Nutrition Evidence Systematic Review Research Articles

Dietary Patterns and Health: Insights From NESR Systematic Reviews to Inform the Dietary Guidelines for Americans

This perspective article shares unique insights from the extensive experience of the US Department of Agriculture Nutrition Evidence Systematic Review branch in conducting systematic reviews on dietary patterns and health outcomes to inform the Dietary Guidelines for Americans. Methodological approaches for reviewing dietary patterns research are described, including approaches to operationalizing definitions and analyzing labeled dietary patterns. The review also describes techniques for synthesizing dietary patterns research across life stages in systematic reviews that inform food-based, federal dietary guidance. Current research activities and recommendations for how to improve or address gaps in dietary patterns research in the future are also discussed.

Evaluating the Science to Inform the Physical Activity Guidelines for Americans Midcourse Report

Evaluating the Science to Inform the Physical Activity Guidelines for Americans Midcourse Report

USDA Nutrition Evidence Systematic Review's collaborative approach for conducting systematic reviews: Promoting diversity of expertise while managing potential conflicts of interest.

U.S. Department of Agriculture's (USDA) Nutrition Evidence Systematic Review (NESR) Branch develops food-and nutrition-related systematic reviews and other evidence synthesis products. NESR has established itself as a key resource for the Federal government when making evidence-informed decisions related to public health nutrition, such as the development of the Dietary Guidelines for Americans. NESR's systematic review methodology is rigorous, protocol-driven, and highly collaborative. NESR's systematic reviews examine the complex interplay between diet and health with input and support from various collaborators, including Federal stakeholders, expert groups, and public stakeholders. Implementing NESR's rigorous methodology ensures that the appropriate steps are taken to minimize conflict of interest, producing systematic reviews that are high-quality, trustworthy, and useful to end users who make decisions based on their findings. This article describes how NESR's systematic review process leverages a diversity of expertise and experience, while managing potential conflicts of interest. It describes the groups who collaborate to conduct NESR systematic reviews, their expertise, and why their involvement is critical for ensuring the rigor and utility of NESR's work.

Perspective: USDA Nutrition Evidence Systematic Review Methodology: Grading the Strength of Evidence in Nutrition- and Public Health–Related Systematic Reviews

The USDA's Nutrition Evidence Systematic Review (NESR) team conducts food- and nutrition-related systematic reviews used to inform US Federal guidelines and programs, including the Dietary Guidelines for Americans. NESR's systematic review methodology includes a step to grade the strength of the evidence underlying conclusion statements, which is critical for ensuring that end users understand the level of certainty in conclusions when using them to make decisions. Over time, NESR has ensured its grading process not only remains state of the art but is also designed specifically for systematic reviews that inform Federal guidelines and programs on nutrition and public health. The NESR grading process used by the 2020 Dietary Guidelines Advisory Committee included 5 grading elements: risk of bias, consistency, directness, precision, and generalizability. Evidence was grouped by study design and assessed against these elements, and the grade assigned to the entire body of evidence took into consideration the strengths and limitations of each design. Based on this assessment, 1 of 4 grades was assigned: strong, moderate, limited, or grade not assignable. The grade was clearly communicated by integrating specific language into each conclusion statement (e.g., "strong evidence demonstrates" or "limited evidence suggests"), and supported by rationale documented in the review. NESR's grading process aligns with approaches used by other organizations that conduct systematic reviews, while retaining aspects unique to NESR's role in informing Federal nutrition and public health guidelines and programs. It provides a framework that promotes consistency in grading across food- and nutrition-related reviews, while offering flexibility that allows for thorough consideration of the body of evidence underlying an individual conclusion statement. NESR's rigorous and transparent methods for grading the strength of evidence in food- and nutrition-related systematic reviews ensure that decisions related to nutrition and public health are based on the strongest available evidence.

Breastfeeding and risk of overweight in childhood and beyond: a systematic review with emphasis on sibling-pair and intervention studies

Breastfeeding is associated with a lower risk of subsequent overweight or obesity, but it is uncertain whether this is a causal relation because most studies have not adequately reduced risk of bias due to confounding. The aim of this review was to examine whether 1) ever compared with never consuming human milk and 2) different durations of human milk consumption among infants fed human milk are related to later risk of overweight or obesity, with emphasis on sibling-pair and intervention studies. The 2020 Dietary Guidelines Advisory Committee, together with the Nutrition Evidence Systematic Review team, conducted a systematic review of articles relevant to healthy full-term infants in countries with a high or very high level of human development. We searched PubMed, Embase, Cochrane, and CINAHL; dual-screened the results using predetermined criteria; extracted data from and assessed the risk of bias for each included study; qualitatively synthesized the evidence; developed conclusion statements; and graded the strength of the evidence. The review included 42 articles, including 6 cohorts with sibling-pair analyses and 1 randomized controlled trial of a breastfeeding promotion intervention. Moderate evidence suggested that ever, compared with never, consuming human milk is associated with a lower risk of overweight and obesity at ages 2 y and older, particularly if the duration of human milk consumption is>6 mo. However, residual confounding cannot be ruled out. Evidence was insufficient to determine the relation between the duration of any human milk consumption, among infants fed human milk, and overweight and/or obesity at age 2 y and older. Further research, using strong study designs, is needed to disentangle the complex relation between infant feeding practices and the risk of subsequent overweight or obesity, as well as the biological and behavioral mechanisms if the relation is causal.

Evaluation of Dietary Patterns and All-Cause Mortality

The 2020 Dietary Guidelines Advisory Committee conducted a systematic review of existing research on diet and health to inform the current Dietary Guidelines for Americans. The committee answered this public health question: what is the association between dietary patterns consumed and all-cause mortality (ACM)? To ascertain the association between dietary patterns consumed and ACM. Guided by an analytical framework and predefined inclusion and exclusion criteria developed by the committee, the US Department of Agriculture's Nutrition Evidence Systematic Review (NESR) team searched PubMed, the Cochrane Central Register of Controlled Trials, and Embase and dual-screened the results to identify articles that were published between January 1, 2000, and October 4, 2019. These studies evaluated dietary patterns and ACM in participants aged 2 years and older. The NESR team extracted data from and assessed risk of bias in included studies. Committee members synthesized the evidence, developed conclusion statements, and graded the strength of the evidence supporting the conclusion statements. A total of 1 randomized clinical trial and 152 observational studies were included in the review. Studies enrolled adults and older adults (aged 17-84 years at baseline) from 28 countries with high or very high Human Development Index; 53 studies originated from the US. Most studies were well designed, used rigorous methods, and had low or moderate risks of bias. Precision, directness, and generalizability were demonstrated across the body of evidence. Results across studies were highly consistent. Evidence suggested that dietary patterns in adults and older adults that involved higher consumption of vegetables, fruits, legumes, nuts, whole grains, unsaturated vegetable oils, fish, and lean meat or poultry (when meat was included) were associated with a decreased risk of ACM. These healthy patterns were also relatively low in red and processed meat, high-fat dairy, and refined carbohydrates or sweets. Some of these dietary patterns also included intake of alcoholic beverages in moderation. Results based on additional analyses with confounding factors generally confirmed the robustness of main findings. In this systematic review, consuming a nutrient-dense dietary pattern was associated with reduced risk of death from all causes.

Seafood Intake During Childhood and Adolescence and Neurocognitive Development and Risk of Cardiovascular Disease: A NESR Systematic Review

ObjectivesTo inform the Dietary Guidelines for Americans, 2020–2025, USDA and HHS identified important public health questions to be examined by the 2020 Dietary Guidelines Advisory Committee. The Committee conducted two systematic reviews with support from USDA’s Nutrition Evidence Systematic Review (NESR) team to answer the following questions: What is the relationship between seafood consumption during childhood and adolescence and 1) neurocognitive development and 2) risk of cardiovascular disease (CVD)? MethodsThe Committee developed protocols that described how they would use NESR’s systematic review methodology to examine the evidence related to seafood intake during childhood and adolescence and neurocognitive development and risk of CVD. NESR librarians conducted a literature search and NESR analysts dual-screened the results using pre-defined inclusion and exclusion criteria to identify articles published between January 2000 and October 2019. NESR analysts extracted data and assessed risk of bias of included studies. The Committee synthesized the evidence, developed conclusion statements, and graded the strength of the evidence underlying the conclusion statements. ResultsThirteen (6 from 3 randomized controlled trials [RCT] and 7 from 6 prospective cohort studies [PCS]) and four (2 RCT and 2 PCS) articles met inclusion criteria for the systematic reviews on the relationship between seafood consumption during childhood and adolescence and 1) neurocognitive development and 2) risk of CVD, respectively. For all neurocognitive outcomes, no conclusions could be drawn due to an inadequate number of studies, inconsistency in results, and heterogeneity of outcome assessments. For all CVD outcomes, no conclusions could be drawn due to the few number of included studies and methodological limitations present in some studies. ConclusionsInsufficient evidence is available to determine the relationship between seafood consumption during childhood and adolescence and neurocognitive development and risk of developing CVD. More well-designed studies are needed to determine whether consuming seafood during childhood and adolescence impacts health outcomes. Funding SourcesUSDA, Food and Nutrition Service, Center for Nutrition Policy and Promotion, Alexandria, VA.

Dietary Patterns and Gestational Weight Gain and Postpartum Weight Loss: A NESR Systematic Review

ObjectivesTo inform the 2020–2025 Dietary Guidelines for Americans, USDA and HHS identified important public health questions to be examined by the 2020 Dietary Guidelines Advisory Committee. The Committee conducted 2 systematic reviews with support from USDA’s Nutrition Evidence Systematic Review (NESR) team to answer the following questions: What is the relationship between dietary patterns (DP) consumed during 1) pregnancy and gestational weight gain (GWG)?, and 2) lactation and postpartum weight loss (PPWL)? MethodsThe Committee developed protocols that described how they would use NESR’s systematic review methodology to examine the systematic review questions. NESR conducted a literature search and dual-screened the results using pre-defined inclusion and exclusion criteria to identify articles published between Jan 2000 and Nov 2019. NESR extracted data and assessed risk of bias of included studies. The Committee synthesized the evidence, developed conclusion statements, and graded the strength of the evidence underlying the conclusion statements. ResultsTwenty-six articles were included in the GWG review and 1 article in the PPWL review. The GWG review included 5 RCTs and 21 prospective cohort studies. Two RCTs showed that a “beneficial” DP was associated with lower GWG. Thirteen of the 20 observational studies showed an association between DP and GWG. Although the DPs examined were characterized by different combinations of foods and beverages, the patterns consistently associated with lower GWG were higher in vegetables, fruits, nuts, legumes, and fish and lower in added sugars and red and processed meats. The PPWL review included only one RCT, which was limited by high attrition, issues with implementing the intervention, and lack of blinding. ConclusionsLimited evidence suggests that certain DPs during pregnancy are associated with a lower risk of excessive GWG. These patterns are higher in vegetables, fruits, nuts, legumes, and fish, and lower in added sugar, and red and processed meat (Grade: Limited). Insufficient evidence is available to determine the relationship between DPs during lactation and PPWL (Grade: Grade Not Assignable). Funding SourcesUSDA, Food and Nutrition Service, Center for Nutrition Policy and Promotion.

Dietary Patterns and Bone Health: A NESR Systematic Review

Abstract Objectives To inform the 2020–2025 Dietary Guidelines for Americans, USDA and HHS identified important public health questions to be examined by the 2020 Dietary Guidelines Advisory Committee. The Committee conducted a systematic review with support from USDA's Nutrition Evidence Systematic Review (NESR) team to answer the question: What is the relationship between dietary patterns consumed and bone health? Methods The Committee developed protocols that described how they would use NESR's systematic review methodology to examine the evidence. NESR librarians conducted a literature search, and NESR analysts dual-screened the results using pre-defined inclusion and exclusion criteria to identify articles published between 2014 and 2019 that evaluated dietary patterns and bone health, which updates an existing review of evidence from 2000 to 2014. NESR analysts extracted data and assessed risk of bias of included studies. The Committee synthesized the evidence, developed conclusion statements, and graded the strength of the evidence underlying the conclusion statements. Results This systematic review update includes seven prospective cohort studies in adults and two in children, in addition to the thirteen studies included in the existing review. Most studies had few risks of bias, with good consistency, directness, precision and generalizability. Results from studies in adults were consistent in the foods and beverages in the dietary patterns associated with reduced fracture risk. Based on this new evidence in adults, the Committee updated the grade from limited to moderate. Evidence in children remains insufficient. Conclusions Moderate evidence indicates that a dietary pattern higher in fruits, vegetables, legumes, nuts, low-fat dairy, whole grains, and fish, and lower in meats (particularly processed meats), sugar sweetened beverages, and sweets is associated with favorable bone health outcomes in adults, primarily decreased risk of hip fracture. (Grade: Adults – Moderate) Insufficient evidence is available to determine the relationship between dietary patterns consumed during childhood and bone health. (Grade: Children – Grade not assignable) Funding Sources USDA, Food and Nutrition Service, Center for Nutrition Policy and Promotion, Alexandria, VA.

Dietary Patterns and All-Cause Mortality: A NESR Systematic Review

Abstract Objectives To inform the 2020–2025 Dietary Guidelines for Americans, the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) identified important public health questions to be examined by the 2020 Dietary Guidelines Advisory Committee. The Committee conducted a systematic review with support from USDA's Nutrition Evidence Systematic Review (NESR) team to answer the following question: What is the relationship between dietary patterns consumed and all-cause mortality? Methods The Committee developed protocols that described how they would use NESR's systematic review methodology to examine the evidence related to dietary patterns and all-cause mortality. NESR librarians conducted a literature search. NESR analysts dual-screened the results using pre-defined inclusion and exclusion criteria to identify articles published between 2000 and 2019 that evaluated dietary patterns and all-cause mortality. NESR analysts extracted data and assessed risk of bias of included studies. The Committee synthesized the evidence, developed conclusion statements, and graded the strength of the evidence underlying the conclusion statements. Results This review included one hundred and fifty-three studies, which were well-designed and conducted using rigorous methods, with low or moderate risks of bias. Precision, directness, and generalizability were demonstrated across the body of evidence. Results across studies were highly consistent in the foods and beverages included in the dietary patterns associated with reduced ACM risk. Robustness of results were confirmed by analyses with confounding factors. Conclusions Strong evidence demonstrates that dietary patterns in adults and older adults characterized by vegetables, fruits, legumes, nuts, whole grains, unsaturated vegetable oils, and fish, lean meat or poultry when meat was included, are associated with decreased risk of all-cause mortality. These patterns were also relatively low in red and processed meat, high-fat dairy, and refined carbohydrates or sweets. Some of these dietary patterns also included alcoholic beverages in moderation. (Grade: Strong) Funding Sources USDA, Food and Nutrition Service, Center for Nutrition Policy and Promotion, Alexandria, VA.

Folic Acid From Supplements or Fortified Foods Consumed During Pregnancy and/or Lactation and Health Outcomes in Mothers and Their Children: A NESR Systematic Review

ObjectivesTo inform the Dietary Guidelines for Americans, 2020–2025, USDA and HHS identified the following important public health question for the 2020 Dietary Guidelines Advisory Committee to answer with support from USDA’s Nutrition Evidence Systematic Review (NESR) team: What is the relationship between folic acid from supplements and/or fortified foods consumed before and during pregnancy and lactation and health outcomes? MethodsThe Committee developed protocols to describe how they would use NESR’s systematic review methodology to examine the evidence. NESR conducted a literature search and dual-screened the results using pre-defined inclusion and exclusion criteria for articles published between 1980 and 2019. NESR extracted data and assessed risk of bias of included studies. The Committee synthesized the evidence, developed conclusion statements, and graded the strength of the evidence underlying the conclusion statements. ResultsThis systematic review included 30 articles, most of which were well-designed RCTs. Observational studies had risk of bias concerns. The study populations did not fully represent the diversity of the U.S. population. ConclusionsStrong evidence indicates that folic acid supplements consumed before and/or during pregnancy are positively associated with folate status. Moderate evidence indicates that folic acid supplements consumed during lactation are positively associated with folate status. Limited evidence suggests that folic acid supplements consumed during early pregnancy may have a beneficial effect on reducing the risk of hypertensive disorders during pregnancy among women at high-risk versus no supplementation. Moderate evidence indicates that higher versus lower levels of folic acid supplements consumed during pregnancy does not affect the risk of hypertensive disorders during pregnancy among women at low-risk. Moderate evidence indicates that folic acid supplements consumed during lactation does not influence folate levels in human milk. Insufficient or no evidence was available to examine folic acid and gestational diabetes or child developmental, or folic acid from fortified foods and any outcome. Funding SourcesUSDA, Food and Nutrition Service, Center for Nutrition Policy and Promotion.

Seafood Intake During Pregnancy and Lactation and Child Neurocognitive Development: A NESR Systematic Review

ObjectivesTo inform the Dietary Guidelines for Americans, 2020–2025, the USDA and HHS identified important public health questions to be examined by the 2020 Dietary Guidelines Advisory Committee. The Committee conducted a systematic review with support from USDA’s Nutrition Evidence Systematic Review (NESR) team to answer the question: What is the relationship between seafood consumption during pregnancy and lactation and neurocognitive development in the child? MethodsThe Committee developed a protocol that described how they would use NESR’s systematic review methodology to examine evidence related to seafood intake during pregnancy and lactation and child neurocognitive development. NESR librarians conducted a literature search (2000–2019) and NESR analysts dual-screened the results using pre-defined inclusion and exclusion criteria. NESR analysts extracted data and assessed risk of bias of included studies. The Committee synthesized the evidence, developed conclusion statements, and graded the strength of evidence underlying the conclusion statements. ResultsTwenty-six articles (from 18 prospective cohort studies [PCS]) met inclusion criteria; all assessed prenatal seafood intake and none assessed seafood intake during lactation. Evidence from 15 PCS suggests that prenatal seafood intake has beneficial associations with cognitive development, particularly in young children. Evidence from 12 PCS suggests that there may be a beneficial association between prenatal seafood intake and language/communication development. Less consistent evidence and/or scant to no evidence was available for movement/physical or social-emotional/behavioral development, attention-deficit/hyperactivity disorder, autism, academic performance, anxiety, and depression. ConclusionsModerate evidence indicates that seafood intake during pregnancy is associated favorably with measures of cognitive development in young children. Limited evidence suggests that seafood intake during pregnancy may be associated favorably with measures of language and communication development in the child. Insufficient or no evidence was available for all other relationships assessed. Funding SourcesUSDA, Food and Nutrition Service, Center for Nutrition Policy and Promotion, Alexandria, VA.

Dietary Patterns During Lactation and Human Milk Composition and Quantity: A NESR Systematic Review

ObjectivesTo inform the Dietary Guidelines for Americans, 2020–2025, the USDA and HHS identified important public health questions to be examined by the 2020 Dietary Guidelines Advisory Committee. The Committee conducted a systematic review with support from the USDA’s Nutrition Evidence Systematic Review (NESR) team to answer the question: What is the relationship between dietary patterns consumed during lactation and human milk composition and quantity? MethodsThe Committee developed protocols to describe how they would use NESR’s SR methodology to examine the evidence related to dietary patterns (DP) during lactation and human milk (HM). NESR librarians conducted a literature search and NESR analysts dual-screened the results using pre-defined inclusion and exclusion criteria to identify articles published between 2000 and 2019. NESR analysts extracted data from and assessed the risk of bias of included studies. The Committee synthesized the evidence, developed conclusion statements, and graded the strength of the evidence. ResultsThis systematic review included 7 articles. Three articles from 2 cross-sectional studies examined DP and HM, while 4 articles from 3 randomized controlled trials examined diets based on macronutrient distributions and HM. The body of evidence was limited by small sample sizes, risk of bias concerns, heterogeneous methods, and study populations with limited racial/ethnic and socioeconomic diversity. ConclusionsLimited evidence suggests that maternal consumption of diets higher in fat (>35% fat) and lower in carbohydrate during lactation is related to higher total fat in HM collected in the maternal postprandial period. Limited evidence suggests that certain maternal DP during lactation, including diets based on macronutrient distributions, are related to the relative proportions of saturated fat and monounsaturated fatty acids in HM, and of polyunsaturated fatty acids in HM collected in the maternal postprandial period. Insufficient or no evidence was available to assess the association between DP during lactation and HM quantity, as well as total protein, water- and fat-soluble vitamins, minerals, human milk oligosaccharides, and bioactive proteins in HM. Funding SourcesUSDA, Food and Nutrition Service, Center for Nutrition Policy and Promotion.

The effect of egg consumption on cardiometabolic health outcomes: an umbrella review.

This umbrella review provides an overview of the consistency and gaps in the evidence base on eggs and cardiometabolic health. PubMed, Web of Science, Cochrane Library, the Nutrition Evidence Systematic Review and Agency for Healthcare Research and Quality databases were screened for evidence-based reviews in English that assessed human studies on egg consumption and cardiometabolic outcomes. Seven systematic reviews and fifteen meta-analyses were identified, with eighteen of these published since 2015. Overall, the systematic reviews were of low quality, while meta-analyses were of moderate- to high-quality. No association of increased egg intake and risks of heart disease or stroke in the general population were found in the meta-analyses. Increased risk of heart failure was noted in two meta-analyses that analysed the same three cohort studies. Five recent meta-analyses reported no increased risk of type 2 diabetes mellitus (T2DM) in the general population, although increased risk in US-based populations only has been reported. Older (<2013) meta-analyses reported increased risks of cardiovascular disease (CVD) or heart disease in T2DM populations, and no recent evidence-based reviews were identified. Finally, only one meta-analysis reported intervention studies specifically on eggs and biomarkers (i.e. lipids), and the results contradicted those from observation studies. Recent evidence-based reviews conclude that increased egg consumption is not associated with CVD risk in the general population. More research is needed on the positive associations between egg consumption and heart failure and T2DM risk, as well as CVD risk in diabetics, before firm conclusions can be made.

Systematic review methods for the Pregnancy and Birth to 24 Months Project

The USDA's Nutrition Evidence Systematic Review (NESR) team specializes in conducting systematic reviews (SRs) to inform federal nutrition policy and programs. The NESR's dedicated staff collaborate with leading scientists to answer important food- and nutrition-related public health questions by objectively reviewing, evaluating, and synthesizing research using state-of-the-art methodology. NESR uses a rigorous, protocol-driven methodology that is designed to minimize bias; to ensure availability of SRs that are relevant, timely, and high quality; and to ensure transparency and reproducibility of findings. This article describes the methods used by NESR to conduct a series of SRs on diet and health in infants, toddlers, and women who are pregnant as part of the Pregnancy and Birth to 24 Months Project.

Types and amounts of complementary foods and beverages consumed and growth, size, and body composition: a systematic review

Systematic reviews (SRs) were conducted by the Nutrition Evidence Systematic Review (NESR) team for the USDA's and the Department of Health and Human Services' Pregnancy and Birth to 24 Months Project. The aim was to describe the SRs examining the relationship between types and amounts of complementary foods and beverages (CFBs) and growth, size, and body-composition outcomes. The NESR team collaborated with subject matter experts to conduct this SR. The literature was searched and screened using predetermined criteria. For each included study, data were extracted and risk of bias was assessed. The evidence was qualitatively synthesized to develop a conclusion statement, and the strength of evidence was graded. This SR includes 49 articles that examined type, amount, or both of CFBs consumed and growth, size, and body-composition outcomes. Moderate evidence suggests that consuming either different amounts of meat, meat instead of iron-fortified cereal, or types of CFBs with different fats or fatty acids does not favorably or unfavorably influence growth, size, or body composition. In relation to overweight/obesity, insufficient evidence is available with regard to the intake of meat or CFBs with different fats or fatty acids. Limited evidence suggests that type and amount of fortified infant cereal does not favorably or unfavorably influence growth, size, body composition, or overweight/obesity. Limited evidence suggests that sugar-sweetened beverage consumption during the complementary feeding period is associated with increased obesity risk in childhood but is not associated with other measures of growth, size, or body composition. Limited evidence showed a positive association between juice intake and infant weight-for-length and child body mass index z scores. Insufficient evidence is available on other CFBs or dietary patterns in relation to outcomes. Although several conclusions were drawn, additional research is needed that includes randomized controlled trials, examines a wider range of CFBs, considers issues of reverse causality, and adjusts for potential confounders to address gaps and limitations in the evidence.

Caregiver feeding practices and child weight outcomes: a systematic review

As part of the USDA-Department of Health and Human Services Pregnancy and Birth to 24 Months Project, we conducted systematic reviews (SRs) on topics important for health and nutrition of young children. The purpose of the present SR was to examine the relation between caregiver feeding practices in children from birth to 24 mo and child weight gain, size, and body composition. A search of articles published from January 1980 to January 2017 in 4 databases identified 8739 references. Nutrition Evidence Systematic Review (NESR) analysts used the Nutrition Evidence Library Risk of Bias Assessment Tool to assess potential bias in the studies, and a Technical Expert Collaborative graded the body of evidence using the NESR grading rubric. Twenty-seven articles were included in this review (8 controlled trials, 19 longitudinal cohort studies). Moderate evidence from randomized controlled trials suggests that providing responsive feeding guidance to teach mothers to recognize and respond appropriately to children's hunger and satiety cues can lead to "normal" weight gain and/or "normal" weight status in children aged ≤2 y compared with children whose mothers did not receive responsive feeding guidance. Moderate evidence from longitudinal cohort studies indicates an association between maternal feeding practices and the child's weight status and/or weight gain, but the direction of effect has not been adequately studied. Restrictive feeding practices are associated with increased weight gain and higher weight status, and pressuring feeding practices are associated with decreased weight gain and lower weight status. Evidence suggests that a mother's feeding practices are related to concerns about her child's body weight. This review highlights the importance of the interaction between caregivers and infants and toddlers related to child feeding practices on children's weight outcomes. Research is needed on more diverse populations with consistent methodological app-roaches and objective measures.

Infant milk-feeding practices and cardiovascular disease outcomes in offspring: a systematic review

During the Pregnancy and Birth to 24 Months Project, the US Departments of Agriculture and Health and Human Services initiated a review of evidence on diet and health in these populations. The aim of these systematic reviews was to examine the relation of 1) never versus ever feeding human milk, 2) shorter versus longer durations of any human milk feeding, 3) shorter versus longer durations of exclusive human milk feeding, and 4) lower versus higher intensities of human milk fed to mixed-fed infants with intermediate and endpoint cardiovascular disease (CVD) outcomes in offspring. The Nutrition Evidence Systematic Review team conducted systematic reviews with external experts. We searched CINAHL, Cochrane, Embase, and PubMed for articles published January 1980-March 2016, dual-screened the results using predetermined criteria, extracted data from and assessed the risk of bias for each included study, qualitatively synthesized the evidence, developed conclusion statements, and graded the strength of the evidence. The 4 systematic reviews included 13, 24, 6, and 0 articles, respectively. The evidence was insufficient to draw conclusions about endpoint CVD outcomes across all 4 systematic reviews. Limited evidence suggests that never versus ever being fed human milk is associated with higher blood pressure within a normal range at 6-7 y of age. Moderate evidence suggests there is no association between the duration of any human milk feeding and childhood blood pressure. Limited evidence suggests there is no association between the duration of exclusive human milk feeding and blood pressure or metabolic syndrome in childhood. Additional evidence about intermediate outcomes for the 4 systematic reviews was scant or inconclusive. There is insufficient evidence to draw conclusions about the relationships between infant milk-feeding practices andendpoint CVD outcomes; however, some evidence suggests that feeding less or no human milk is not associated with childhood hypertension.

Complementary feeding and bone health: a systematic review

Proper nutrition during infancy and toddlerhood is crucial for supporting healthy growth and development, including bone health. Complementary feeding is the process that starts when human milk or infant formula is complemented by other foods and beverages, beginning during late infancy and continuing to 24 mo of age. This article aims to describe systematic reviews (SRs) conducted by the Nutrition Evidence Systematic Review team for the USDA and the Department of Health and Human Services Pregnancy and Birth to 24 Months Project to answer these questions: what is the relationship between 1) timing of introduction of complementary foods and beverages (CFBs) or 2) types and/or amounts of CFBs consumed and bone health? Methods: The literature was searched with the use of 4 databases (CINAHL, Cochrane, Embase, and PubMed) to identify articles published from January 1980 to July 2016 that addressed these topics and met predetermined criteria for inclusion. For each study, data were extracted and risk of bias was assessed. The evidence was qualitatively synthesized to develop a conclusion statement, and the strength of the evidence was graded. Three articles addressed the timing of introduction of CFBs and bone health during childhood (through 18 y of age), and 2 addressed the types and/or amounts of CFBs consumed relative to bone health. Insufficient evidence was available to draw conclusions about the relationships between the timing of CFB introduction and types and/or amounts of CFBs consumed and bone health. Therefore, a grade was not assignable for these SRs. The ability to draw conclusions was limited by an overall lack of research, failure to adjust for several key confounding factors, and heterogeneity in studies with regard to methodology, subject populations, and results. Additional research is needed that addresses these gaps and limitations.

Infant milk-feeding practices and diabetes outcomes in offspring: a systematic review

During the Pregnancy and Birth to 24 Months Project, the US Departments of Agriculture and Health and Human Services initiated a review of evidence on diet and health in these populations. The aim of these systematic reviews was to examine the relation of 1) never versus ever feeding human milk, 2) shorter versus longer durations of any human milk feeding, 3) shorter versus longer durations of exclusive human milk feeding, and 4) feeding a lower versus higher intensity of human milk to mixed-fed infants with type 1 and type 2 diabetes in offspring. The Nutrition Evidence Systematic Review team conducted systematic reviews with external experts. We searched CINAHL, Cochrane, Embase, and PubMed for articles published January 1980-March 2016, dual-screened the results according to predetermined criteria, extracted data from and assessed the risk of bias for each included study, qualitatively synthesized the evidence, developed conclusion statements, and graded the strength of the evidence. The 4 systematic reviews included 21, 37, 18, and 1 articles, respectively. Observational evidence suggests that never versus ever feeding human milk (limited evidence) and shorter versus longer durations of any (moderate evidence) and exclusive (limited evidence) human milk feeding are associated with higher type 1 diabetes risk. Insufficient evidence examined type 2 diabetes. Limited evidence suggests that the durations of any and exclusive human milk feeding are not associated with intermediate outcomes (e.g., fasting glucose, insulin resistance) during childhood. Limited to moderate evidence suggests that feeding less or no human milk is associated with higher risk of type 1 diabetes in offspring. Limited evidence suggests no associations between the durations of any and exclusive human milk feeding and intermediate diabetes outcomes in children. Additional research is needed on infant milk-feeding practices and type 2 diabetes and intermediate outcomes in US populations, which may have distinct metabolic risk.