filling americaâ€™s fiber intake gap: summary of a roundtable to

The Journal of Nutrition

Supplement: Filling America’s Fiber Gap—Probing Realistic Solutions

Filling America’s Fiber Intake Gap: Summary ofa Roundtable to Probe Realistic Solutions with aFocus on Grain-Based Foods1,2

Roger Clemens,3* Sibylle Kranz,4 Amy R. Mobley,5 Theresa A. Nicklas,6 Mary Pat Raimondi,7

Judith C. Rodriguez,8 Joanne L. Slavin,9 and Hope Warshaw10

3Department of Pharmacy, University of Southern California, Los Angeles, CA; 4Department of Nutrition Science, Purdue University,

West Lafayette, IN; 5Department of Nutritional Sciences, University of Connecticut, Storrs, CT; 6Baylor College of Medicine, USDA/ARS

Children’s Nutrition Research Center, Houston, TX; 7Academy of Nutrition and Dietetics (formerly American Dietetic Association),

Chicago, IL; 8Department of Nutrition and Dietetics, University of North Florida, Jacksonville, FL; 9Department of Food Science and

Nutrition, University of Minnesota, St. Paul, MN; and 10Hope Warshaw Associates, LLC, Alexandria, VA

Abstract

Current fiber intakes are alarmingly low, with long-term implications for public health related to risk of coronary heart

disease, stroke, hypertension, certain gastrointestinal disorders, obesity, and the continuum of metabolic dysfunctions

including prediabetes and type 2 diabetes. Eating patterns high in certain fibers are known to lower LDL cholesterol and

blood pressure, lower blood glucose, and decrease insulin resistance in people with prediabetes and type 2 diabetes; help

with both weight loss and maintenance; and improve bowel regularity and gastrointestinal health. With .90% of adults

and children who fall short of meeting their daily fiber recommendations, the 2010 Dietary Guidelines for Americans once

again classified fiber as a nutrient of concern. Despite efforts over the past decade to promote adequate fiber through fruit,

vegetable, and whole-grain intakes, fiber consumption has remained flat at approximately half the daily recommended

amount. The public health implications of inadequate fiber intake prompted the roundtable session “Filling America’s Fiber

Gap: Probing Realistic Solutions,” which assembled nutrition researchers, educators, and communicators to identify

challenges, opportunities, and realistic solutions to help fill the current fiber gap. The roundtable discussions highlighted

the need for both consumer and professional education to improve acceptance for and inclusion of grain-based foods with

added fiber as one strategy for increasing fiber intakes within daily energy goals. J. Nutr. 142: 1390S–1401S, 2012.

Introduction

Inadequate fiber intake is widespread, with,3%of all Americansmeeting recommended intakes (1). It is recognized that the

development of many risk factors associated with highlyprevalent chronic diseases could be reduced by increasingconsumption of fiber (2). Evidence suggests that fiber plays acritical role in reducing the risk of cardiovascular disease,obesity, and prediabetes and type 2 diabetes and is essential foroptimal digestive health. Fiber was identified as an “under-consumed nutrient of public health concern” by the 2010Dietary Guidelines Advisory Committee (2). This statement wasbased on mean intakes well below Adequate Intake (AI)11 levels,coupled with fiber’s established role in risk reduction ofcoronary heart disease and its emerging role in contributing tosatiety and weight control (2).

With support from unrestricted educational funding from theKellogg Company, a group of leading nutrition researchers,educators, and communicators, with expertise in fiber research,food technology, and consumer and professional education,convened on October 27, 2011, for a roundtable discussionentitled “Filling America’s Fiber Gap: Probing Realistic Solu-tions.” Objectives of the roundtable included identifying chal-

1 Published in a supplement to The Journal of Nutrition. Published as a synopsis

of participants’ views and perspectives at the roundtable meeting “Filling

America’s Fiber Gap: Probing Realistic Solutions,” held in Chicago Illinois,

October 27, 2011.The meeting was sponsored by Kellogg Company. The

coordinator for this supplement is Betsy Hornick. Supplement Coordinator

disclosures: Betsy Hornick is supported by funds from the Kellogg Company, and

is a nutrition writer and consultant for FoodMinds, LLC, a food and nutrition

affairs company that represents the Kellogg Company. The supplement is the

responsibility of the Guest Editor to whom the Editor of The Journal of Nutrition

has delegated supervision of both technical conformity to the published

regulations of The Journal of Nutrition and general oversight of the scientific

merit of each article. The Guest Editor for this supplement is A. Catharine Ross.

Guest Editor disclosure: A. Catharine Ross has no conflicts to report. Publication

costs for this supplement were defrayed in part by the payment of page charges.

This publication must therefore be hereby marked “advertisement” in accordance

with 18USC section 1734 solely to indicate this fact. The opinions expressed in this

publication are those of the authors and are not attributable to the sponsors or the

publisher, Editor, or Editorial Board of The Journal of Nutrition.2 Authors disclosures: R. Clemens, S. Kranz, A. R. Mobley, T. A. Nicklas, M. P.

Raimondi, J. C. Rodriguez, J. L. Slavin, and H. Warshaw, no conflicts of interest.

All authors received an honorarium for their participation in the roundtable.

* To whom correspondence should be addressed. E-mail: [email protected].

11 Abbreviations used: AI, Adequate Intake; DGA, Dietary Guidelines for

Americans; IOM, Institute of Medicine; RD, registered dietitian.

1390S ã 2012 American Society for Nutrition.

First published online May 30, 2012; doi:10.3945/jn.112.160176.

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lenges and realistic solutions for translating current fiber guidanceinto practical advice for obtaining fiber from a variety ofsources, both whole and enriched, to help Americans better meettheir daily fiber recommendations within their energy needs. Themeeting included brief presentations by the participants, with afocus on their areas of expertise related to the public healthconcern about low fiber intakes, followed by discussions of thechallenges of adhering to current dietary guidance, and oppor-tunities for filling the fiber intake gap. Consideration of theeffects on energy intake was also a focus because of the emphasison energy balance in the 2010 Dietary Guidelines for Americans(DGA) (3).

The roundtable experts agreed that all fiber-containing foods,including fruit, vegetables, legumes, and whole grains, shouldplay a role in helping Americans meet their daily fiber needs.With evidence that fiber intake is closely linked to energy intake,there was recognition of the challenges of increasing fiber whileattempting to reduce energy intake, as is the goal for many whoare overweight (4). This prompted the need to focus solutions onimmediate and realistic small-step changes that could beimplemented within current eating patterns. Considering thatnearly all Americans fall short of meeting their fiber needs, yetmeet or exceed their daily recommendations for grain foods (5),the roundtable discussions centered on opportunities to improvethe fiber content of grain-based food choices as a strategy withan immediate potential for increasing fiber intakes withoutexceeding energy goals. This article summarizes the roundtableproceedings and call-to-action, focusing on realistic and energy-neutral (minimal or no effect on energy intake) solutions to helpincrease fiber intakes among Americans.

Fiber is generally recognized as the carbohydrates and ligninthat escape digestion in the upper gastrointestinal tract, undergocomplete or partial fermentation in the colon, and exert varyingbeneficial physiologic effects depending on the type of fiber (6).The roundtable participants acknowledged the fact that auniversally accepted definition for fiber does not exist, whereinlies the confusion in what can be designated as “fiber.” With thisunderstanding, the participants agreed to use the Institute ofMedicine’s (IOM’s) definition for total fiber in their discussions,which differentiates between dietary (naturally occurring) andfunctional (isolated) fibers, because the IOM is an authoritativesource for science-based dietary standards and recommenda-tions in the United States (7). However, the participants alsorecognized that the American Association of Cereal Chemistsand, most recently, the Codex Alimentarius Commission includein their definitions of dietary fiber the naturally occurring plantfibers in addition to analogous carbohydrates, such as fibersobtained from food by physical, enzymatic, or chemical means,and synthetic fibers (Table 1) (8,9). The roundtable participantsagreed on definitions of various nutrition- and fiber-relatedterminology used in the discussions (Table 2).

Today’s Inadequate Fiber Intake: “A Public

Health Concern for All Americans”

Fiber was first identified as a “nutrient of concern” forAmericans in the 2005 DGA, and this categorization wasreaffirmed in 2010 (3,12). Mean intakes of fiber range from 10to 18 g/d for individuals aged 2 y (Fig. 1), indicating that mostAmericans need to double their consumption to meet the IOMfiber recommendation of 19–38 g/d (7,13). This translates to$90% of adults and children with fiber intakes below the dailyrecommended amount (14).

The AI for fiber is 14 g/1000 kcal, an amount associated withreducing the risk of cardiovascular disease (7). The AI is basedon total daily fiber intake and does not differentiate between theIOM designations of “dietary” (intrinsic, or naturally occurring)and “functional” (added, or isolated) fiber (7). Other beneficialphysiologic effects of sufficient intake of differing types of fiberinclude healthy laxation, normalization of total and LDLcholesterol, reduction in blood glucose and insulin levels, andprotection against weight gain through its effects on satiety(6,15,16). In children, increased fiber intake has been found tobe associated with better diet quality, which in turn is associatedwith lower risk for overweight or obesity (17,18).

At a time when two-thirds of American adults and 1 in 3children are overweight or obese (19,20), and many are alsoundernourished despite excess energy intake, energy balance is acritical consideration (3). Current dietary guidance directs con-sumers to increase intakes of nutrient-dense and fiber-containingfoods, yet emphasizes maintaining energy balance over time toachieve and sustain a healthy weight (3). This poses a keychallenge in modifying current eating patterns to meet overallnutrient needs without exceeding energy goals. To meet dailyfiber needs, the 2010 DGA recommend increased consumptionof cooked dry beans and peas, other vegetables, fruit, wholegrains, and other foods with naturally occurring fiber (3). Onthe basis of USDA nutrient profiles for food groups (Table 3),recommended intakes of vegetables and fruit will provide;63% of the daily fiber goal for a 2000-kcal intake, whereasrecommended intakes of grains will provide ;36% of dailyfiber, with whole-grain choices accounting for the majority ofthe grain group’s fiber at ;28% of the daily fiber goal (21).

Fruit and vegetable intakes. Current consumption of fruit andvegetables is well below recommended intakes. According to theCDC, 40% of people nationwide consume fruit and vegetables#2 times/d (22). The typical American meets only 42% and59% of his or her fruit and vegetable goals (3), respectively, andthe vast majority of Americans aged $2 y have usual intakesbelow recommended amounts of fruit (80%) and vegetables(89%) (23).

Whole-grain intakes. Among the plant-based foods recom-mended to increase fiber intake, whole grains are recognized andpromoted in the 2010 DGA as a food to increase as part of adietary pattern that meets daily fiber goals. In addition tocontributing to fiber intake, whole-grain consumption is asso-ciated with improved diet quality and nutrient intake in bothchildren and adults (24,25). The typical American eating patternmeets only 15% of the whole-grain goal, or ,28 g (1 oz) of therecommended 85 g (3-oz equivalents)/d (3). More than 99% ofAmericans (aged 2 y) are not consuming recommended amountsof whole grains, yet nearly two-thirds meet daily intake goals fortotal amount of grains, including refined grains (23). In fact,mean daily intakes of total grains of 181 g (6.4 oz) are slightlyabove the recommended amount of 170 g (6 oz)/d for a 2000-kcal diet, whereas whole-grain intakes are 17 g (0.6 oz)/dcompared with the recommended amount of $85 g (3 oz)/d, orone-half of total grain intake (5).

A focus on grain-based foods. The amounts of fiber in grains,fruit, and vegetables recommended by the 2010 DGA to closethe fiber intake gap vary considerably, and many choices withinthese food groups are not considered a “good” source of fiber,defined as equivalent to 10–19% of the Daily Value, or 2.5–4.9 gper reference serving, nor an “excellent” source of fiber, defined

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as equivalent to $20% of the Daily Value or $5 g per referenceserving, as defined by the FDA (26). Americans attempting toachieve increased intakes of fruit and vegetables would require a

considerable change in behavior, because higher fiber fruits andvegetables currently are not widely consumed and efforts tochange this have not resulted in measurable improvements (27).

TABLE 1 Current definitions of fiber

Organization (reference) Definition

Institute of Medicine (7) Dietary fiber consists of nondigestible carbohydrates and lignin

that are intrinsic and intact in plants. Functional fiber consists

of isolated, nondigestible carbohydrates that have beneficial

physiologic effects in humans. Total fiber is the sum of dietary fiber

and functional fiber.

American Association of Cereal Chemists (8) Dietary fiber is the edible parts of plants or analogous carbohydrates

that are resistant to digestion and absorption in the human small

intestine, with complete or partial fermentation in the large

intestine. Dietary fiber includes polysaccharides, oligosaccharides,

lignin, and associated plant substances. Dietary fibers promote

beneficial physiologic effects including laxation, and/or blood

cholesterol attenuation, and/or blood glucose attenuation.

Codex Alimentarius Commission (9) Dietary fiber means carbohydrate polymers1 with $10 monomeric

units2, which are not hydrolyzed by the endogenous enzymes in the

small intestine of humans and belong to the following categories:d Edible carbohydrate polymers naturally occurring in the food

as consumedd Carbohydrate polymers that have been obtained from food raw

material by physical, enzymatic, or chemical means and which

have been shown to have a physiologic effect of benefit to health

as demonstrated by generally accepted scientific evidence to

competent authoritiesd Synthetic carbohydrate polymers that have been shown to have

a physiologic effect of benefit to health as demonstrated by

generally accepted scientific evidence to competent authorities

1 When derived from a plant origin, dietary fiber may include fractions of lignin and/or other compounds associated with polysaccharides in

the plant cell walls. These compounds also may be measured by certain analytic method(s) for dietary fiber. However, such compounds are

not included in the definition of dietary fiber if extracted and reintroduced into a food.2 The decision on whether to include carbohydrates of 3 to 9 monomeric units should be left up to national authorities.

TABLE 2 Glossary of terms

Term Definition (reference)

Energy balance The balance between energy (kcal) consumed through eating and

drinking and energy expended through physical activity and

metabolic processes (3).

Added fiber (also known as functional, isolated, or novel fiber) Isolated or synthesized nondigestible carbohydrates that have

beneficial physiologic effects in humans. May be extracted from the

original food source that it is being added back to, such as bran

added to grain-based foods, or from fruit, vegetables, legumes,

nuts, and seeds; modified forms of traditional fibers (e.g.,

fructooligosaccharides, or FOS, from inulin); or manufactured from

other ingredients such as corn or wheat (7).

Functional foods Whole foods and fortified, enriched, or enhanced foods that have a

potentially beneficial effect on health when consumed as part of a

varied diet on a regular basis at effective levels (10).

Nutrient dense A way to describe foods or beverages that provide vitamins, minerals,

and other substances that may have positive health effects, with

relatively low energy contribution. Nutrient-dense foods and

beverages are low in solid fats and minimize or exclude added solid

fats, sugars, starches, and sodium (3).

Whole grain The intact, ground, cracked, or flaked fruit of the grain whose principal

components—the starchy endosperm, germ, and bran—are

present in the same relative proportions as they exist in the intact

grain (11).

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However, modifying grain-based food choices may be a morereasonable small step toward higher fiber consumption withoutincreased energy intakes (4). Most Americans are already meeting(or exceeding) daily total grain recommendations (5); thus, a shiftfrom low-fiber to higher fiber grain-based foods may be anachievable public health goal. This recognition was the focus ofthe remaining roundtable discussions and recommendationsaround grain-based foods.

Barriers to Meeting Fiber

Recommendations

Limited understanding and recognition of fiber’s role inhealthThe roundtable experts recognized that the fiber deficit has long-term health implications for Americans, potentially contributingto increased risk of chronic diseases and obesity (15,16,28,29),yet agreed that understanding and recognition of this fiber deficitas a public health concern and priority are often overlooked.Whereas science continues to point to fiber’s role in promotinghealth and reducing the risk of developing some noncommuni-cable diseases, these benefits are primarily longer term, makingfiber intake less of an immediate concern to consumers andhealth professionals. Unlike many other nutrient inadequacies,the clinical signs or symptoms of low fiber intakes are not directlyevident. However, there are some immediate benefits of adequate

intakes of fiber, such as promoting healthy laxation in additionto contributing to satiety, which have short- and long-termimplications related to weight management and reducing therisk of obesity, prediabetes, and type 2 diabetes (30). Data on theeffect of fiber intake on children’s health are limited (31).

The lack of new clinical research on fiber benefits combinedwith poor understanding of the effects of low fiber intake havegiven fiber less prominence as a nutrient of concern by healthprofessionals. Recommendations for fiber intake in the 2010DGA are based primarily on achieving nutrient density, ratherthan physiologic benefits. Although much of what we knowabout fiber’s effects on health is based on observational data,most of the clinical studies of fiber’s physiologic benefits havebeen conducted using isolated forms of fiber rather than whole,fiber-containing foods (7,15). Current dietary guidance, whichemphasizes foods that contain naturally occurring fiber, disre-gards clinical research outcomes that use isolated fibers todemonstrate health benefits, which are the same fibers usedwhen adding fiber back to grain foods. Yet, intact fiber in foodsis typically perceived as healthier and accepted as providinghealth benefits without undergoing the same clinical scrutiny todemonstrate these effects. The 2010 DGA call attention todietary fiber that occurs naturally in foods as helping to reducethe risk of heart disease, obesity, and type 2 diabetes and asessential for optimal digestive health. In its advice to consumefoods naturally high in dietary fiber, however, the DGAoverestimate the ability of these foods to meet fiber needs intypical diets, and undervalue the potential role and contributionof foods that contain added fiber.

Whole grains, fiber, and health. The health-protectivemechanisms of whole grains are complex and are likely due tothe interaction between fiber, minerals, antioxidants, andbioactive compounds (32). Epidemiologic studies have sug-gested an association between higher intakes of whole grain andreduced risk of heart disease, certain types of cancer, type 2diabetes, and obesity (33). However, recent research suggeststhat not all whole grains exert the same effects (34,35). A reviewexamining the association between whole grains, based on theFDA definition, and reduction in risk for cardiovascular diseasefound an association, but only when the definition of wholegrains was broadened to include studies using fiber-rich bran andgerm (36), which suggests that the fiber components of wholegrains deliver the key benefits. Although whole grains arebelieved to play an important role in the diet beyond fiber (33),

FIGURE 1 Daily fiber intakes per indi-

vidual, compared with recommended in-

takes. Values are means 6 SEM, n =

8529, estimated from Day 1 dietary recall

interviews conducted in What We Eat in

America, NHANES 2007–2008. The 24-h

recalls were conducted in person, by

trained interviewers, using the USDA 5-

step Automated Multiple-Pass Method.

Food intakes were coded, and nutrient

values were determined using the USDA

Food and Nutrient Database for Dietary

Studies 4.0, which is based on nutrient

values in the USDA National Nutrient

Database for Standard Reference, Re-

lease 22. Intakes of nutrients are based

on the consumption of food and bever-

ages and do not include intake from

supplements or medications. Mean fiber intakes for individuals aged $2 y do not include breast-fed children. Data are from (7,13).

TABLE 3 Expected fiber in USDA food groups/subgroups1

Food group Serving Mean fiber

g/serving

Fruit 0.5 cup 1.1

Dark-green vegetables 0.5 cup 2.1

Orange vegetables 0.5 cup 2.1

Cooked dry beans (legumes) 0.5 cup 6.0

Starchy vegetables 0.5 cup 1.7

Other vegetables 0.5 cup 1.1

Whole grains 28 g (1 oz) 2.4

Refined grains 28 g (1 oz) 0.7

Meat 28 g (1 oz) 0.1

1 From (21). Mean fiber reflects fiber amounts of the food group or subgroup

composite, a representation of the foods contained in the group in amounts that

correspond to relative consumption. Fiber data derived from USDA National Nutrient

Database for Standard Reference, Release 17.


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this point is often overlooked in dietary guidance that emphasizesconsumption of whole grains as a primary way to increase fiberintake. To help differentiate and reduce confusion, there is a needin future research and education to clearly delineate between“whole grains” and “fiber” to avoid the interchange of the food(whole grains) with the nutrient (fiber) and to provide clearerdirection for choosing grain foods that provide at least a goodsource of fiber, an idea yet to be embraced by policymakers. Forexample, the recently released Nutrition Standards in theNational School Lunch and School Breakfast Programs includenew directives that all grains must be “whole-grain rich” within2y after implementation (37), yet do not address a fiber re-quirement for defining a food that is “whole-grain rich.” By notusing fiber as a marker of whole-grain quality, the roundtableexperts considered this to be a missed opportunity for clarifyingthe role of fiber in providing key health benefits in whole grains.

Confusion about “good sources” of fiberThe roundtable experts discussed how current fiber and whole-grain recommendations may have unintended consequences ofmaking it more challenging to achieve adequate fiber intakes.For example, dietary guidance emphasizes eating more ofspecific foods to achieve fiber recommendations, including fruit,vegetables, legumes, and whole grains, yet many of the foods inthese categories are not considered a “good” or “excellent”source of fiber based on FDA labeling definitions. Some naturallyoccurring fiber-containing foods are also higher in moisture,including many fruit and vegetables, and contain only 1–3 g offiber per serving. This is illustrated in the mean fiber content perserving for food groups/subgroups on the basis of typicalconsumption, which is used to assess adequacy of the USDA’sfood intake patterns (Table 3).

Results from an analysis of consumers’ fiber sources foundthat adults’ mean intake of 13.8 g fiber/d comes from ;25different food items in a single day, including a variety of foodssuch as vegetables, sandwiches, fruit, ready-to-eat cereals, andpotatoes (38). Although white flour and white potatoes providethe most fiber in the U.S. food supply, these are not concentratedfiber sources but instead are widely consumed foods (16,39).Foods that provide at least a “good” or “excellent” source offiber include most legumes, foods that contain additional bran,or foods that include other added-fiber ingredients. By empha-sizing whole, plant-based foods in dietary guidance, consumershave the perception that they can achieve recommended fiberintakes by choosing a variety of fruit, vegetables, andwhole grains.In reality, meeting recommended fiber intakes requires a carefulselection of foods within food groups, which includes the challengeof first meeting recommended daily servings and then choosingfoods that provide fiber in the upper range for that food group.

Moreover, any increase or addition of fiber-containing foodsmust be paired with other dietary trade-offs to avoid exceedingenergy needs, a critical consideration in today’s nutrition en-vironment. A modeling study examined the effects on fiberintake and calories when currently consumed fiber-containingfoods (grains, vegetables, fruit) increased by 10, 25, 50, or100% (4). Although fiber intakes increased from 16.9 to 29.5g/d, there was a concurrent energy increase ranging from 104–1042 kcal/d. This illustrates the concern with simply advisingconsumers to increase their intakes of fiber-containing foodswithout consideration of energy needs.

Fiber amounts in different whole grains vary widely, yet thereis a perception among consumers and health professionals thatwhole grains deliver substantial amounts of fiber. A study thatsurveyed food and nutrition professionals and groups of

consumers found that most believed the major benefit of eatingwhole grains was for the fiber (40). Consumer research indicatesthat Americans are indeed seeking out whole-grain food choicesfor the purpose of getting more fiber and for the health benefitsassociated with adequate whole-grain and fiber intakes. The2010 Food and Health Survey conducted by the InternationalFood Information Council found that ;7 out of 10 Americansare trying to consume more fiber (72%) and whole grains (73%)(41). Similar findings were reported by the Academy of Nutritionand Dietetics (formerly the American Dietetic Association) 2011Trends Survey, with nearly half of American adults reporting theyhave increased their consumption of whole grains compared withother foods over the past 5 y (42).

Whole-grain labeling and content do not guarantee fiberThe roundtable experts agreed that whole-grain labeling offoods may be a source of consumer confusion regarding fibercontent. There has been a proliferation of packaged foods thatboast their “whole grain” content, estimated by the WholeGrain Council as a 20-fold increase in the number of new whole-grain product launches from 2000 (164 new products) to 2010(3272 new products) (43). However, this has not translated toincreased whole-grain and fiber intakes, despite a recommenda-tion, beginning with the 2005 DGA, that all age groups shouldconsume at least half of their grain servings as whole grains tohelp increase fiber intakes. At the same time, it has becomeincreasingly clear that labeling claims for “fiber” and “wholegrain” may be synonymous in the minds of consumers (38). Yet,all whole-grain foods do not qualify as a “good” source of fiber.A web-based study in 1000 adults was conducted to measureperceptions and understanding of the relationship betweenwhole grains, fiber, and potential health benefits. This researchfound that 85% of respondents believed that if a product in-dicates it is made with whole grains, then it also contains at leasta good source of fiber (38).

There is also contradiction in consumers’ perceptions ofwhole-grain products and the actual amounts of fiber deliveredby products that contain whole grains. A marketplace audit wasconducted of nationally distributed ready-to-eat cereals withwhole-grain claims, such as “made with whole grains,” “rich inwhole grains,” and “whole grain guaranteed” during a 3-yperiod from 2005 to 2008 (38). The fiber content in the 72cereals analyzed ranged from 0 to 11 g/serving, with nearly halfof the cereals containing less than the minimum amount of fiberto be labeled as a “good” source of fiber. Approximately 60% ofthese cereals with whole-grain claims that provided less than a“good” source of fiber contained #1 g of fiber. With evidencethat consumers are seeking out more whole-grain products withan expectation of obtaining fiber, this scenario has the potentialto create the unintended consequence of increased energy intakewithout a substantial increase in fiber intake.

The misunderstanding of whole grains and fiber is likely duein part to a lack of clear and consistent labeling of whole-graincontaining products. The FDA issued “draft guidance” forwhole-grain label statements in 2006, but these are yet to befinalized (44). Although this guidance allows manufacturers tomake factual statements about the amount of whole grain,content claims (e.g., good or excellent source of whole grains)are not approved, with the rationale that source claims forwhole-grain content are considered to be implied claims aboutfiber content and may be misleading. Despite the lack of labelingguidelines for whole grains, the FDA approved a health claimlinking diets rich in whole-grain foods and other plant foodswith reduced risk of heart disease and certain cancers (45).

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Foods that bear the whole-grain health claim are required tocontain $51% whole-grain ingredients by weight per referenceamount and to meet criteria for fat and cholesterol, but there isnot a minimum requirement for fiber content. Likewise, the“Whole Grain Stamp,” a popular icon developed by the WholeGrains Council, allows a food that contains$8 g (0.5 serving) ofwhole grains to qualify for using the basic stamp or that containsa minimum of 16 g of whole grain per serving to qualify for thealmost identical stamp, “100% Whole Grain” (46). However,the product’s fiber content is not part of these requirements.

Sensory, attitudinal, and economic factorsIn the roundtable discussions, it became clear that multiple levelsof influence affect behaviors that determine fiber intake. TheInternational Food Information Council’s 2011 Food andHealth Survey indicated that taste and price are the primaryfactors influencing purchasing decisions for foods and beveragesoverall (47). Healthfulness was the third most important factor,with convenience following closely behind. When asked aboutbarriers to consuming functional foods, consumers identified ex-pense, taste, and availability/convenience as the top 3 barriers(47). Sensory barriers to increasing fiber intake, particularly fromwhole-grain foods, include taste, texture, color, and moisturecontent in addition to the perception that cost is greater (48).Consumers and marketers tend to have a negative perception ofthe taste and texture of fiber, with marketing that often focuses onhow specific fiber-containing foods do not taste like “cardboard”and actually taste good.

For consumers who may choose to reduce or control theirintake of carbohydrates, such as individuals with diabetes orthose attempting to manage their weight, fiber intake may becompromised based on the false assumption that carbohydrate-containing foods are unhealthy and should be limited. In fact,research supports the use of lower energy/fat diets with $25 gfiber/d over low-carbohydrate diets for people with diabetes andfor weight loss (49). With regard to blood glucose control inpeople with diabetes, it is generally believed that an increasedfiber intake helps to modulate blood glucose (2), but this effect isgenerally not seen with typical fiber intakes of ,24 g/d (50).

In an effort to change attitudes and behaviors, educators andcommunicators often take a binary approach, suggesting thesame solutions to ongoing problems, such as the general adviceto “choose more fruit, vegetables, and whole grains to improvefiber intakes.” Although this not only limits innovation, it alsonarrows the scope of the problem and prevents new solutionsfrom being considered, such as the use and acceptance of addedfiber in foods that Americans already consume. In the case of fiber,improving outcomes must go beyond approaches that simply focuson increasing knowledge. Consumers need to value fiber and havereasons to care about eating more fiber. They also need skills forhow to select and prepare good-tasting foods with more fiber.

Agricultural and economic challenges are important consid-erations in meeting recommendations for increasing intakes offruit, vegetables, and whole grains. To support the production ofcrops needed to supply adequate amounts of produce and grains,millions of additional acres of cropland would be required (51),making it unlikely that current production of whole grains couldsupply the quantities needed to meet recommended intakes.

Opportunities to Fill the Fiber Intake Gap

After discussing the obstacles consumers encounter in meetingcurrent fiber recommendations, the roundtable experts focusedon identifying opportunities to improve intakes of fiber to help

close the gap between current and recommended fiber con-sumption. The discussions centered around understanding andaddressing consumer attitudes and behaviors, whole-grainlabeling reform, focusing on all types of fiber, optimizing eatingoccasions, and education and resources for health professionals.

Meet consumers where they are to overcome barriersThe roundtable experts emphasized the importance of takingconsumers’ current understanding and dietary behaviors intoaccount to help them overcome the barriers they face inincreasing their fiber intake. This requires segmenting the targetaudience and providing small-step guidance that is realistic andaddresses their unique concerns. Recognizing that consumersalready meet recommendations for total grains makes this animportant area of focus. Simple swaps from low-fiber grainchoices to whole grain or fiber-added enriched grains with atleast a “good” source of fiber offer a way to boost fiber intakewithout affecting energy intake and do not require a consider-able behavior change. Breaking down the barriers of taste,texture, cost, and convenience may prove that fiber-containingfoods can be accessible, tasty, and affordable. Sampling, demon-strations to show how to increase fiber in food preparation, anduse of coupons are ways to expose consumers to less familiarfiber-containing foods. Incentives for increasing fiber werediscussed, with agreement that fiber for weight managementand health benefits for children and families were strategies thatwould be most likely to motivate consumers.

Fiber for weight management. The 2010 DGAwere releasedat a time of rising concern about the health of Americans, withrecognition that nutrient-poor intakes and physical inactivityhave contributed to the obesity epidemic in American adults andchildren. The DGA clearly point out the need to focus on main-taining energy balancewhile consumingmore nutrient-dense foodsand beverages. This dichotomy of getting more nutrients for fewerkilocalories is a concept that consumers need to understand andimplement. Unlike several other nutrients of concern—calcium,potassium, and vitamin D—fiber is unique in that different types offiber are associated with varying health benefits, and adequateintakes of this nutrient also play a role in weight management(16,30).

A recent study evaluating the effect of consumption of totalfiber and types of fiber on the prevalence of overweight andobesity found that total fiber intake is inversely related to BMI,waist circumference, and percentage of obesity (29). The inverserelationship between fiber intake and body weight was morepronounced for cereal fiber compared with fruit and vegetablefiber, which may be a factor in the low consumption of fruit andvegetables and the inconsistent association between fruit andvegetable intake and adiposity (27,52). Fiber is believed to play arole in weight management by slowing digestion, contributing tosatiety, and subsequent reduced energy intake (30). In addition,higher fiber intakes may delay digestion of other macronutrientsin the small intestine, and reduce postprandial blood glucose,which improves insulin sensitivity and favors fat oxidation(30,53).

In children, a lower risk of overweight and obesity withincreased fiber intake has been observed (54). This investigationusing national intake data found that children who consumehigh amounts of fiber consume large amounts of lower-fiberfoods, such as French fries and pizza. Thus, establishing theevidence for a beneficial effect of fiber intake on children’s healthis confounded by the fact that children who meet the intakerecommendations are likely overconsumers and are therefore


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overweight or obese. In communications to improve fiberintakes, a focus on the benefit of managing weight is a strategyfor getting the attention of consumers, including parents ofoverweight children, who have concerns about weight.

Health benefits for children and families. Fiber recommen-dations for children vary, whether based on energy needs, age, orweight, due to the fact that effects of fiber on child health havenot been studied closely. However, evidence suggests thatreducing constipation, obesity, and type 2 diabetes could beachieved in children with increased intakes of fiber (31). Becausechildren’s dietary intake patterns are likely to track into adult-hood, increasing fiber intakes during the earlier years of lifepresents an opportunity to improve children’s health andpotentially influence their health as adults in a positive way.

Fiber is consistently consumed at inadequate levels by mostpreschool-aged children, yet in a study in which children wereprovided with higher-fiber snacks and lunch items in a day caresetting, they were found to try and like these foods, with theresult of higher daily intakes of fiber (55,56). Interestingly, parentsand child care providers may make the assumption that theirchildren will not like certain fiber-containing foods, with theunintended consequence of limiting their fiber intakes along withother nutrients of concern. Although it has been shown thatchildren prefer familiarity and consistency in their diets, and maybe reluctant to try new foods, exposing children to a variety offiber sources beginning in the first years of life makes them moreaccepting of novel foods (31,57,58). Other options for parents areto add fiber to foods that children like, such as using whole-wheatflour in baked goods or substituting whole-grain versions ofcrackers, chips, and pizza crust in place of lower-fiber products.

An added outcome associated with consuming higher fiberfoods is greater intake of other nutrients and the improvement ofdiet quality (17), which in turn may potentially affect weight andhealth. Furthermore, if children accept and like a new food, itoften leads to children requesting the new foods at home; thus,parents may change their dietary habits to match their children’slikes. Home availability and accessibility of foods such as fruit,vegetables, and whole grains can be an important factor inimproving consumption (59). This underscores the importanceof helping parents learn how to select whole-grain foods thatprovide a good source of fiber (60).

Call for clear and consistent labeling of fiber inwhole-grain foodsA critical need identified by the roundtable experts to helpimprove fiber intakes from grain foods is to develop clearer,universal messaging that also focuses on the fiber content inwhole-grain products. This could help address the confusionaround fiber and whole grains and may help promote greaterfiber intakes from all grain products, including whole grains andenriched grains with added fiber. The 2010 Dietary GuidelinesAdvisory Committee acknowledged that there is no consistentway that whole-grain foods are defined and determined, andidentified developing a universally accepted definition andcriteria for “whole-grain foods” as an area for future research(2). Defining what constitutes a whole-grain food would allowconsumers to better identify foods that can help them meetrecommendations for whole grain and fiber, and it would allowcomparison of research studies examining the effectiveness ofwhole grains, independent of fiber content, on biomarkers andhealth conditions, such as cardiovascular disease, diabetes, andobesity (2).

Currently, the FDA’s draft guidance allows food manufac-turers to include factual statements about whole grains onpackage labels, such as “8 grams of whole grains” or “100%whole grains” (44), which consumers tend to equate with claimsabout fiber content. This lack of clarity in whole-grain labelingmay be feeding the confusion around fiber and whole grains,with the unintended consequence of exacerbating the fiberdeficit. Eligibility criteria for whole-grain claims based on theamount of fiber per serving is a logical approach that would helpto inform and reinforce the expectation that whole-grainproducts can deliver a good source of fiber.

Label statements on whole-grain products that include aqualifying statement to highlight total fiber could bring greaterprominence to the fiber content while reinforcing whole grainsas a source of varying amounts of fiber. The use of food labels tomake purchasing decisions is linked to healthier eating, withhigher fiber intakes among food label users (61). In recognitionthat every gram of fiber counts toward reaching daily fiber goals,teaching consumers to check for fiber on a product’s NutritionFacts label is a simple action to help determine fiber content,especially for products that note their whole-grain content. Thisencourages consumers to pay closer attention to fiber amounts intheir typical food choices and promotes selection of whole-grain-containing foods with greater amounts of fiber per serving.

Focus on all forms and sources of fiberThe roundtable experts agreed that more emphasis needs to beplaced on consuming adequate fiber, whether intrinsic or added.Regardless of whether fiber occurs naturally in food or is added,both forms become part of the total fiber content of the food,referred to as Total Fiber by the IOM, and the amount reflectedon the Nutrition Facts label (7). Similarly, DRI recommenda-tions and fiber definitions from the American Association ofCereal Chemists and Codex address dietary fiber without dif-ferentiation of amounts of naturally occurring and added fibers.Thus, it is logical that recommendations for obtaining fiber fromfood should be inclusive of all types of fibers (intrinsic andadded).

Adding nutrients to foods to promote positive health benefitsis a practice that is well accepted and has been successful inreducing nutrient deficits. With folic acid, for example, fortifi-cation of widely consumed grains has raised intake of thisnutrient to more desirable levels, with subsequent reduction inrates of neural tube birth defects (62). A recent analysis of usualintakes of micronutrients in individuals aged 2 y found thatmany Americans would not achieve the recommended micro-nutrient intake levels set forth in the DRI recommendationswithout enrichment, fortification, or supplementation (63).Compared with intakes from naturally occurring nutrients,enrichment and/or fortification dramatically improved intakesof several key nutrients, including folate, thiamine, iron, andvitamins A and D. The 2010 DGA acknowledge that “fortifiedfoods and supplements may be useful in providing one or morenutrients that otherwise might be consumed in less thanrecommended amounts” (3). Although extensive fiber fortifica-tion of food was not considered a solution, roundtable partic-ipants agreed that adding fiber lost in processing back toenriched grains or adding to the fiber that is naturally present inwhole-grain foods are realistic and potentially impactful solu-tions. As a nutrient of concern, total fiber content could be usedto establish the quality of a grain food.

The IOM acknowledges that consuming fiber from a varietyof sources with the objective of increasing total fiber intakeoffers varying health benefits specific to the fiber source (Table

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4). Certain sources of fiber deliver more than physiologicbenefits and also offer functional and/or nutritional properties.Growing recognition of the positive benefits of different types offibers, both intrinsic and added, has contributed to a greater useof isolated fibers as food ingredients, particularly in grain foods.

Achieve energy balance with added fiber in grain-basedfoods. In its recommendations for grain foods, the 2010 DGAadvise that at least half of total grain intake should be fromwhole grains, with the remaining from enriched grains. Wholegrains are recognized in the DGA as a source of nutrients suchas iron, magnesium, selenium, B vitamins, and fiber, with thecaveat that whole grains vary in their fiber content. The DGAacknowledge that whole grains higher in fiber have additionalhealth benefits but offer little advice on strategies to consumefoods with added fiber despite mounting evidence and recogni-

tion that isolated fibers also exert important physiologic healthbenefits (6). This signifies the need for additional research andeducation to create greater awareness of the benefits andimportance of added fiber as a strategy for filling the fiber intakegap.

Current recommendations to increase fiber intake pose achallenge to consumers who also need to manage energy intakewhile maximizing nutrient intake. All grain-based foods, in-cluding whole- and enriched-grain products, are logical vehiclesfor added fibers because intakes of grain-based foods alreadymeet daily recommendations. A modeling study using intakedata obtained from NHANES 2003–2006 simulated variousapproaches to increasing fiber in Americans’ diets and measuredthe effect on total energy intake when whole-grain intakeincreased and when fiber was added to grain foods already beingconsumed (4). The addition of 2.5 or 5.0 g of fiber per serving to

TABLE 4 Types, effects, and sources of fiber ingredients

Isolated, modified, or synthesizedfibers added to foods Main physiologic effects

Usually isolated orderived from

b-Glucan and oat bran Blood lipid lowering Oats and barley

Attenuates blood glucose response

Cellulose Laxation Plant foods

Chitin/chitosan Blood lipid lowering (as seen in animal studies) Fungi or shellfish

Guar gum Blood lipid lowering Guar bean (legume)


Short-chain fructooligosaccharide, including inulin,

oligofructose

Laxation Chicory root

Gut health Jerusalem artichoke

Microbiota modulation toward a more healthful community Synthesized from sucrose

Blood lipid lowering

Galactooligosaccharide (64,65) Gut health Legume extract

Microbiota modulation toward a more healthful community Dairy products

Immune system modulation Human milk

Pectin Blood lipid lowering Plant foods


Polydextrose Laxation Synthesized from dextrose

(glucose)

Psyllium Laxation Psyllium husk (plant)

Blood lipid lowering


Resistant dextrins Blood lipid lowering Corn and wheat


Resistant starch Laxation Plant foods

Gut health

Attenuates blood glucose response when substituted for

digestible carbohydrates

Soluble corn fiber (66) Attenuates blood glucose response Corn

Gut health

Wheat bran Laxation Wheat


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grain foods low in fiber resulted in fiber intakes of 24.7 and 39.1g/d, respectively, without an increase in energy intake. Increasingconsumption of currently available whole-grain foods to therecommended levels increased fiber intake in all adults to 25.3 g/d, but with an additional increase in energy of 1266 kcal/d (4).

Optimize eating occasions with the greatest potentialimpactNational eating-occasion data (NHANES 2007–2008) showsthat breakfast and snacks contribute 18% and 21%, respec-tively, to the total daily fiber intake of Americans, comparedwith lunch (25%) and dinner (36%) (67). These findingsillustrate the potential for focusing on breakfast and snackingas eating occasions to help consumers increase fiber intake.Eating breakfast has been associated with managing bodyweight, higher -quality diets, and cognitive performance, espe-cially in children (68–72). It also offers an opportunity toconsume fiber and whole grains, which have the potential toenhance overall diet quality and offer satiety (24,30). Theseimportant benefits combined with the wide variety of breakfastfoods available that provide fiber, such as whole-grain and fiber-added cereals and breads, give breakfast the potential formaking a substantial impact on increasing fiber intakes in bothchildren and adults. Additional choices for higher-fiber breakfastitems “on the go” and tips for easy substitutions can help toincrease the fiber contribution of the breakfast meal.

Snacks offer another opportunity for increasing fiber con-sumption, especially for children, with an array of snack-foodchoices, whole-grain and/or fiber-added crackers, chips, bakedgoods, and granola bars. As with any unfamiliar food, childrenare more likely to enjoy higher-fiber snack foods when they areexposed at an earlier age, and when influential adults such asparents, caregivers, teachers, and coaches model healthy higher-fiber snacking habits. Cultural food practices should also beconsidered in fiber education. For example, some Latinos usecereals as a snack food and add grains to beverages (e.g., batidode trigo and atole).

Health professional education and resourcesThe roundtable discussions underscored the importance ofreaching consumers with accurate and practical informationabout fiber. To do this, health professionals must understand thesignificance and potential long-term consequences of the fiberdeficit, and their pivotal role in helping consumers makenecessary changes to increase fiber intakes through both naturallyoccurring and added fiber sources. As research continues toexplore the mechanisms and benefits of fiber and whole grains,including sources of isolated/added fibers, health professionalswill need resources to stay current in their knowledge of fiber aswell as practical tools for working with consumers. An onlinesurvey (unpublished results, Kellogg Company, August 2010) of150 registered dietitians (RD) in general or medical practicespecialty groups revealed that fiber from natural, whole-foodsources was preferred by RD participants for addressing the fiberdeficit. There was general consensus among the RD participantsthat adding fiber to foods is also an acceptable option,particularly when fiber is added to traditional sources of fiber,including breads, ready-to-eat cereals, and cereal bars. Yet, RDparticipants expressed concern that some fiber-added foods maynot offer the same benefits as natural fiber sources. With regardto whole grains, .90% of the RD participants surveyedexpected that “whole-grain labeled products” will provide atleast a good source of fiber (3 g/serving).

To help RD and other health professionals overcome theseknowledge gaps and improve their communications with con-sumers, the roundtable experts recommended several key strategies:

� Develop continuing education modules to address the latest

research on fiber, with emphasis on the importance of fiber variety

and the physiologic value of all types of fiber, whether intact or

added, in providing beneficial effects. Additional learning on theregulatory aspects of nutrient claims related to fiber, and how to

use language consistent with approved regulatory guidance,

particularly for whole grains, was also recommended.

� Debunk common myths about fiber, including the belief thatwhole grain is equivalent to fiber, and concerns about added-fiber

sources, such as isolated and synthesized fibers. Help consumers

understand that all types of fiber deliver important physiologicbenefits, and become familiar with the types of ingredients that

may be used to add fiber to grain-based foods.

� Acquire and use cultural competency skills to better understand

how to address fiber in typical food choices, practices, andbehaviors of ethnic groups and develop culturally appropriate

programs and messages to optimize fiber intakes.

� Offer practical, “how to” guidance to show consumers how to

select and serve foods that provide fiber. For example, samplemenus can illustrate how small changes in food choices, including

use of foods with added fiber, can add up to dramatic changes in

daily fiber intakes while controlling energy intake (73).� Address consumer concerns with taste, time, and cost, which may

include showing how to prepare foods with more fiber through

recipes and food demonstrations, food budgeting and shopping to

address cost concerns of fiber sources, and meal planning usingMyPlate resources (e.g., ChooseMyPlate.gov) to show how to

incorporate a variety of fiber sources into daily meals. Recognize

the importance of meeting consumers where they are with their

dietary and lifestyle behaviors, and encourage them to makeincremental small changes that can have a dramatic impact on

improving diet quality, including increasing fiber intake, without

consuming additional calories (74).� Emphasize label reading as an essential skill for selecting grain

foods, with fiber content recommended as a marker for comparing

and choosing grain foods, including whole grains. A simple

criterion such as “choose grain foods with at least 3 g of fiber (orwith $10% of the Daily Value) per serving” offers a straightfor-

ward strategy for consumers to make an informed decision about

both whole-grain products and added-fiber foods.

Closing the fiber intake gap will require involvement byvarious sectors of influence, including educators, health andculinary professionals, policymakers, and the food industry.Continued discussion and exploration of the potential benefits ofall fiber sources will help support development of clear andconsistent messages to reinforce the importance of adequatefiber intakes. Additional resources, including review papers andposition statements, can provide support for the variety of fibersources and address needs for research and educational tools onall types of fiber, including naturally occurring and fibers addedto foods. Industry can be leveraged as a resource to help supportneeds for research and education with objective, applicable, andpractical information for students and practitioners. Industrycan also play a role in increasing fiber intakes through productinnovation with development of good-tasting and affordablefoods that provide fiber, including adding fiber to lower-fiber,nutrient-dense grain-based foods.

Summary

Fiber’s essential role in optimal health creates an urgency to helpAmericans overcome the barriers that hinder adequate fiber

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intakes. There was consensus among roundtable participantsthat grain foods offer a unique opportunity to help Americansincrease their fiber intakes. With current grain intakes at orslightly above recommended amounts, making simple changesto choose grain foods with a good or excellent source of fibermay be the most realistic and impactful way to help Americansmake immediate progress toward filling the fiber intake gapwhile staying within energy needs. The roundtable expertsagreed that an energy-neutral strategy to increase fiber intakes isadding fiber back to selected enriched grain foods when it waslost in processing or adding more fiber to whole-grain products.

Roundtable participants acknowledged the importance ofmeeting daily recommendations for other fiber-containing foodssuch as fruit, vegetables, and legumes, yet recognized that in-creasing intakes of these foods to recommended amountsrequires more complex behavior changes, including how toincrease servings of these foods while reducing intakes of otherfoods to stay within daily energy goals.

The roundtable concluded with several key statements thatframe the current fiber intake situation and that provide realisticsolutions to close the fiber intake gap:

� Americans’ fiber intake is a public health concern for both adults

and children, with potential consequences that may increase therisk of several chronic diseases and obesity. Although fiber is

recognized by the 2010 DGA as a nutrient of concern, recom-

mendations to improve fiber intakes focus on increased consump-

tion of fruit, vegetables, and whole grains, with little recognitionof the effect on total energy intake and the positive role of adding

fibers to foods to help close the fiber intake gap. With increased

emphasis on energy balance, added fiber in select grain-basedfoods is a practical and energy-neutral solution.

� All forms and sources of fiber, including intrinsic and added fiber,

can play a role in closing the fiber intake gap. The 2009 Codex

definition of fiber acknowledges dietary fiber as naturally occur-ring, isolated from food, or synthetically derived (9). This

recognizes the contributions of both intrinsic and added fiber,

thus giving value to all sources of fiber.

� Small changes in eating patterns—and to foods people alreadyenjoy—can help to increase fiber intakes without increasing energy

intake. Meal occasions with the most potential for increasing fiber

intake are breakfast and snacks.� Use of fiber as a marker for grain-based food quality offers a

practical way to identify grain-based foods that provide a good

source of fiber (3 g/serving), including whole grains and enriched

grains with added fiber. Using “whole grain” to characterize onlygrain-based food quality does not tell the complete nutritional

story because many whole-grain products are not good sources of

fiber.

� Eligibility criteria for whole-grain labeling claims based on theamount of fiber per serving would help to inform and reinforce the

expectation that whole-grain products vary in their fiber content

and, with careful selection, they can deliver a good source of fiber.

� There are opportunities to educate health professionals and otheradvocates with proof that illustrates how all fiber sources have

important health benefits and can contribute to filling Americans’

fiber intake gap.

AcknowledgmentsAll authors contributed to the meeting presentations and fullyparticipated in roundtable discussions, which was the basis forthe article. The authors thank Betsy Hornick, Supplement Coor-dinator, for developing a manuscript based on the authors’contributions and their discussions at the Fiber Roundtable. Allauthors contributed content to the article based on their individualexpertise as follows: R.C. contributed content related to foodscience, agricultural implications, and Dietary Guidelines for

Americans insights; J.L.S. contributed content related to fiberbenefits and its physiologic role and Dietary Guidelines forAmericans insights; T.A.N. contributed content related to foodmodeling with added fibers; S.K. contributed content related tochildren’s nutrient needs and increasing fiber intakes amongchildren; A.R.M. contributed content related to behaviorchange needs and modeling; H.W. contributed content relatedto diabetes; J.C.R. contributed content related to education andhealth professional outreach; and M.P.R. contributed contentrelated to nutrition policy and health professional education.All authors had responsibility for final content. All authors readand approved the final manuscript.

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