and public health practitioners invested their efforts in prevention first, where there is every reason to believe we could be successful. These efforts should be informed by a robust body of knowledge, and it is recommended that NHLBI lead the effort to expand the body of knowledge on primary prevention of obesity.

Name of idea submitter and other team members who worked on this idea : Russell Pate

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Goal 3: Advance Translational Research

Move beyond the use of self-report for dietary intake quantification

There is a need to move beyond the use of self-report for dietary intake quantification towards funding the development of new technology and broader use of objective measures. There is no question that the effects of diet on health, quality of life, and longevity are of great interest to many and plausibly of great importance. Because of that, tremendous research resources have been provided to study this topic. Given ...more »

Submitted by (@nhlbiforumadministrator)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Virtually all authors and investigators in this area recognize that such measurements are limited in their validity; the common mantra is that while limited, these methods nevertheless have sufficient validity to merit being used in scientific investigations. In contrast, a growing group of investigators, ourselves included, think that this common mantra is not reasonable. Virtually all authors and investigators in this area recognize that such measurements are limited in their validity; the common mantra is that while limited, these methods nevertheless have sufficient validity to merit being used in scientific investigations. In contrast, a growing group of investigators, ourselves included, think that this common mantra is not reasonable. Instead we believe that the evidence clearly shows that with at least respect to self-reported energy intake, the measurements are so inaccurate that they do not warrant being used as a basis for scientific investigations and conclusions, even when no better measurement is available. Therefore, at least in investigations involving energy intake, we believe that self-report methods should be abandoned for purposes of drawing scientific conclusions about energy intake, and that funds made available for human dietary investigations be directed toward development of new, objective methods and technologies that can replace self-report methods.

Feasibility and challenges of addressing this CQ or CC :

We believe that the scientific community would benefit from development of methods of measuring dietary intake that do not rely upon self-report. We are not recommending that more investment go into refining self-report methods but rather that replacement methods be sought. Some investigators are interested in devices such as smartphone photography as a way of enhancing self-report. It is our intuition that such methods will only be modest enhancements and will be subject to very substantial biases, since they rely on subject cooperation. Instead, we believe that that methods based on principles of physics, engineering, and chemistry (and generally less prone to human filtering/interference) are likely to be more useful in the long run. Investing in such methods could take at least two forms. First, funders could invest in the development of new technologies and techniques. Second, funders could invest in ways that alter the economic conditions for the use of existing techniques, notably doubly-labelled water (DLW). It is remarkable how much the cost of genotyping has decreased in the last several decades, driven by market incentives and a market initially catalyzed by NIH investment. This is not the case with DLW, which has stayed at a fairly constant price for 30 years. We suggest that it may be possible for the NIH to create a market incentive for reductions in price by initially catalyzing a large demand through an infusion of funding for research using DLW.

Name of idea submitter and other team members who worked on this idea : David B. Allison, Ph.D.; Kevin Fontaine, Ph.D.; Kathryn A. Kaiser, Ph.D.; Andrew W. Brown, Ph.D.; Edward C. Archer, Ph.D.

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Goal 3: Advance Translational Research

Ranking Impact of Dietary Changes on Reducing cardiovascular disease Risk

Of the components of DASH diet, which dietary changes have the greatest impact on reducing cardiovascular disease risk factors?

How can we rank the relative health effects of individual dietary changes such as reducing sodium, increasing fiber, reducing saturated/trans fats, etc. to identify where to target interventions for promoting initial dietary changes?

Submitted by (@nhlbiforumadministrator1)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

This will inform intervention, education, and outreach efforts.

Feasibility and challenges of addressing this CQ or CC :

Similar studies have been conducted in that time frame.

Strong evidence shows that following a DASH-style dietary pattern can lower blood pressure and improve blood lipids, and thus reduce risk for cardiovascular disease. The DASH dietary pattern is high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, and nuts and low in sweets, sugar-sweetened beverages, and red meats. In terms of nutrients, the DASH dietary pattern is low in saturated fat, total fat, and cholesterol and rich in potassium, magnesium, and calcium, as well as protein and fiber.

Name of idea submitter and other team members who worked on this idea : NHLBI Staff

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Goal 2: Reduce Human Disease

What causes the structural abnormalities that cause sleep apnea, and how can they be prevented?

It is estimated that up to 28% of the population suffer from sleep apnea, which impairs functioning and reduces quality of life, while increasing risk of accidents and a variety of cardiovascular, metabolic, and neuropsychiatric diseases. A large portion of sleep apnea cases are caused by abnormal oro-nasal-maxillo-mandibular features that result in crowding of the upper airway, making it vulnerable to collapsing or ...more »

Submitted by (@bmdixon)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

Obstructive sleep apnea (OSA) is a common condition, which causes chronic fatigue and daytime sleepiness, as well as cognitive impairments affecting learning, concentration, and memory. Over the long term, it increases many health risks, including accidents, cardiovascular disease, and depression. OSA is characterized by partial, or complete, blockage of the airway during sleep, so that breathing repeatedly pauses or airflow is limited, causing repeated arousals from sleep. It is usually secondary to a narrow, or collapsible, airway due to either 1) obesity or overweight, or 2) abnormal morphology of the mandible or maxilla bones, which crowds facial structures, such as the tongue and nose, narrowing the pharynx. The causes of obesity are already being well studied, but there is relatively little research on the etiology of the structural abnormalities involved in OSA. Abnormalities of facial structure are widespread in the population causing, not only OSA, but also orthodontic problems that require many to get braces or have wisdom teeth extracted, and widespread temporomandibular joint (TMJ) problems. However, multiple studies have documented that these abnormalities are almost completely absent from populations living a preindustrial, agrarian or forager, lifestyle, making them a “disease of civilization”. In particular, the abnormalities are associated with consumption of a modern diet of processed foods during prenatal, infant, and early childhood development.

Feasibility and challenges of addressing this CQ or CC :

Current evidence implicates three factors in the development of these structural abnormalities: prenatal maternal nutrition (especially vitamin K2 status), breastfeeding vs. bottle-feeding, and frequency of consumption of tough foods after weaning (which provides exercise to the jaw). We need to form a large cohort and study orthodontic development prospectively from fetal development through mid-childhood, with data on diet, feeding practices, and physiological measures of nutrient status. Measurement methods are available using existing technologies to collect the necessary data on each of these measures. Determining the causes responsible for these structural abnormalities will enable further research to demonstrate effective methods of preventing them. Given that many patients with OSA are rendered so miserable by it that they undergo maxillomandibular advancement surgery to correct it, an expensive procedure with a lengthy recovery period, prevention would be a far better solution. This research will move us a big step closer to a future without sleep apnea and its formidable collection of negative effects on health and functioning.

Name of idea submitter and other team members who worked on this idea : Bonnie Dixon

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Goal 2: Reduce Human Disease

Transforming Clinical Practice through Patient-Centered Medical Nutrition and Lifestyle Education

The fact that diet contributes significantly to prevention and treatment of disease is now a foregone conclusion. National and international guidelines offer evidence based recommendations advocating nutrients, foods and eating patterns that are most closely associated with reduced risk. Patients assume that physicians are knowledgeable regarding the role of diet in health and that they are trained to counsel patients ...more »

Submitted by (@lvanhorn)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

AHA/ACC guidelines subsequent to the NHLBI ATPIII all provide diet-related recommendations for improving public health that, if followed, could offer tremendous benefits in reduced disability, death and health care costs. However, imperative to the implementation of these life-saving recommendations, is an informed and educated provider base that is skilled in: assessment of patients’ diets and eating behaviors, evaluation of possible risk factor contributors and initiation of diet counseling or referral to a qualified nutritionist.

 

Nowhere is the opportunity greater to assess, evaluate and offer guidance towards improvement of key diet behaviors than in primary care. Patients perceive physicians as credible, respected sources of nutrition counseling. Physician endorsement of diet and lifestyle change favorably influences patient adherence. Research to evaluate patient-centered medical education and training programs is needed to evaluate and compare patient perception, health impact and health outcomes of these translational nutrition efforts. Ultimately, the goal is to further calculate and quantify the economic and personal benefits that accompany these strategies in order to implement transformed medical education aimed at preventive strategies.

Feasibility and challenges of addressing this CQ or CC :

This is a major challenge due to current medical training focused on diagnosis and treatment rather than prevention. Research is needed to demonstrate cost/benefit of transformative education and training that shifts the focus from treatment to prevention. Successful outcomes can provide preliminary evidence needed to promote a paradigm shift across -medical schools and allied health professions with the ultimate goal of - improving medical practice and quality of life. Evidence is needed that documents patient-centered impact resulting from this training and actual practice. Proposed is a comprehensive, team science approach to testing the results of nutrition and lifestyle medicine in primary care and the biomedical, behavioral and economic impact derived from it.

This represents an ambitious task requiring an academic medical center environment that not only has the educational aspect in place but also the capacity to provide the translational effort at the bedside and in outpatient settings to allow measurement of results. It requires leadership in multiple arenas and coordination between education and clinical application that are crucial to successful implementation. It further requires leadership and expertise in big data, economics, biostatistics and the accompanying technology required to

assess, analyze and report all of the aspects and components inherent in a project of this magnitude.

Name of idea submitter and other team members who worked on this idea : Linda Van Horn, PhD, RD

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Goal 2: Reduce Human Disease

Additional research needed to identify various contributors of obesity

What are the specific contributors of obesity that lead to chronic positive energy balance and surplus energy storage?

Submitted by (@mturner)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Obesity is a health crisis of epic proportions. About 34% of adults in the US have obesity, up from 31 % in 1999 and about 15% in the years 1960 to 1980. The chronic diseases that result from obesity annually cost over $150 billion in weight-related medical bills. Reduction of obesity improves cardiovascular and other health outcomes, yet what is currently known about obesity is inadequate to combat the global obesity epidemic. A comprehensive understanding about the mechanics of obesity may help in developing more effective preventive and treatment strategies, which in turn will substantially improve cardiovascular and other health measures.

Feasibility and challenges of addressing this CQ or CC :

Years of obesity research have revealed the complex nature of this disease and its multi-factorial etiology. While research has firmly established the role of energy balance in weight gain and weight loss, it is important to discover upstream factors that predispose only certain individuals to energy imbalance. This may be addressed by further focusing on newly identified putative contributors of obesity, including but not limited to the impact of sleep deprivation, ambient temperature, age at first pregnancy, intrauterine and intergenerational factors, neuro-endocrine factors, epigenetics, environmental chemicals and endocrine disruptors, gut microbes, infections and the immune system, and social and behavioral factors associated with obesogenic behaviors. These studies may provide mechanistic insight that may also lead to the development of new pharmacological approaches. It is possible that cause-specific prevention or treatment approaches may yield more effective results than generic approaches that do not necessarily consider upstream modulators of energy imbalance, or inter-individual differences.

Name of idea submitter and other team members who worked on this idea : The Obesity Society

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Goal 1: Promote Human Health

Reduce burden of vascular disease

How can we reduce the burden of vascular disease by promoting healthy lifestyle including diet, exercise, and smoking cessation?

Submitted by (@societyforvascularsurgery)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

­Conduct community level and scale studies in higher risk populations, identify effective tools to achieve healthy lifestyle and prevent or retard the progression of vascular disease. Determine which interventions work.

Name of idea submitter and other team members who worked on this idea : Society for Vascular Surgery

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