Fat is the most valuable food known to Man May 26, 2011

Posted by ADAM PARTNERS in High Fat Low Carb Diet.
Tags: Adenosine triphosphate, Adipose tissue, Carbohydrate, Fat, Fatty acid, Ketone, Ketone bodies, Low-carbohydrate diet, Muscle, Protein
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PROFESSOR JOHN YUDKIN

Introduction

We now know that we should eat a diet that is low in carbohydrates. But a plethora of books published in the last decade have been low-carb, high-protein, or low-carb, high-fat, or low-carb, high-‘good’-fats, or all sorts of other mixtures. In other words, the real confusion lies in what we should replace the carbohydrates with: for example, should it be protein or fats? And if fats, what sort of fats? This article, I hope, will answer the question and put any doubts out of your mind. In a nutshell, carbs should be replaced with fats, and those fats should be mainly from animal sources.

Our bodies use carbs for only one purpose: to provide energy. When we cut down on carbs, the energy our bodies need has to come from somewhere else.

There are only two choices: Protein or fat. ATP: our bodies’ fuel.

The fuel that our body cells use for energy is actually neither glucose nor fat, it is a chemical called adenosine triphosphate (ATP). A typical human cell may contain nearly one billion molecules of ATP at any one moment, and those may be used and re-supplied every three minutes.[i] This huge demand for ATP, and our evolutionary history, has resulted in our bodies’ developing several different pathways for its manufacture.

Oxygen and mitochondria

Living organisms have two means to produce the energy they need to live. The first is fermentation, a primitive process that doesn’t require the presence of oxygen. This is the way that anaerobic (meaning ‘without oxygen’) bacteria break down glucose to produce energy. Our body cells can use this method. The second – aerobic (meaning ‘using oxygen’) – method began after the Earth began to cool down and its atmosphere became rich in oxygen. After this event, a new type of cell – a eukaryotic cell – evolved to use it. Today all organisms more complex than bacteria use this property and all animal life requires oxygen to function. When we breathe in, our lungs are used to extract the oxygen in air and pass it to the bloodstream for transport through the body. And in our bodies, it is our body cells’ mitochondria – little power plants that produce most of the energy our bodies need – that use this oxygen. The process is called ‘respiration’. This process takes the basic fuel source and oxidises it to produce ATP. The numbers of mitochondria in each cell varies, but as much as half of the total cell volume can be mitochondria. The important point to note is that mitochondria are primarily designed to use fats.

Which source of base material is best?

The question now, in this era of dietary plenty, is: Which source is healthiest? There are three possible choices:

glucose, which comes mainly from carbohydrates, although protein can also be utilised as a glucose source by the body if necessary;
Fats, both from the diet and from stored body fats;
Ketones which are derived from the metabolism of fats

Not all cells in our bodies use the same fuel.

Cells that can employ fatty acids are those that contain many mitochondria: heart muscle cells, for example. These cells can make energy from fatty acids, glucose, and ketones, but given a choice, they much prefer to use fats.

Cells that cannot use fats must use glucose and/or ketones, and will shift to preferentially use ketones. These cells also contain mitochondria.

But we also have some cells that contain few or no mitochondria. Examples of cells with few mitochndria are white blood cells, testes and inner parts of the kidneys; and cells which contain no mitochondria are red blood cells, and the retina, lens and cornea in the eyes. These are entirely dependent on glucose and must still be sustained by glucose.

This means that when we limit carb intake, the same energy sources must be used, but a greater amount of energy must be derived from fatty acids and the ketones derived from fatty acids, and less energy from glucose.

Sources of glucose

To understand how a low carb diet works, we need to look at how we eat. This process is one of eating, digestion, hunger and eating again. During our evolution, we also must have experienced long periods when food was in short supply and we starved. This is a pattern our bodies are adapted to. And they have developed mechanisms to cope with a wide range of circumstances.

Firstly, the human body must contain adequate levels of energy to sustain the essential body parts that rely on glucose. The brain and central nervous system may be a particular case as, although the brain represents only a small percentage of body weight, it uses between twenty and fifty percent of all the resting energy used by the body.[ii] Fortunately the brain can also use ketone bodies derived from fats. During fasting in humans, and when we are short of food, blood glucose levels are maintained by the breakdown of glycogen in liver and muscle and by the production of glucose primarily from the breakdown of muscle proteins in a process called gluconeogenesis, which literally means ‘glucose new birth’.[iii]

But we don’t want to use lean muscle tissue in this way: it weakens us. We want to get the glucose our bodies need from what we eat. Some of that will come from carbs, the rest from dietary proteins. Our bodies need a constant supply of protein to sustain a healthy structure. This requires a fairly minimal amount of protein: about 1 to 1.5 grams per kilogram of lean body weight per day is all that is necessary to preserve muscle mass.[iv] Any protein over and above this amount can be used as a source of glucose.

Dietary proteins are converted to glucose at about fifty-eight percent efficiency, so approximately 100g of protein can produce 58g of glucose via gluconeogenesis.[v] During prolonged fasting, glycerol released from the breakdown of triglycerides in body fat may account for nearly twenty percent of gluconeogenesis.[vi] Body fats are stored as triglycerides, molecules that contain three fatty acids combined with glycerol. The fatty acids are used directly as a fuel, with the glycerol stripped off. This is not wasted. As the glycerol is nearly ten percent of triglyceride by weight and two molecules of glycerol combine to form one molecule of glucose, this also supplies a source of glucose.

The case for getting energy from fat and ketones

When most people think of eating a low-carb diet, they tend to think of it as being a protein-based one. This is false. All traditional carnivorous diets, whether eaten by animals or humans, are more fat than protein with a ratio of about eighty percent of calories from fat and twenty percent of calories from protein. Similarly, the main fuel produced by a modern low-carb diet should also be fatty acids derived from dietary fat and body fat. We find in practice that free fatty acids are higher in the bloodstream on a low-carb diet compared with a conventional diet.[vii] [viii]

But fats also produce an important secondary fuel: ‘ketone bodies’. Ketones were first discovered in the urine of diabetic patients in the mid-19th century; for almost fifty years thereafter, they were thought to be abnormal and undesirable by-products of incomplete fat oxidation. In the early 20th century, however, they were recognised as normal circulating metabolites produced by liver and readily utilised by body tissues. Ketones are an important substitute for glucose.

During prolonged periods of starvation, fatty acids are made from the breakdown of stored triglycerides in body fat.[ix] On a low-carb diet, the fatty acids are derived from dietary fat, or body fat if the diet does not supply enough. Free fatty acids are converted to ketones by the liver. They then provide energy to all cells with mitochondria. Within a cell, ketones are used to generate ATP. And where glucose needs the intervention of bacteria, ketones can be used directly. Reduction of carbohydrate intake stimulates the synthesis of ketones from body fat.[x] This is one reason why reducing carbs is important. Another is that reducing carbohydrate and protein intake also leads to a lower insulin level in the blood. This, in turn, reduces the risks associated with insulin resistance and the Metabolic Syndrome.

Ketone formation and a shift to using more fatty acids also reduces the body’s overall need for glucose. Even during high-energy demand from exercise, a low-carb diet has what are called ‘glucoprotective’ effects. What this all means is that ketosis arising from a low-carb diet is capable of accommodating a wide range of metabolic demands to sustain body functions and health while not using, and thus sparing, protein from lean muscle tissue. Ketones are also the preferred energy source for highly active tissues such as heart and muscle.[xi]

All this means that more glucose is available to the brain and other essential glucose-dependent tissues.

he case against getting energy from protein

We know, then, that dietary fats can produce all the energy the body needs, either directly as fatty acids or as ketone bodies. But, as there is still some debate about the health implications of using fats, why not play safe and eat more protein?

There is one simple reason: While the body can use protein as an energy source in an emergency, it is not at all healthy to use this method in the long term. All carbs are made up of just three elements: carbon, hydrogen and oxygen. All fats are also made of the same three elements. Proteins, however, also contain nitrogen and other elements. When proteins are used to provide energy, these must be got rid of in some way. This is not only wasteful, it can put a strain on the body, particularly on the liver and kidneys.

Excess intake of nitrogen leads in a short space of time to hyperammonaemia, which is a build up of ammonia in the bloodstream. This is toxic to the brain. Many human cultures survive on a purely animal product diet, but only if it is high in fat.[xii] [xiii] A lean meat diet, on the other hand cannot be tolerated; it leads to nausea in as little as three days, symptoms of starvation and ketosis in a week to ten days, severe debilitation in twelve days and possibly death in just a few weeks. A high-fat diet, however, is completely healthy for a lifetime.

Perhaps one of the best documented studies is that of the Arctic explorer, Vilhjalmur Stefansson and a colleague.[xiv] They ate an animal meat diet for more than a year to see whether such a diet could be healthy. Everything was fine until they were asked to eat only lean meat. Dr McClelland, the lead scientist, wrote:

‘At our request he began eating lean meat only, although he had previously noted, in the North, that very lean meat sometimes produced digestive disturbances. On the third day nausea and diarrhea developed. When fat meat was added to the diet, a full recovery was made in two days.’
This was a clinical study, but Stefansson had already lived for nearly twenty years on an all-meat diet with the Canadian Inuit. He and his team suffered no ill effects whatsoever.

Low-carb, high-fat diet and weight loss

There is just one other consideration: If you want to lose weight, the actual material you want to rid your body of is fat. But to do that you have to change your body from using glucose as a fuel to using fat – including your own body fat. This is another reason not to use protein as a substitute for carbs, as protein is also converted to glucose.

If you think about it, Nature stores excess energy in our bodies as fat, not as protein. It makes much more sense, therefore, to use what we are designed by Nature to use. And that is fat.

So what levels of carbs, fats and proteins are required?

Clinical experience and studies into low-carb diets over the last century suggest that everybody has a threshold level of dietary carbohydrate intake where the changeover from glucose-burning to fat and ketone burning takes place. This varies between about sixty-five and 180 grams of carbs per day.[xv]

If your carb intake is below this threshold, then your body fat will be broken down to generate ketones to supply your brain and other cells that would normally use glucose. In the early trials for the treatment of obesity, carb levels were very much reduced to supply only about ten percent of calories. This works out at around fifty or sixty grams of carb for a 2,000 calorie daily intake.

For diabetics, the level may need to be lower to counteract insulin resistance. Typical levels of carb intake for a type-2 diabetic are around fifty grams per day; the level should be lower still at about thirty grams a day for a type-1 diabetic.

A Polish doctor, Jan Kwasniewski, who has used a low-carb diet to treat patients with a wide range of medical conditions for over thirty years, recommends a ratio of one part carb to two parts protein to between three and four parts fat, by weight.

I see no reason to disagree with this. What it means in practice is that on a 2,000 calorie per day diet, we should get:

-Ten to fifteen percent of calories from carbs

-Twenty to thirty percent of calories from protein and

-Sixty to seventy percent of calories from fats.

Or put another way, as it is difficult to work out percentages in this way, fifty to seventy-five grams of carb and the rest from meat, fish, eggs, cheese, and their natural fats.

Potential for other diseases

The traditional Inuit (Eskimo) diet is a no-carb diet. It is notable that the Inuit diet described by Drs Vilhjalmur Stefansson and Hugh Sinclair in the 1950s is very similar in regard to percentages of fat/protein/carb intake to the experimental low-carb diets used in recent obesity studies.[xvi]

The Inuit diet was comprised of seal, whale, salmon, and a very limited amount of berries and the partially digested contents of animals’ stomachs.

On this diet, blood cholesterol levels were very high as were free fatty acids, but – and this in much more important – triglycerides were low.[xvii] [xviii]

It is interesting to note that the Inuit were of great interest to research scientists because they had practically none of the diseases we suffer, including obesity, coronary heart disease and diabetes mellitus.[xix] [xx]

References
[i]. Alberts B. Molecular Biology of the Cell, edn 4. New York: Garland Science; 2002: p 93.

[ii]. Cahill GF. Survival in starvation. Am J Clin Nutr 1998; 68:1–2.

[iii]. Exton JH. Gluconeogenesis. Metabolism 1972; 21:945–990.

[iv]. Volek JS, Sharman MJ, Love DM, et al. Body composition and hormonal responses to a carbohydrate-restricted diet. Metabolism 2002; 51:864–870

[v]. Krebs HA. The metabolic fate of amino acids. In Mammalian Protein Metabolism, vol 1, Munro HN, Allison JB, eds. New York: Academic Press, 1964:164

[vi]. Vazquez JA, Kazi U. Lipolysis and gluconeogenesis from glycerol during weight reduction with very low calorie diets. Metabolism 1994; 43:1293–1299.

[vii]. Phinney SD, Bistrian BR, Wolfe RR, Blackburn GL. The human metabolic response to chronic ketosis without caloric restriction: physical and biochemical adaptation. Metabolism 1983; 32:757–768.

[viii]. Bisshop PH, Arias AM, Ackermans MT, et al. The effects of carbohydrate variation in isocaloric diets on glycogenolysis and gluconeogenesis in healthy men. J Clin Endocrinol Metab 2000; 85:1963–1967.

[ix]. Cahill GF Jr. Starvation in man. N Engl J Med 1970; 19:668–675.

[x]. Klein S, Wolfe RR. Carbohydrate restriction regulates the adaptive response to fasting. Am J Physiol 1992; 262:E631–E636.

[xi]. Neely JR, Morgan HE. Relationship between carbohydrate and lipid metabolism and the energy balance of heart muscle. Annu Rev Physiol 1974; 36:413–459.

[xii]. Speth, John D. and Katherine A. Spielmann 1982 Energy source, protein metabolism, and hunter-gatherer subsistence strategies. Journal of Anthropological Archaeology 2:1-31.

[xiii]. Noli & Avery. Protein poisoning and Coastal Subsistence. J Archaeol Sci. 1988; 15:395-401

[xiv]. McClelland, et al. Clinical Calorimetry: XLV, XLVI, XLVII. Prolonged Meat Diets…… J Biol Chem 1930-31; 87:651, 87:669, 93:419

[xv]. Klein S, Wolfe RR. Op cit.

[xvi]. Stefansson V. The Fat of the Land. Macmillan Press, New York, 1957.; Sinclair HM: The diet of Canadian Indians and Eskimos. Proc Nutr Soc 1952, 12:69–82.

[xvii]. Bang HO, Dyerberg J, Nielsen AB: Plasma lipid and lipoprotein pattern in Greenlandic West-Coast Eskimos. Lancet 1971; I:1143–1146.

[xviii]. Feldman SA, Ho KJ, Lewis LA, et al. Lipid and cholesterol metabolism in Alaskan arctic Eskimos. Arch Pathol 1972; 94:42–58.

[xix]. Bjerregaard P, Dyerberg J: Mortality from ischaemic heart disease and cerebrovascular disease in Greenland. Int J Epidem 1988, 17:514–519.

[xx]. Sagild U, Littauer J, Jespersen CS, Andersen S: Epidemiological studies in Greenland 1962–1964. I. Diabetes mellitus in Eskimos. Acta Med Scand 1966, 179:29–39.

A Metabolic Paradigm Shift, or Why Fat is the Preferred Fuel for Human Metabolism (marksdailyapple.com)
Atkins Diet: A-OK? (fitsugar.com)
Healthy Low-Carb Snacks (fitsugar.com)
Your Brain On Ketones (psychologytoday.com)
Living Low-Carb (everydayhealth.com)
Study shows dramatic link between cancer, high-carb diets (canada.com)
Cracking the Low-Carb Code (everydayhealth.com)

Anorexia Nervosa appears to be particularly deadly August 2, 2011

Posted by ADAM PARTNERS in ANOREXIA NERVOSA, EATING DISORDERS.
Tags: Anorexia nervosa, Archives of General Psychiatry, Bulimia nervosa, Doctor of Philosophy, Eating disorder, Eating disorder not otherwise specified, Loughborough University, Mortality rate, Patient
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ANOREXIA ANYONE?

Patients with an eating disorder of any type have a significantly increased risk for death, but anorexia nervosa appears to be particularly deadly and linked to the highest mortality and suicide rates, new research shows.

In a new meta-analysis, similarly elevated mortality rates were found for those with bulimia nervosa and eating disorder not otherwise specified (EDNOS). However, the rate was even higher for those with anorexia nervosa, with a weighted annual rate of 5 deaths per 1000 person-years. Of those who died, 1 in 5 did so by committing suicide.

In addition, an older age at first presentation for those with anorexia, especially between the ages of 20 and 29 years, was found to be a significant predictor of mortality.

“It was not surprising to find out that mortality in eating disorders, particularly [anorexia], was high. It was, however, surprising to find out the high levels of deaths by suicides among this population,” lead author Jon Arcelus, PhD, from the Eating Disorders Service in Leicester and Loughborough University, United Kingdom, toldMedscape Medical News.The study was published in the July issue of the Archives of General Psychiatry.

Previous Research ‘Confusing’

Most previous research looking at mortality and eating disorders have focused on those with anorexia, with the standardized mortality ratio (SMR) varying widely, according to the investigators.

This study gives clinicians some information about predictive factors they can use in their day-to-day work. It should also give the primary care doctors and the general population a message that [eating disorders] are serious and the quicker they are treated the better.

They note that other studies have suggested a low mortality risk for bulimia, which is “surprising” because of the medical complications associated with purging behaviors.

“We were aware that eating disorders, particularly [anorexia] had high mortality rates. However, the message from the literature was very confusing. Our aim was to clarify this, to come with the best available figure of mortality, and to investigate whether we could say something about predictive factors,” said Dr. Arcelus.

His team evaluated data from 36 peer-reviewed articles that included mortality rates for patients with eating disorders and were published between January 1966 and September 2010.

The studies reported outcomes of specific disorders during person-years, including 166,642 total for anorexia, 32,798 for bulimia, and 22,644 for EDNOS.

The researchers examined both weighted mortality (deaths per 1000 person-years) and SMRs (ratio of observed to expected deaths).

Highest Mortality for Anorexia

Results showed that the highest mortality rates were found for those with anorexia (weighted mortality, 5.1; SMR, 5.86).

Of the 12,808 total patients with anorexia, 639 died (mean follow-up period, 12.82 years). Among these, 1.3 deaths per 1000 person-years were from suicide.

The weighted mortality rates and SMRs were 1.74 and 1.93, respectively, for bulimia and 3.31 and 1.92 for EDNOS. There were 57 deaths among 2585 total patients with bulimia and 59 deaths among 1879 patients with EDNOS. However, only 6 of the studies chosen reported EDNOS mortality data.

“Despite the relatively small number of studies, the examination of this group is important given that these patients represent such a large proportion of patients observed in practice,” explain the investigators.

Although age at first assessment was found to be a significant mortality risk factor for those with anorexia (P = .01), prognostic factors were not assessed for bulimia or EDNOS because of the small number of studies looking at these specific disorders.

Finally, there was no significant differences in observed mortality between the bulimia and EDNOS group, but a 2.7-fold higher rate was found for the anorexia group compared with the bulimia group.

“Future robust studies should inform physicians of the predictive factors associated with mortality rate in patients with EDNOS and [bulimia]; so far, late presentation of [anorexia] appears to be the only clear predictor of death among these disorders,” write the investigators.

They also note that the SMR they found for patients with anorexia was “much higher” than for other psychiatric disorders, reporting that past studies have found SMRs in male and female patients of 2.8 and 2.5 for those with schizophrenia, 1.9 and 2.1 for those with bipolar disorder, and 1.5 and 1.6 in those with unipolar disorder, respectively.

Undiagnosed

“This study adds to the burgeoning literature on the extent of mortality rates with all eating disorders,” Kathryn Zerbe, MD, director of the Oregon Psychoanalytic Institute in Portland, told Medscape Medical News.

“As the study concludes, and we have really suspected this for some time, eating disorders have the highest mortality rate of really any psychiatric illness,” said Dr. Zerbe.

She noted that this meta-analysis looked only at studies where the specific eating disorder was known.

“One of our concerns in mental health, especially for women, is the number of EDNOS patients who are never diagnosed; and their mortality rate is charted as something else. So how many of these get missed in general medicine? If they’re never diagnosed, they never get into a program and are never written about.”

Dr. Zerbe, who was not involved with this study, has twice been on the American Psychiatric Association’s Practice Guidelines Task Force for eating disorders, including the most recent edition. She explained that the diagnostic criteria for EDNOS “has shifted” over the years.

This paper raises awareness that all eating disorders across the board must be treated as life-threatening illnesses.

“It used to be a catch-all term. As research has gone on, we actually expanded it to include what I call ‘subclinical anorexia.’ And I see a lot of these people in my practice, those who don’t meet all the criteria for [anorexia or bulimia], including those who binge but don’t purge,” she said.

“What is nice about this paper is that it raises awareness that all [eating disorders] across the board must be treated as life-threatening illnesses.”

Deadliest Psychiatric Disorder: Anorexia (webmd.com)
Eating Disorders Often Reduce Lifespan (medicalnewstoday.com)
Food disorder claim ‘misleading’ (bbc.co.uk)
Are eating disorders reason to see a child psychiatry consultation? (zocdoc.com)
Depression and Eating Disorders (everydayhealth.com)
Why You Need to Take an EDNOS Diagnosis Seriously (psychologytoday.com)
The Dangers of Eating Disorders (everydayhealth.com)
Eating Disorders Appear to Raise Risk of Death (nlm.nih.gov)
Eating Disorders and Bipolar Disorder (everydayhealth.com)
Patients with eating disorders have higher death rate (news.bioscholar.com)
Eating Disorders: Anorexia, Bulimia, and Binge Eating Disorder (everydayhealth.com)
All About Anorexia Nervosa (everydayhealth.com)
Power Foods (psychologytoday.com)

Scientific evidence that macaroni and cheese, ice cream, and chocolate do indeed comfort. August 2, 2011

Posted by ADAM PARTNERS in Carbohydrates, COMFORT FOODS, DRUG ADDICTION, FOOD, Obesity, Pharmacology, Uncategorized.
Tags: Bethesda Maryland, Comfort food, Doctor of Philosophy, Fatty acid, Functional magnetic resonance imaging, Journal of Clinical Investigation, Leuven, National Institute of Diabetes and Digestive and Kidney Diseases, University of Manchester
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PROVEN THEN? ICE CREAM COMFORTS THE SOUL?

In an experiment with healthy volunteers, researchers found fatty acids administered to the stomach blunt the behavioral and nerve cell responses to sad emotion, providing scientific evidence that comfort foods such as macaroni and cheese, ice cream, and chocolate do indeed comfort.

The brief report was published online July 25 in the Journal of Clinical Investigation. “Everyone knows this from personal experience,” lead author Lukas Van Oudenhove, MD, PhD, from the University of Leuven, Belgium, told Medscape Medical News. “Now we have scientific proof that this widely known phenomenon has a scientific basis.”Dr. Van Oudenhove explained that he has always been interested in gut brain signalling in the context of gastrointestinal pain.

“I have performed studies where we do distention of the stomach and the esophagus and look at the brain mechanisms that are involved in processing these painful and nonpainful sensations. Those studies showed that emotions could modulate or interact with these sensations,” he said.

By chance, his colleagues at the University of Manchester, in the United Kingdom, had been studying signals in the brain induced by fatty acids in the stomach when Dr. Van Oudenhove arrived there to do a fellowship. It was then that the researchers decided to see just how emotions interact with the gut brain signals generated by fatty acids.

To do this, they recruited healthy volunteers to undergo four 40-minute functional magnetic resonance imaging (fMRI) examinations while listening to emotional music and viewing sad, fearful faces to induce sad emotion. At the same time, the participants randomly received either a saline or a fatty-acid intragastric infusion.

The researchers rated the participants’ sensations of hunger, fullness, and mood.

The investigators found that participants receiving the fatty acids reported feeling less sad when they were viewing the sad faces or hearing the sad music. In addition, the fMRI images of the brain showed that fatty-acid infusion lessened the neural responses to sad emotions in regions of the brain, including the medulla/pons, midbrain, hypothalamus, thalamus, striatum, cerebellum, insula, hippocampus, amygdala, and cingulate cortex.

“We already knew that there was some interactions between emotions and food, but mostly we were thinking about that in terms of the sensory aspects of feeding, like smell and taste and sight,” Dr. Van Oudenhove said.

“Here, we showed for the first time that if you bypass all of this and you administer foods in a completely subconscious way, without anyone knowing whether they were getting saline or fatty acids, we still see this effect on emotion. This is where the novelty of this study lies.”

Not Ready for Prime Time

As intriguing as the finding is, there is still a long way to go before it can be applied clinically, Dr. Van Oudenhove said.

“This study needs to be replicated in a larger sample of healthy volunteers to confirm our results and also to tease out the mechanisms of communication between the gut and the brain that are actually involved in the phenomenon that we described. We need to establish exactly how this works,” he said.

If this pans out, the next step would be to see whether these mechanisms are abnormal in people with certain disorders, such as depression, obesity, and eating disorders.

“It’s only after we show that gut brain signalling is abnormal in these conditions that we can start thinking about any therapeutic implications. So I see this more as a preclinical study,” Dr. Van Oudenhove said.

In an accompanying editorial, Giovanni Cizza, MD, PhD, and Kristina I. Rother, MD, from the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, write that the field of research on the mind-body connection “has suffered from a Cartesian top-down approach, in which the brain or mind is presumed to influence the body.”

This study shows that this mind-body relationship is bi-directional and that the body can be a powerful modulator of emotions, they note, citing as an example the practice by neonatologists of giving sugar to a neonate before they perform an invasive procedure to shorten the time the baby cries in pain.

The study broadens “our understanding of the ties between food and mood and underscore promising targets for obesity treatments,” they write.

Fatty food boosts mood, even when you don’t know you’ve eaten it (healthzone.ca)
Fatty ‘Comfort’ Foods May Alter Brain’s Response To Sadness (nlm.nih.gov)
Study looks at why fatty foods help to lift our mood (ctv.ca)
Study offers clues to emotional eating (cnn.com)
Why Comfort Foods Are So Comforting (webmd.com)
Mozzarella Sticks Are The New Prozac (theawl.com)
Cheer up: A view of how fatty foods makes you feel less sad (eurekalert.org)
Why We Indulge In Emotional Eating (huffingtonpost.com)
Schizophrenia and Fatty Acids (everydayhealth.com)
Why Ice Cream Chases the Blues Away (psychologytoday.com)
DHA During Pregnancy May Cut Infant Colds (webmd.com)
Best Foods for a Bad Mood (brighthub.com)

AND SUDDENLY, DR ATKINS IS PROVED CORRECT, YET AGAIN, FOLKS August 2, 2011

Posted by ADAM PARTNERS in Atkins Diet, DIETRY GUIDELINES FOR AMERICANS, Dr Atkins, High Fat Low Carb Diet, Obesity.
Tags: Apolipoprotein B, Center for Nutrition Policy and Promotion, Doctor of Philosophy, High-fructose corn syrup, Low-density lipoprotein, National Center for Research Resources, The Journal of Clinical Endocrinology and Metabolism, United States, University of California Davis
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Railroad tank car transporting high fructose corn syrup.

Results from a new study show that adults who consumed 25% of their daily calories as fructose or high-fructose corn syrup beverages (a percentage within current government guidelines) for 2 weeks experienced increases in serum levels of cholesterol and triglycerides, to prove Dr Atkins true on his account that sugar consumption was directly linked to high cholesterol.

The authors of the study, recently accepted for publication in the Endocrine Society’s Journal of Clinical Endocrinology & Metabolismand slated to be published in the October 2011 print issue, say the results should spur the government to reevaluate the guidelines.

Senior author Kimber Stanhope, PhD, from the departments of nutrition and molecular biosciences, University of California, Davis, and colleagues say the study was conducted to help sort out a discrepancy in 2 prominent sets of recommendations: The Dietary Guidelines for Americans, jointly published by the US Department of Health and Human Services and the US Department of Agriculture, recommend that people consume a maximum of 25% of their daily calories as added sugars. In contrast, the American Heart Association recommends an upper limit of 5%.

“While there is evidence that people who consume sugar are more likely to have heart disease or diabetes, it is controversial as to whether high sugar diets may actually promote these diseases, and dietary guidelines are conflicting,” remarked Dr. Stanhope in a press release.

To shed light on the effects of the higher government-recommended threshold, the researchers had 48 overweight and normal-weight adults (age, 18-40 years; body mass index, 18-35 kg/m²) consume beverages that contained fructose, high-fructose corn syrup, or glucose at the 25% upper limit for calorie intake for 2 weeks.

During the first 3.5 days of the trial, the participants stayed at an inpatient facility for baseline testing while consuming a balanced diet consisting of 55% complex carbohydrates. The following 12 days were at home on an ad libitum diet with the addition of 3 daily drinks of glucose-, fructose-, or high-fructose corn syrup-sweetened beverages (n = 16/group) that provided 25% of their energy requirements. The last 3.5 days were spent back at the inpatient facility for repeated testing while the participants were consuming energy-balanced diets containing 25% sugar-sweetened beverages and 30% complex carbohydrate.

At the end of the study period, participants who consumed fructose or high-fructose corn syrup in their drinks exhibited elevated blood levels of low-density lipoprotein (LDL) cholesterol, triglycerides, and apolipoprotein B (apo B).

Participants who consumed glucose in their beverages exhibited no such changes. More specifically, the 24-hour triglyceride area under the curve (AUC) increased compared with baseline during consumption of fructose (increase, 4.7 ± 1.2 mmol/L x 24 hours; P = .0032) and high-fructose corn syrup (increase, 1.8 ± 1.4 mmol/L x 24 hours; P = .035), but not glucose (decrease, 1.9 ± 0.9 mmol/L x 24 hours; P = .14). Similarly, fasting LDL and apoB concentrations were increased during consumption of fructose (LDL increase, 0.29 ± 0.082 mmol/L; P = .0023; apoB increase, 0.093 ± 0.022 g/L; P = .0005) and high-fructose corn syrup (LDL increase, 0.42 ± 0.11 mmol/L; P < .0001; apoB, 0.12 ± 0.031 g/L; P < .0001), but not glucose (LDL increase, 0.012 ± 0.071 mmol/L, P= .86; apoB increase, 0.0097 ± 0.019 g/L; P = .91).

One limitation is the lack of inclusion of sucrose in the study.

“There is growing evidence linking increases of postprandial triglyceride concentrations with proatherogenic conditions,” Dr. Stanhope and her colleagues explain. Their results add to this existing evidence, even in young adults. “It is [also] important to note,” write the authors, “that for both the current and [a] previous study [by our research group], the differential effects of fructose and [high-fructose corn syrup] compared to complex carbohydrate on the 24-h [triglyceride] profile were most marked in the late evening, approximately 4 and 6 hours after dinner. Studies investigating the relationship between this late-evening peak and proatherogenic changes would be of interest, as would investigations into the sources of the [triglycerides] that contributes to these peaks,” such as diet or fatty acids derived from adipose lipolysis.

According to the researchers, survey data suggest that 13% of the US population consumes 25% or more of their calories from added sugar. The current data provide evidence that this level of sugar consumption in young, healthy, normal, and overweight adults contributes to dyslipidemia after only 2 weeks and contradicts conclusions from recent reviews suggesting that “sugar intakes as high as 25-50% of energy have no adverse long-term effects” in terms of the metabolic syndrome, and “that fructose consumption up to 140 grams/day does not result in a biologically relevant increase of fasting or postprandial [triglycerides] in healthy, normal weight or overweight or obese” individuals.

Furthermore, the researchers conclude, their findings indicate the need for the government to reconsider its recommendations that include a maximal upper limit of 25% of total energy requirements from added sugar.

The study was supported by the National Heart, Lung and Blood Institute and by the National Center for Research Resources, both of the National Institutes of Health. One author has consulted for Denka Seiken Company and for Otsuka Pharmaceutical Company, Ltd, both in Tokyo, Japan. Another author is currently employed by Denka Seiken Co., and a third was formerly employed by this same company. Dr. Stanhope and the remaining 8 authors have disclosed no relevant financial relationships.

Eating too much sugar ‘may put your heart in danger’ (news.bioscholar.com)
Fructose consumption increases risk factors for heart disease (eurekalert.org)
High-Fructose Corn Syrup Linked to High Blood Pressure (fitsugar.com)
High-Fructose Corn Syrup and Type 2 Diabetes (everydayhealth.com)
Health Updates 1 August 2011 (rjwh617dotcom.wordpress.com)
New Name, but Same Sweetener: HFCS = Corn Sugar (fitsugar.com)
High-Fructose Corn Syrup vs. Sugar (fitsugar.com)
High Fructose Corn Syrup (realepiphany.wordpress.com)
Fructose consumption increases risk factors for heart disease (medicalxpress.com)
“Splenda” I kicked it!! (myjourneytofitness.com)

Experts crying foul over conclusion that salt consumption is safe August 2, 2011

Posted by ADAM PARTNERS in SALT.
Tags: Cochrane Library, Exeter University, Heart disease, Heart failure, Lancet, Low sodium diet, Rod Taylor, Salt
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SALT - MORE PRECIOUS THAN GOLD IN ANTIQUITY

Two preventive-medicine experts in the UK are crying foul over a recent and controversial meta-analysis that concluded cutting salt consumption would have no clear health benefits [1]. In a Comment published in the July 30, 2011 issue of the Lancet, Dr Feng J He (Queen Mary University, London, UK) and Dr Graham A MacGregor (Wolfson Institute of Preventive Medicine, Barts, London, UK) say that the meta-analysis published simultaneously by Taylor and colleagues in the Cochrane Review [2] and the American Journal of Hypertension [3] and press release that accompanied it “reflect poorly on the reputation of the Cochrane Library and the authors.”

As previously reported by heartwire , Taylor et al’s meta-analysis included seven randomized controlled trials of dietary salt reduction in normotensives (three studies), hypertensives (two studies), a mixed population (one study), and one trial of patients with heart failure.

At follow-up, relative risks for all-cause mortality and cardiovascular mortality for both normotensives and hypertensives were only mildly to moderately reduced, and not to a statistically significant degree. In congestive heart failure patients, salt restriction actually significantly increased all-cause death.

He and MacGregor, in their Comment, reanalyze the same data but combined the normotensives and hypertensives. They also omitted the heart-failure trial–a group of “very ill” patients taking large doses of diuretics in whom salt restrictions would seldom be recommended, MacGregor observed. In the combined patient analysis, they find a now statistically significant 20% reduction in cardiovascular events and a nonsignificant reduction in all-cause mortality.

“The results of our reanalysis, contrary to the claims by Taylor and colleagues, support current public-health recommendations to reduce salt intake in the whole population,” He and MacGregor conclude.

Misleading Public Messages?

In an interview with heartwire , MacGregor, who is also chair of both the Consensus Action on Salt and Healthand the World Action on Salt and Health, said he and his coauthor felt Taylor et al’s conclusions in the paper itself were measured. But they take issue with both the “Plain Language Summary” printed within the main article and with a press release sent out by the publisher.

“The press release and the paper have seriously misled the press and thereby the public,” they write. “For example, in the UK the Daily Express front-page headline read, ‘Now salt is safe to eat–Health fascists proved wrong after lecturing us all for years,’ and there were similar headlines throughout the world.”

“In actual fact, the findings we have when we reanalyze the data are the exact opposite of what the others conclude in their attention-grabbing headlines,” MacGregor told heartwire .

An Urgent Retort

Asked why their comment was sent to the Lancet rather than one of the two publications in which the Taylor et al paper was published, MacGregor cited the need for a swift, high-profile response.

“Obviously this is somewhat urgent–this caused headline news around the world, and the [salt-industry trade association] SALT Institute has a huge amount on its website about this,” he said. “We wanted to get this correction in [print] very quickly and get it some publicity, because it’s obviously totally wrong to claim salt reduction is not beneficial.” In fact, he points out, Taylor et al’s review “doesn’t say that; it says we need more evidence. We say it is [beneficial]; we’ve done this reanalysis, and we’ve got the evidence. In fact, all the evidence about salt is overwhelming. . . . It all shows that salt is a major factor bringing up our blood pressure.”

Asked to respond to He and MacGregor’s Comment, Dr Rod Taylor (University of Exeter, UK) told heartwirethat he and his coauthors are preparing a “formal letter in response” that they plan to submit to the Lancet, and “We’d rather make use of our letter as our communication vehicle in this case.”

He and MacGregor declare they have no conflicts of interest.

Cutting salt intake can reduce stroke risk (telegraph.co.uk)
Modest reduction in salt intake can cut stroke risk (news.bioscholar.com)
I’ll Give You My Salt Shaker When You Pry It From My Cold, Dead Fingers (reason.com)
Eat Less Salt – and Die? (psychologytoday.com)
Heart Benefits From Cutting Back on Salt? (webmd.com)
Salt-Reduction Efforts May Need Different Approach (blogs.wsj.com)
Review Raises Questions Over Benefits of Cutting Salt (nlm.nih.gov)
Review adds salt to a familiar concern (nature.com)
Do high salt diets impair reading comprehension? (weightymatters.ca)
Salt cut may not end heart attacks (mirror.co.uk)

Partially Hydrogenated Oils July 30, 2011

Posted by ADAM PARTNERS in High Fat Low Carb Diet.
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Metabolic Poisons:

What’s Wrong with Partially Hydrogenated Oils?

Summary

Consuming partially hydrogenated oils is like inhaling cigarette smoke. They will kill you — slowly, over time, but as surely as you breathe. And in the meantime, they will make you fat!

Contents

Why Fats are Important

What is Hydrogenation?

What’s Wrong with Hydrogenation?

Partially Hydrogenated Oils Make You Fat!

You Eat More

Your Metabolism Slows

Avoiding Hydrogenation

Deep-Fried Foods: The Ultimate Killer

What You Can Do

The Legal Outlook

Epilog, 2009: Food Industry Sneaks Trans Fats Back In

The Bigger Picture

Resources

Metabolic Poisons:
What’s Wrong with Partially Hydrogenated Oils?

Summary
Consuming partially hydrogenated oils is like inhaling cigarette smoke. They will kill you — slowly, over time, but as surely as you breathe. And in the meantime, they will make you fat!
[1700 words]

Eric Armstrong
TreeLight.com/Health

Contents

Why Fats are Important

The first thing to understand about fats is that the essential fatty acids they contain are truly essential. They are the “active ingredient” in every bodily process you can name:

brain cell function and nervous system activity
hormones and intra-cellular messengers
glandular function and immune system operation
hemoglobin oxygen-transport system
cell wall function:
- passing oxygen into the cell
- passing nutrients into the cell
- keeping foreign bodies out of the cell
digestive-tract operation
- assimilating nutrients
- blocking out allergens

In short, the essential fatty acids (contained mostly in polyunsaturated oils) are the most important nutrients there are — more important than vitamins, minerals, or even proteins. Because, without them, there is no life. They are the substance and foundation of life energy.

What is Hydrogenation?

Hydrogenation is the process of heating an oil and passing hydrogen bubbles through it. The fatty acids in the oil then acquire some of the hydrogen, which makes it more dense. If you fully hydrogenate, you create a solid (a fat) out of the oil. But if you stop part way, you a semi-solid partially hydrogenated oil that has a consistency like butter, only it’s a lot cheaper.

Because of that consistency, and because it is cheap, it is a big favorite as a butter-substitute among “food” producers. It gives their products a richer flavor and texture, but doesn’t cost near as much as it would to add butter.

Note:
Until the 1970’s, food producers used coconut oil to get that buttery flavor and texture. The American obesity epidemic began when it was replaced with partially hydrogenated vegetable oil — most often soybean oil. For more information, see Coconut Oil and Palm Kernel Oil: Miracle Medicine and Diet Pill.

What’s Wrong with Hydrogenation?

Unlike butter or virgin coconut oil, hydrogenated oils contain high levels of trans fats. A trans fat is an otherwise normal fatty acid that has been “transmogrified”, by high-heat processing of a free oil. The fatty acids can be double-linked, cross-linked, bond-shifted, twisted, or messed up in a variety of other ways.

The problem with trans fats is that while the “business end” (the chemically active part) is messed up, the “anchor end” (the part that is attached to the cell wall) is unchanged. So they take up their position in the cell wall, like a guard on the fortress wall. But like a bad guard, they don’t do their job! They let foreign invaders pass unchallenged, and they stop supplies at the gates instead of letting them in.

In short, trans fats are poisons, just like arsenic or cyanide. They interfere with the metabolic processes of life by taking the place of a natural substance that performs a critical function. And that is the definition of a poison. Your body has no defense against them, because they never even existed in our two billion years of evolution — so we’ve never had the need or the opportunity to evolve a defense against them.

But the worst part is that in the last stages of oil processing (or “refining”), the oil is literally steam distilled to remove its odor. So it doesn’t smell. But a hydrogenated oil is much worse than rancid butter. So it it did smell, it would smell worse than the most rancid butter you’ve ever seen. (And that goes for all refined oils, not just the hydrogenated ones. It’s just that hydrogenated oils are everywhere in the American diet.) So the next time you see “partially hydrogenated oil” on a label, think “rancid butter”.

Partially Hydrogenated Oils Make You Fat!

Partially hydrogenated oils will not only kill you in the long term by producing diseases like multiple sclerosis and allergies that lead to arthritis, but in the meantime they will make you fat!

You Eat More

It’s not like you have any choice in the matter. Remember that the essential fatty acids are vital to every metabolic function in your body. You will get the quantity of essential fatty acids that you need to sustain life, no matter what. You will not stop being hungry until you do.

If you are consuming lots of saturated fats, you really have no choice but to become fat, because saturated fats contain only small quantities of the polyunsaturated fats that contain the essential fatty acids you need. The key to being thin, then, is to consume foods containing large amounts of polyunsaturated oils. (Those foods include fish, olives, nuts, and egg yolks.) Over the long term, those foods remove your sense of hunger.

Note:
The difference between a “fat” and an “oil” is temperature. A “fat” is a lipid that is solid at room temperature. An “oil” is one that is liquid at room temperature. Both are lipids (or “oil/fat”). Change the temperature, and you can convert an oil into a fat, or vice versa.

Partially hydrogenated oils make you gain weight the same way that saturated fats do — by making you consume even more fat to get the the essential fatty acids you need. But partially hydrogenated fats are even worse. Not only do they produce disease over the long term, but they interfere with the body’s ability to ingest and utilize the good fats!

Picture it like this. The trans fats are now the guards along the watchtower. The essential fatty acids (the support troops) are waiting outside to get into the fort (the cell), so they can be distributed along the watchtower (the cell wall). But the guards won’t let them in! So they have to find someplace to stay in town. Over time, more and more troops are finding lodging in town. So new houses (fat cells) have to built to keep them in. The town grows more and more swelled with troops (fat), and it gets bigger and bigger (fatter). It’s not a pretty picture at all, when you realize that the town is your belly, buns, face, and neck.

Your Metabolism Slows

Worse, most partially hydrogenated oil is partially hydrogenated soybean oil. That’s a problem, because soybean oil depresses the thyroid–which lowers your energy levels, makes you feel less like exercising, and generally makes you fatter!

Of course, soybeans have been used for centuries in the Orient–but mostly as the basis for soy sauce and tofu. Asians didn’t have soy milk, soy burgers, soy this and soy that. Most of all, they never used concentrated essence of soybean, in the form of soybean oil. And they didn’t hydrogenate it, and they didn’t use it in everything.

Walking down supermarket aisles in America, you find product after product with partially hydrogenated oil–often in products you would never expect. But why not? After all, it’s cheaper than butter. And it’s not illegal. Yet. When you eat out, restaurant breads and fried foods are loaded with stuff.

As a result, Americans are consuming soybean oil–partially hydrogenated soybean oil–in virtually everything they eat. It’s no wonder that America is experiencing epidemic levels of diabetes, obesitiy, heart disease, and cancer.

Avoiding Hydrogenation

When you start reading food labels, it is astonishing how many products you will find that contain partially hydrogenated oils. In the chips aisle, there are maybe two brands that don’t: Lay’s Classic Potato Chips (not their other brands), and Laura Scudders chips. Most every other package on the shelf does.

Then there are the cookies and crackers. Most every single one does. About the only cookie that doesn’t is Paul Neuman’s fig newtons. Among peanut butters, the all-natural brands (Adams and Laura Scudders) don’t. All the rest seem to.

Even some items on the “health food” shelf, like Tigers Milk bars, contain partially hydrogenated oils. Can you imagine that?? A product marketed as a “health food” that contains partially hydrogenated oils? If they want to market it as a candy bar, fine. Caveat emptor. But to market it as a health food calls for a class action lawsuit on the basis of false advertising.

The more labels you read, the more astonished you will be at the variety and number of places that this insidious little killer shows up. Do read the labels. Do recoil in disgust, and do throw the product back on the shelf — or throw it on the floor, where it belongs.

And it’s not just partially hydrogenated oils, anymore…
When I first wrote this article in 1998, I asked myself, “What’s going to happen when consumers begin to become aware of the dangers of partially hydrogenated oils? Are manufacturers going to stop using it? I figured that the answer, unfortunately, would be “No”. They would probably just give it a new name. Well, it appears that the worst may have come to pass. Alert readers Robin Jutras, Gerard Lally, and ___ clued me in to the fact that manufacturers are now using mono- and di-glycerides–which are also hydrogenated oil products.

Deep-Fried Foods: The Ultimate Killer

Fortunately, this information is beginning to penetrate the public consciousness. Recently, a news special covered the subject. The reporter got some of the details wrong, but the general message was right on the money. And the one surprising tidbit of information in the report was the fact that most of the deep-fried foods served in fast food joints are fried in partially hydrogenated oils!

Now, deep frying all by itself is pretty bad. After all, you are applying a lot of heat. But if that heat is applied to a saturated fat, there is a limit to how much harm it can do. A saturated fat doesn’t have a “business end”. There is no part of it that is chemically active. It’s inert. Your body can burn it for fuel, but it can’t use it to carry out any of your metabolic processes.

But because a saturated fat is inert, it can’t be hurt much by heat. It’s not all that good for you, but it’s not terrible either. So if you’re going to fry, fry in a fully saturated fat like lard, or coconut oil. Or, use butter, which consists mostly of short-chain saturated fats that are easily burned for fuel, plus conjugated linoleic acid (CLA) which improves health (Bruce Fife, Detox, 68). And butter tastes great. It’s so good, in fact, that you don’t even need to use very much to get a lot of flavor. So at home you can fry with butter to get gourmet-quality food that is also healthy.

Even better, you could fry with coconut oil — which consists of medium chain fatty acids that contain 2/3’s the calories of long-chain saturated fats. They’re also metabolized differently, so they’re burned for energy instead of being stored as fat. And if that’s not enough, 50% of coconut oil consists of lauric acid, a medium-chain fatty acid that’s anti-bacterial, anti-viral, anti-fungus, and anti-yeast. (For more information, see Coconut Oil and Palm Kernel Oil: Miracle Medicine and Diet Pill.)

For commercial deep frying, though, butter is prohibitively expensive. Things were better when foods were fried in beef tallow and coconut oil, because they had a lot of flavor and the saturated fats aren’t harmed by the heat. But all that saturated fat sounds bad, so restaurants switched to partially hydrogenated vegetable oils. One “healthy” Mexican restaurant even advertised that they fried in vegetable oil. That would be somewhat better than partially hydrogenated oil — assuming that they weren’t using partially hydrogenated vegetable oil in the the first place — but subjecting the unsaturated fatty acids contained in a vegetable oil to the high heat of a deep frying vat is deadly, especially when the oil is used and reused all day long. The result would be the same kind of trans fats that you get in the hydrogenation process!

But the absolute worst commercial frying is done by the fast-food chains, who almost uniformly do their deep frying in cheap, deadly partially hydrogenated oil. Any fats that escaped being transmogrified in the hydrogenation process are now subjected to the deep frying process. It’s a miracle that any of the unsaturated fats escape being transmogrified, if any of them do.

What You Can Do

For starters, read food labels and avoid anything that contains the words “hydrogenated”. That means partially hydrogenated oils, hydrogenated oils, or anything of that kind (and mono-diglycerides, as well).

Note:
In 2006, a new FDA regulation takes effect that requires manufacturers to list the amount of trans fats on their product labels. Much as I would like to tell you that you can simply look for “0% trans fats” on the label, it would be useless for you to do so. The FDA wanted to put the words, “Warning: Trans fats may be dangerous to your health” on the labels–the same warning that first appeared on cigarettes–but the industry wouldn’t let them. And the way the labeling law works, the product can contain a significant percentage of trans fat, and still claim “0%”. Simply put, the labeling law is nearly useless. For more information, see What’s Wrong with Trans Fat Labels?

When eating out, avoid deep-fried foods at all costs, and pretend you’re allergic to wheat. (You probably are! Something like 50% of the population is. See What’s Wrong with Wheat?) And when you avoid wheat you stay away from both partially hydrogenated oils and high fructose corn syrup–another deadly ingredient in the American food supply that is rarely used in other countries–except where American corporations are involved.

If you follow those steps, you will do a good job of protecting yourself. But there is a simple thing you can do to help protect others, as well:

When you see a food that contains partially hydrogenated oils (especially if it claims to be healthy), put it back on the shelf upside down and backwards. (Sometimes it’s impossible to put things back upside down, so at least put them on the shelf backwards.)

To find out why this is an effective boycott strategy, see How to Carry Out an Effective Consumer Boycott.

The Legal Outlook

With any luck, the first lawsuits against “food” producers will begin in the next 10-20 years. The scientific knowledge has been available since the early 1990’s, at least, so there is no doubt they are fully aware of what they are doing. They have been ignoring the health effects for the sake of profit. Such behavior is both unethical and immoral. With luck, some day it will be illegal, as well.

Note:
When I originally wrote this article in 1998, I feared that as soon as the public became educated as to its danger, corporations would simply change the name of the substance or find something equally dangerous to replace it with. Fortunately, the FDA required labeling of trans fats, rather than partially hydrogenated oils. That forestalled the inevitable name change. But corporations have indeed found another process–one that may or may not be safer. To find out more, read What’s Wrong with Interesterified Oils?

Epilog, 2009: Food Industry Sneaks Trans Fats Back In

Once the FDA started requiring trans fats to be listed on the label, I thought that we were finally home free. Unfortunately, it turns out that the food industry has other options. Mono- and Di-Glyceridesare designated as “emulsifiers” rather than fats, so the trans fats they contain “don’t count”. (Until you ingest them.)

The Bigger Picture

As described in What’s Wrong with American Foods?, there is more than one thing wrong with the American food supply. It is a sad fact that American corporations put profit above all other considerations–above morality, above truth, above your health. They don’t regulate themselves, they’re not held in check by government, and the fiction that they are regulated by “the market” is, quite simply, a lie. That problem, and the only possible solution, is described more fully in What’s Wrong with American Corporations?. It’s a problem we must solve, for the sake of our children’s health, if for no other reason.

Resources

Food for Memory and Concentration – 3 Memory Foods that help students concentrate ~ Smart Study Guide for Better Grades July 30, 2011

Posted by ADAM PARTNERS in High Fat Low Carb Diet.
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Food for Memory and Concentration – 3 Memory Foods that help students concentrate A healthy, iron-rich breakfast early in the morning is the best food for memory and concentration. It keeps you alert all day long and gets you through the mental and physical rigors of school and college.Apart from this, there are three foods that when consumed regularly, are proven to increase brain power, memory, study retention and better performance in tests and exams.These are: Fish – They contain omega-3 fatty acids which is great for your hair as well as the grey cells. Cranberries – They contain vital antioxidants that help in boosting memory function. Egg yolk – Rich in choline, egg yolks are important for optimum brain health and hence, superior concentration.

via Food for Memory and Concentration – 3 Memory Foods that help students concentrate ~ Smart Study Guide for Better Grades.

Hunger for salt co-opted by drug addiction July 28, 2011

Posted by ADAM PARTNERS in DRUG ADDICTION.
Tags: Duke University, George Koob, La Jolla, Proceedings of the National Academy of Sciences, San Antonio Express-News, Scripps Research Institute, Specific appetite, Substance dependence
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SALT MY KINGDOM FOR SOME SALT

When the first slimy amphibians crawled onto dry land a few million years ago, they brought with them a powerful craving from that salty, primordial sea.

How powerful? It turns out that the genes and neural networks in the brain that regulate hunger for salt seem to be the same ones at play in drug addiction. And that could have some far-reaching implications — helping to explain why narcotics addiction is so hard to treat, and maybe why people are so drawn to some pretty unhealthy foods, said an international team of scientists with localties.

“The desire to ingest salt is an instinct that has been known for a while,” said Dr. Wolfgang Liedtke, assistant professor of neurobiology at Duke University, one of the lead authors of a new study. “But now comes this notion that salt appetite uses pathways that also have been taken advantage of by cocaine and opiate addiction. That helps us understand why the lust to gratify salt appetite has such a powerful influence on human behavior.”

Salt is a critical part of diet, maintaining healthy fluid levels in the body and important for muscle and nerve function. Beyond that, its ability to keep food from rotting helped forge early civilizations. Roman soldiers were paid with it.

Yet inland, the mineral is relatively hard to come by. Early humans learned to mine it from the earth. Meat-eating animals get salt from the flesh of their prey. But veggie-loving animals sometimes go to great lengths to get it.

Liedtke points to mountain goats in Italy that scale an almost vertical dam to reach salt deposits in the rock, and a herd of elephants in Kenya that learned over generations to march single-file a mile into a dark cave to reach a saltlick.

“And all of that, just to lick salt,” he said. “It’s crazy, but that’s what they do.”

And while the researchers aren’t suggesting that a craving for salt makes one more likely to crave narcotics, Liedtke said that ancient, ingrained desire for the salty might explain why drug addiction is so stubborn to overcome. “Our findings imply that abstinence-aimed therapies are up against reward systems that have evolved over hundreds of millions of years, thus conferring a powerful survival advantage.”

The discovery, published this month in the Proceedings of the National Academy of Science, that the mechanisms in the brain were similar in salt appetite and drug addiction came from studying how genes turned on and off when rats were fed or deprived of salty water.

In some cases, medication was used to increase the animals’ hunger for salt. In others, they were given a drug to block the effects of dopamine — a chemical messenger in the brain also linked to drug addiction — which decreased the animals’ desire for salt.

That activity was in the hypothalamus — a part of the brain that controls hunger, thirst and sleep. In particular, they found a link to orexin, a substance that’s been implicated in appetite, sleep and addiction.

The other lead author, Dr. Derek Denton, an Australian scientist who also has an adjunct appointment at the Texas Biomedical Research Institute in San Antonio, has studied instinctive behavior, including salt appetite, for decades. Also taking part in the study was Dr. Donald Hilton, clinical associate professor of neurosurgery at the University of Texas Health Science Center, who has a “side-interest” in addiction and recently co-wrote a controversial paper on the parts of the brain that might be responsible for pornography addiction.

Some addiction experts have long speculated that narcotics addiction might have piggybacked onto some ancient system of craving, including Dr. George Koob, who studies the neurobiology of addiction disorders at Scripps Research Institute in La Jolla, Calif.

“I think it’s really exciting,” said Koob, who didn’t take part in the study. “They’re studying a basic, metabolic drive that converts into motivated behavior. And they link it to the hypothalamus and orexin.”

Laura Almasy, a geneticist at Texas Biomed who studies the genetics of addiction and also wasn’t involved in the study, agreed the findings make sense.

“Addiction is damaging, but the way it starts is that someone takes a substance and it feels good, so they do it again,” Almasy said. “And I think what this paper suggests is that the mechanism for why it feels good is that cocaine and opioids are hitting the pathways that were laid down to help us regulate salt intake.”

via Hunger for salt co-opted by drug addiction – San Antonio Express-News.

A classic instinct — salt appetite — is linked to drug addiction (eurekalert.org)
Addictive drugs hijack brain’s fundamental pathways (theage.com.au)
Drug addiction. (solitaryhorizons.com)
Salt cravings may be the origin of all drug addictions [Mad Science] (io9.com)
CNN: Addiction: The Disease that Lies (asapnys.wordpress.com)
Do Instinctive Salt Cravings Make You A Real Junkie? (medicalnewstoday.com)
Silent Drug Addiction in the Elderly Concerning to The Recovery Place (prweb.com)
Drug Addiction Will Kill You. Ask Amy Winehouse. (zwingliusredivivus.wordpress.com)
The Weight-Loss Surgery Of The Future Is All In Your Head (Literally) (blisstree.com)

BATH SALTS THE NEW DRUG IN THING July 18, 2011

Posted by ADAM PARTNERS in DRUG ADDICTION, Pharmacology.
Tags: American Association of Poison Control Centers, Bath Salt, Chuck Schumer, Drug Enforcement Administration, Drug prohibition law, Ivory Wave, Methylenedioxypyrovalerone, Pennsylvania, Synthetic cannabis, United States
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A box of bath salts with some of the contents ...

AND NOW THIS IS DRUGS

Dr. Jeffrey J. Narmi could not believe what he was seeing this spring in the emergency room at Schuylkill Medical Center in Pottsville, Pa.: people arriving so agitated, violent and psychotic that a small army of medical workers was needed to hold them down.

They had taken new stimulant drugs that people are calling “bath salts,” and sometimes even large doses of sedatives failed to quiet them.

“There were some who were admitted overnight for treatment and subsequently admitted to the psych floor upstairs,” Dr. Narmi said. “These people were completely disconnected from reality and in a very bad place.”

Similar reports are emerging from hospitals around the country, as doctors scramble to figure out the best treatment for people high on bath salts. The drugs started turning up regularly in the United States last year and have proliferated in recent months, alarming doctors, who say they have unusually dangerous and long-lasting effects.

Though they come in powder and crystal form like traditional bath salts — hence their name — they differ in one crucial way: they are used as recreational drugs. People typically snort, inject or smoke them.

Poison control centers around the country received 3,470 calls about bath salts from January through June, according to the American Association of Poison Control Centers, up from 303 in all of 2010.

“Some of these folks aren’t right for a long time,” said Karen E. Simone, director of the Northern New England Poison Center. “If you gave me a list of drugs that I wouldn’t want to touch, this would be at the top.”

At least 28 states have banned bath salts, which are typically sold for $25 to $50 per 50-milligram packet at convenience stores and head shops under names like Aura, Ivory Wave, Loco-Motion and Vanilla Sky. Most of the bans are in the South and the Midwest, where the drugs have grown quickly in popularity. But states like Maine, New Jersey and New York have also outlawed them after seeing evidence that their use was spreading.

The cases are jarring and similar to those involving PCP in the 1970s. Some of the recent incidents include a man in Indiana who climbed a roadside flagpole and jumped into traffic, a man in Pennsylvania who broke into a monastery and stabbed a priest, and a woman in West Virginia who scratched herself “to pieces” over several days because she thought there was something under her skin.

“She looked like she had been dragged through a briar bush for several miles,” said Dr. Owen M. Lander, an emergency room doctor at Ruby Memorial Hospital in Morgantown, W.Va.

Bath salts contain manmade chemicals like mephedrone and methylenedioxypyrovalerone, or MDPV, also known as substituted cathinones. Both drugs are related to khat, an organic stimulant found in Arab and East African countries that is illegal in the United States.

They are similar to so-called synthetic marijuana, which has also caused a surge in medical emergencies and been banned in a number of states. In March, the Drug Enforcement Administrationused emergency powers to temporarily ban five chemicals used in synthetic marijuana, which is sold in the same types of shops as bath salts.

Shortly afterward, Senator Bob Casey, Democrat of Pennsylvania, asked the agency to enact a similar ban on the chemicals in bath salts. It has not done so, although Gary Boggs, a special agent at D.E.A. headquarters in Washington, said the agency had started looking into whether to make MDPV and mephedrone controlled Schedule I drugs like heroin and ecstasy.

Mr. Casey said in a recent interview that he was frustrated by the lack of a temporary ban. “There has to be some authority that is not being exercised,” he said. “I’m not fully convinced they can’t take action in a way that’s commensurate with the action taken at the state level.”

Senator Charles E. Schumer, Democrat of New York, introduced federal legislation in February to classify bath salts as controlled Schedule I substances, but it remains in committee. Meanwhile, the drugs remain widely available on the Internet, and experts say the state bans can be thwarted by chemists who need change only one molecule in salts to make them legal again.

And while some states with bans have seen fewer episodes involving bath salts, others where they remain fully legal, like Arizona, are starting to see a surge of cases.

Dr. Frank LoVecchio, an emergency room doctor at Banner Good Samaritan Medical Center in Phoenix, said he had to administer general anesthesia in recent weeks to bath salt users so agitated that they did not respond to large doses of sedatives.

Dr. Justin Strittmatter, an emergency room doctor at the Gulf Coast Medical Center in Panama City, Fla., said he had treated one man whose temperature had shot up to 107.5 degrees after snorting bath salts. “You could fry an egg on his forehead,” Dr. Strittmatter said.

Other doctors described dangerously elevated blood pressure and heart rates and people so agitated that their muscles started to break down, releasing chemicals that led to kidney failure.

Mark Ryan, the director of the Louisiana Poison Center, said some doctors had turned to powerful antipsychotics to calm users after sedatives failed. “If you take the worst attributes of meth, coke, PCP, LSD and ecstasy and put them together,” he said, “that’s what we’re seeing sometimes.”

Dr. Ryan added, “Some people who used it back in November or December, their family members say they’re still experiencing noticeable paranoid tendencies that they did not have prior.”

Before hitting this country, bath salts swept Britain, which banned them in April 2010. Experts say much of the supply is coming from China and India, where chemical manufacturers have less government oversight.

They are labeled “not for human consumption,” which helps them skirt the federal Analog Act, under which any substance “substantially similar” to a banned drug is deemed illegal if it is intended for consumption.

Last month, the drug agency made its first arrests involving bath salts under the Analog Act through a special task force in New York. Undercover agents bought bath salts from stores in Manhattan and Brooklyn, where clerks discussed how to ingest them and boasted that they would not show up on a drug test.

“We were sending out a message that if you’re going to sell these bath salts, it’s a violation and we will be looking at you,” said John P. Gilbride, special agent in charge of the New York field division of the D.E.A.

The authorities in Alton, Ill., are looking at the Analog Act as they prepare to file criminal charges in the death of a woman who overdosed on bath salts bought at a liquor store in April.

“We think we can prove that these folks were selling it across the counter for the purposes of humans getting high,” said Chief David Hayes of the Alton police.

Chief Hayes and other law enforcement officials said they had been shocked by how quickly bath salts turned into a major problem. “I have never seen a drug that took off as fast as this one,” Chief Hayes said. Others said some people on the drugs could not be subdued with pepper spray or even Tasers.

Chief Joseph H. Murton of the Pottsville police said the number of bath salt cases had dropped significantly since the city banned the drugs last month. But before the ban, he said, the episodes were overwhelming the police and two local hospitals.

“We had two instances in particular where they were acting out in a very violent manner and they were Tasered and it had no effect,” he said. “One was only a small female, but it took four officers to hold her down, along with two orderlies. That’s how out of control she was.”

You: An Alarming New Stimulant, Sold Legally in Many States (nytimes.com)
Maybe This Is Why the Authorities Are Worried About ‘Bath Salts’? [Mike the Mad Biologist] (scienceblogs.com)
Bath Salts: A new class of consumer stimulant products with a dangerous kick. (daveibsen.typepad.com)
Bath Salts are drugs, really (upfrontmenblog.wordpress.com)
Cuomo just says No (timesunion.com)
Bath Salt Tubes (bigsexymedia.com)
Authorities find banned designer drug ‘bath salts’ at many Jersey Shore stores during surprise visits (nj.com)
Minnnesota’s New Synthetic Drug Law Snags First Offender (patspapers.com)
Terrifying new drug causing real problems for emergency rooms (amanwithaphd.wordpress.com)
Bath Salts Drugs: Problems, Ingredients, Dangers, and More (webmd.com)

Part B. Section 3: A Call to Action June 8, 2011

Posted by ADAM PARTNERS in DIETRY GUIDELINES FOR AMERICANS.
Tags: Call to Action, Conditions and Diseases, Diet, Eating, Health, MyPyramid, Nutrition and Metabolism Disorders, Obesity, Overweight, Public health, United States
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Relative risk of death in United States men by...

RISK OF DEATH FOR MEN

Part B. Section 3: Translating and

Integrating the Evidence: A Call to Action

The data clearly document that America is experiencing a public health crisis involving overweight and obesity. Particularly alarming is the further evidence that the obesity epidemic involves American children and

youth, as nearly one in three are classified as overweight or obese. Childhood obesity and overweight is a serious health concern in the United States (U.S.) because of immediate health consequences, as well as because it places a child at increased risk of obesity in adulthood, with all its attendant health problems such as cardiovascular diseases (CVD) and type 2 diabetes (T2D). All adults—parents, educators, caregivers, teachers, policy makers, health care providers, and all other adults who work with and care about children and families—serve as role models in some capacity and share responsibility for helping the next generation prevent obesity by promoting healthy lifestyles at all ages. Primary prevention of obesity, starting in pregnancy and early childhood, is the single best

strategy for combating and reversing America’s obesity epidemic for current and future generations. While there is also an urgent need to improve the health and well- being of children and adults who are already overweight and obese, primary prevention offers the strongest universal benefits. Solving the obesity problem will take a coordinated system-wide, multi-sectoral approach that engages parents as well as those in education, government, healthcare, agriculture, business,

advocacy, and the community. This approach must promote primary prevention among those who are not yet overweight and address weight loss and fitness among those who are overweight.

Disparities in health among racial and ethnic minorities and among different socioeconomic groups have been recognized as a significant concern for decades. Several subgroups of the population (Native Americans, Blacks, Hispanics, and segments of the population with low income) have a strikingly high prevalence of overweight and obesity. Dietary patterns vary among different ethnic and socioeconomic groups. Individuals of lower education and/or income levels tend to eat fewer servings of vegetables and fruits than do those with more education and/or higher income. According to national surveys, Blacks tend to have the lowest intakes

of vegetables and fruits among ethnic groups, but also have a higher prevalence of hypertension and related diseases, such as stroke. Although the reasons for these differences are complex and multifactorial, this Report addresses research indicating that certain dietary changes can provide a means to reduce health disparities. If we are successful in changing dietary intake patterns of all Americans through a systematic

approach, we will go a long way in narrowing the gap in health disparities.

Although obesity is related to many chronic health conditions, it is not the only diet-related public health problem confronting the Nation. Nutritionally suboptimal diets with or without obesity are etiologically related to many of the most common, costly, and yet preventable health problems in the U.S., particularly CVD (atherosclerosis, stroke) and related risk factors (T2D, hypertension, and hyperlipidemia), some cancers, and osteoporosis. Improved nutrition and appropriate eating behaviors have tremendous potential to enhance public health, prevent or reduce morbidity and mortality, and decrease health care costs.

The science is not perfect; evidence is strong in some areas and limited or inconsistent in other areas. Nevertheless, this Report is an urgent call to action to address a major public health crisis by focusing on helping all Americans achieve energy balance through adoption and adherence to current nutrition and physical activity guidelines.

After reviewing its entire Report, the Dietary Guidelines Advisory Committee (DGAC) recognized a need to not only document the evidence, but to translate and integrate major findings that have cross-cutting public health impact and provide guidance on how to implement the changes necessary to enhance the health and well being of the population. Below are the four major cross-cutting findings from the 2010 DGAC Report, followed by suggestions for implementation.

2010 Dietary Guidelines Advisory Committee Report 51

Four Main Integrated Findings to Be Used in Developing the 2010 Dietary Guidelines for Americans

1. Reduce the incidence and prevalence of overweight and obesity of the U.S. population by reducing overall calorie intake and increasing physical activity.

A focus on life-stage approaches (pregnant women, children, adolescents, adults, and older adults) is necessary nationwide to help Americans meet nutrient needs within appropriate calorie intake. To achieve this, Americans should:

Know their calorie needs. In other words, individuals need to know how many calories they should consume each day based on their age, sex, and level of physical activity.

Significantly lower excessive calorie intake from added sugars, solid fats, and some refined grain products.

Increase their consumption of a variety of vegetables, fruits, and fiber-rich whole grains.

Avoid sugar-sweetened beverages.

Consume smaller portions, especially of high- calorie foods.

Choose lower-calorie options, especially when eating foods away from home.

Increase their overall physical activity.

Have access to improved, easy-to-understand labels listing calorie content and portion size on packaged foods and for restaurant meals (especially quick service [i.e., fast food] restaurants, restaurant

chains, and other places where standardized foods are served).

Collectively, these measures will help Americans manage their body weight and improve their overall health. In order to achieve this goal, the public and private sectors must be committed to assisting all Americans to know their calorie needs at each stage of life and help them recognize how to manage and/or lower their body weight. Simple but effective consumer-friendly tools for self-assessment of energy needs and self-monitoring of food and beverage intake are urgently needed and should be developed. These strategies will enable everyone to recognize and implement, both inside and outside the home, dietary

recommendations that have been consistent for decades.

2. Shift food intake patterns to a more plant- based diet that emphasizes vegetables, cooked dry beans and peas, fruits, whole grains, nuts, and seeds. In addition, increase the intake of seafood and fat-free and low-fat milk and milk products, and consume only moderate amounts of lean meats, poultry, and eggs.

This approach will help Americans meet their nutrient needs while maintaining energy balance. Importantly, this will assist Americans to increase their intake of shortfall nutrients, such as potassium and fiber. These goals can be attained through a range of food patterns— from omnivore to vegan—that embrace cultural

heritage, lifestyle, and food preferences. These flexible patterns of eating must encompass all foods and beverages that are consumed as meals and snacks throughout the day, regardless of whether they are eaten at home or away from home.

3. Significantly reduce intake of foods containing added sugars and solid fats because these dietary components contribute excess calories and few, if any, nutrients. In addition, reduce sodium intake and lower intake of refined grains, especially refined

grains that are coupled with added sugar, solid fat, and sodium.

The components of the American diet that are consumed in excess are solid fats and added sugars (SoFAS), refined grains, and sodium. SoFAS alone contribute approximately 35 percent to total energy intake of Americans. Collectively, the consumption of foods containing SoFAS, refined grains, and sodium lead to excessive calorie intake, resulting in weight gain and health consequences such as hypertension, CVD, and T2D. Reducing the intake of these overconsumed components will require much more than individual behavior change. A comprehensive approach is needed. The food industry will need to act to help Americans achieve these goals. Every aspect of the industry, from research and development to production and retail, needs to contribute healthful food solutions to reduce

the intake of SoFAS, certain refined grain products, and sodium. Sound health and wellness policies at the local, state, and national level also can help facilitate these changes.

52 2010 Dietary Guidelines Advisory Committee Report

4. Meet the 2008 Physical Activity Guidelines for Americans.

A comprehensive set of physical activity recommendations for people of all ages and physical conditions was released by the U.S. Department of Health and Human Services in 2008 (HHS, 2008). The

2008 Physical Activity Guidelines for Americans were developed to help Americans to become more

physically active. By objective measures, large portions, indeed the majority, of the U.S. population are

sedentary (Metzger, 2008). In fact, Americans spend most of their waking hours engaged in behaviors that expend very little energy (Matthews, 2008). To increase the public’s participation in physical activity,

compelling multi-sector approaches are needed to improve home, school, work, and community environments to promote physical activity. These changes need to surpass planned exercise and foster greater energy expenditure throughout the day. Improved exposure to recreational spaces, increased use of active transportation, and encouraging development of school and worksite policies that program physical activity throughout the day can help enable Americans

to develop and maintain healthier lifestyle behaviors. Special attention and creative approaches also are needed to help Americans reduce sedentary behaviors, especially television viewing and video game use, among children and adolescents.

A Call to Action

Dietary Guidelines for Americans have been published since 1980. During this time obesity rates have escalated and dietary intake patterns have strayed from

the ideal. The 2010 DGAC recognizes that several of its recommendations have been made repeatedly in prior reports with little or no demonstrable impact. For example, recommended intakes of vegetables and fruit remain woefully unchanged, despite continuing advice to markedly increase intake of these foods. Substantial, high-level barriers appear to impede achievement of these goals, including certain government regulations and policies. Chief among these are land use policy and economic incentives for food manufacturers. The food supply and access to it has changed dramatically over

the past 40 years, contributing to an overall increased calorie intake by many individuals. Since the 1970s, the number of fast food restaurants has increased 147 percent. The portions that are served in restaurants and the serving sizes of foods sold in packages at stores

have increased as well. Moreover, the number of food items at the supermarket has increased from 10,425 in

1978 to 46,852 in 2008, and most of these contribute SoFAS, refined grains, and sodium to the American diet (see Part D. Section 1. Energy Balance and Weight Management for a discussion of recent changes in the food environment). This has far-reaching effects such that the average child now consumes 365 calories per day of added sugars and 433 calories per day of solid fat for a combined total of 798 calories, or more than one- third of total calorie intake (HHS, 2010; see Part D. Section 2. Nutrient Adequacy). Conversely, Americans spend 45 percent less time preparing food at home (see Part D. Section 1. Energy Balance and Weight Management) or eating food at the family table than previously, and this behavioral trend is associated with increased risk of weight gain, overweight, and obesity. In this context, the DGAC concluded that mere repetition of advice will not effectively help Americans achieve these evidence-based and often- repeated goals for a healthy diet.

Ensuring that all Americans consume a health- promoting dietary pattern and achieve and maintain energy balance requires far more than individual behavior change. A multi-sectoral strategy is imperative. For this reason, the 2010 DGAC strongly

recommends that HHS and USDA convene appropriate committees, potentially through the Institute of

Medicine (IOM), to develop a strategic plan focusing on the behaviors and actions needed to successfully implement the four key 2010 DGAC recommendations highlighted above.

A coordinated strategic plan that includes all sectors of society, including individuals, families, educators, communities, allied health professionals, public health advocates, policy makers, scientists, and small and large businesses (e.g., farmers, agricultural producers, food scientists, food manufacturers, and food retailers of all kinds), should be engaged in developing and implementing the plan to help all Americans eat well,

be physically active, and maintain good health. It is important that any strategic plan be evidence-informed, action-oriented, and focused on changes in systems (IOM, 2010a). This systems approach is already underway in countries such as the United Kingdom for obesity prevention (Butland, 2007) with promising results. Recent examples of this approach in the U.S. include an IOM committee convened by HHS and USDA and charged with developing strategies for gradually but dramatically reducing sodium intake, which remains persistently high even after more than 40

2010 Dietary Guidelines Advisory Committee Report 53

years of advice. This IOM committee recently issued its report (IOM, 2010b), providing a comprehensive strategy to reduce dietary sodium intake in the general population by focusing on the food supply and targeting industry to partner in systematic reductions in sodium content of foods. Already there is encouraging evidence that food manufacturers are responding positively and are committed to reducing the sodium content in their food products. Similarly, the U.S. National Physical Activity Plan, released in May 2010, was developed by multiple stakeholders and provides a comprehensive, realistic implementation framework intended to promote physical activity in the American population. Most recently, the May 2010, White House Task Force on Childhood Obesity Report, Solving the Problem of Childhood Obesity Within a Generation, also calls for a multi-sector, systems approach to solving this important public health issue.

An Urgent Need to Focus on Children

Any and all systems-based strategies must include a focus on children. Primary prevention of obesity must begin in childhood. This is the single most powerful public health approach to combating and reversing America’s obesity epidemic over the long term. Trends for childhood overweight and obesity are alarming, with obesity prevalence rates tripling between 1980 and

2004. Although rates for children appear to be leveling off, they remain high, with one-third currently overweight or obese, defined as at or above the 85th percentile on body mass index (BMI)-for-age growth charts (Ogden, 2010). These numbers represent more than 25 million children in the U.S. In order to reverse this trend, we will need to work together as a Nation to improve the food environment to which children are exposed at home, school, and the community. Efforts to prevent childhood obesity need to start very early, even in utero. Increasing evidence indicates that maternal obesity before conception and excessive gestational weight gain represent a substantial risk of childhood obesity in the offspring (see Part D. Section 2. Energy Balance and Weight Management for a detailed discussion of this issue). Thus, addressing maternal nutrition, physical activity, and body weight before conception and during pregnancy as well as emphasizing early childhood nutrition is paramount for preventing the onset of childhood obesity. Areas targeting childhood obesity prevention that should be addressed include, but are not limited to:

Improve foods sold and served in schools, including school breakfast, lunch, and after-school meals and

competitive foods so that they meet the recommendations of the IOM report on school

meals (IOM, 2009) and the key findings of the 2010

DGAC. This includes all age groups of children, from preschool through high school.

Increase comprehensive health, nutrition, and physical education programs and curricula in U.S. schools and preschools, including food preparation, food safety, cooking, and physical education classes and improved quality of recess.

Develop nationally standardized approaches for health care providers to track BMI-for-age and provide guidance to children and their families to effectively prevent, monitor, and/or treat childhood obesity.

Develop nationally standardized approaches for health care providers to improve nutrition, physical activity participation, healthy weight gain during pregnancy, and the attainment of a healthy weight postpartum.

Increase safe routes to schools and community recreational areas to encourage active transportation and physical activity.

Remove sugar-sweetened beverages and high- calorie snacks from schools, recreation facilities, and other places where children gather.

Develop and enforce responsible zoning policies for the location of fast food restaurants near schools

and places where children play.

Increase awareness and promote action around reducing screen time (television and computer or game modules) and removing televisions from children’s bedrooms.

Develop and enforce effective policies regarding marketing of food and beverage products to

children. Efforts in this area are underway through a government interagency committee comprised of

the Federal Trade Commission, Centers for Disease Control and Prevention, USDA, and Food and Drug Administration, as well as some self-regulation

from industry (Omnibus Appropriations Act, 2009).

Develop affordable summer programs that support children’s health, as children gain the most weight during the out-of-school summer months (von Hippel, 2007).

Challenges and Opportunities for Change

Change is needed in the overall food environment to support the efforts of all Americans to meet the key recommendations of the 2010 DGAC (Story, 2009).

54 2010 Dietary Guidelines Advisory Committee Report

The 2010 DGAC recognizes that the current food environment does not adequately facilitate the ability of Americans to follow the evidence-based recommendations outlined in the 2010 DGAC Report. Population growth, availability of fresh water, arable land constraints, climate change, current policies, and business practices are among some of the major challenges that need to be addressed in order to ensure that these recommendations can be implemented nationally. For example, if every American were to

meet the vegetable, fruit, and whole-grain recommendations, domestic crop acreage would need to increase by an estimated 7.4 million harvested acres (Buzby, 2006). Furthermore, the environment does not facilitate the ability of individuals to follow the 2008

Physical Activity Guidelines for Americans. Most home, school, work, and community environments do not promote engagement in a physically active lifestyle. To meet these challenges, the following sustainable

changes must occur:

Improve nutrition literacy and cooking skills, and empower and motivate the population to prepare and consume healthy foods at home, especially among families with children.

For all Americans, especially those with low- income, create greater financial incentives to purchase, prepare, and consume vegetables and fruit, whole grains, seafood, fat-free and low-fat milk and milk products, lean meats, and other healthy foods. Currently, individuals have an economic disincentive to purchase healthy foods.

Improve the availability of affordable fresh produce through greater access to grocery stores, produce trucks, and farmers’ markets.

Increase environmentally sustainable production of vegetables, fruits, and fiber-rich whole grains.

Ensure household food security through measures that provide access to adequate amounts of foods that are nutritious and safe to eat.

Develop safe, effective, and sustainable practices to expand aquaculture and increase the availability of seafood to all segments of the population. Ensure that consumers have access to user-friendly benefit/risk information to make informed seafood choices.

Encourage restaurants and the food industry to offer health-promoting foods that are low in sodium; limited in SoFAS and refined grains; and served in smaller portions.

Implement the U.S. National Physical Activity Plan, a private-public sector collaborative promoting

local, state, and national programs and policies to increase physical activity and reduce sedentary activity (National Physical Activity Plan, 2010). Through the Plan and other initiatives, develop efforts across all sectors of society, including health care and public health; education; business and industry; mass media; parks, recreation, fitness, and sports; transportation, land use, and community design; and volunteer and non-profit. Reducing screen time, especially television, for all Americans also will be important.

The 2010 DGAC recognizes the significant challenges involved in implementing the goals outlined here. These challenges go beyond cost, economic interests, technological and societal changes, and agricultural limitations. Over the past several decades, the value of preparing and enjoying healthy food has eroded, leaving instead the practices of eating processed foods containing excessive sodium, solid fats, refined grains, and added sugars. As a Nation, we all need to value and adopt the practices of good nutrition, physical activity, and a healthy lifestyle. The DGAC encourages all stakeholders to take actions to make every choice available to Americans a healthy choice. To move toward this vision, all segments of society—from

parents to policy makers and everyone else in between—must now take responsibility and play a leadership role in creating gradual and steady change to help current and future generations live healthy and productive lives. A measure of success will be evidence that meaningful change has occurred when the 2015

DGAC convenes.

References

Butland B, Jebb S, Kopelman P, McPherson K, Thomas S, Mardell J, Parry V. Foresight. Tackling Obesities: Future Choice—Project Report. London (UK): Government Office for Science; 2007. http://www.foresight.gov.uk/Obesity/17.pdf. Accessed May 5, 2010.

Buzby JC, Wells HF, Vocke G. Possible Implications for U.S. Agriculture from Adoption of Select Dietary Guidelines. Washington, DC: U.S. Department of Agriculture, Economic Research Service Report No. (ERR-31); 2006.

2010 Dietary Guidelines Advisory Committee Report 55

Institute of Medicine (IOM). School Meals: Building Blocks for Healthy Children. Washington, DC: The National Academies Press; 2009.

Institute of Medicine (IOM). Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making. Washington, DC: The National Academies Press; 2010a.

Institute of Medicine (IOM). Strategies to Reduce Sodium Intake in the United States. Washington, DC: The National Academies Press; 2010b.

Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR, Troiano RP. Amount of Time Spent in Sedentary Behaviors in the United States,

2003–2004. Am J Epidemiol. 2008;167(7):875-81.

Metzger JS, Catellier DJ, Evenson KR, Treuth MS, Rosamond WD, Siega-Riz AM. Patterns of objectively measured physical activity in the United States. Med Sci Sports Exerc. 2008;40(4):630-38.

Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in U.S. children and adolescents, 2007-2008. JAMA.

2010;303(3):242-9.

Omnibus Appropriations Act, Pub. L. No. 111-8. 11

March 2009. Print.

Story M, Hamm MW, Wallinga D. Food systems and public health: linkages to achieve healthier diets and healthier communities. J Hunger and Environ Nut.

2009;4(3):219-24.

National Physical Activity Plan. The U.S. National Physical Activity Plan. http://www.physicalactivityplan.org/theplan.htm. Updated May 5, 2010. Accessed May 5, 2010.

U.S. Department of Health and Human Services (HHS).

2008 Physical Activity Guidelines for Americans. Washington, DC: U.S. Department of Health and Human Services. ODPHP Publication No. U0036;

2008. http://www.health.gov/paguidelines.

U.S. Department of Health and Human Services (HHS). Sources of Selected Nutrients among the U.S. Population, 2005-06. Risk Factor Monitoring and Methods Branch Website. Applied Research Program. National Cancer Institute. http://riskfactor.cancer.gov/diet/foodsources/. Accessed May 5, 2010.

von Hippel PT, Powell B, Downey DB, Rowland NJ. The effect of school on overweight in childhood: gain in body mass index during the school year and during summer vacation. Am J Public Health. 2007;97(4):696–

702.

56 2010 Dietary Guidelines Advisory Committee Report

Part B. Section 3: Translating and Integrating the Evidence: A Call to Action (ingunter.wordpress.com)
Step Up to the Plate Demystifying the government’s new dietary guidelines (theinsider.retailmenot.com)
2011 Dietary Guidelines Take Effect (foodservicewarehouse.com)
What’s Causing the Obesity Epidemic (theness.com)
Higher-protein diets can improve appetite control and satiety (eurekalert.org)
New Dietary Guidelines on Salt Drastic, Simplistic, Unrealistic (prweb.com)
The Financial Cost of Obesity (getrichslowly.org)
Eating location, food source determine childhood obesity (news.bioscholar.com)
Higher-protein diets can improve appetite control and satiety (biosingularity.com)
Obesity And Weight loss with Photoshop (cardsmall.wordpress.com)

Part B. Section 2. Appendix: Dietary Patterns and Health Outcomes June 8, 2011

Posted by ADAM PARTNERS in DIETRY GUIDELINES FOR AMERICANS.
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Part B. Section 2. Appendix: Dietary

Patterns and Health Outcomes

Introduction

Across the world and within the United States, there are striking differences in diet. Concomitantly, there are substantial differences in health outcomes, many of which are related to diet. This section discusses several dietary patterns that are associated with desirable health outcomes. It focuses on total mortality, cardiovascular disease (CVD), and blood pressure, a major diet-related cardiovascular risk factor. The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR), recently reviewed the available evidence of the relationship of cancer with specific dietary factors and overall dietary patterns (WCRF/AICR, 2007). Although several dietary factors were associated with specific types of cancer, it concluded that no firm judgment can be made on the relationship of dietary patterns with cancer, in large

part, because variability in definitions precluded a formal synthesis of evidence.

The study of dietary patterns is complex. First, there is substantial heterogeneity even among diets that fall under a common rubric (e.g., Mediterranean diets). Second, dietary patterns are not static. Traditional diets known for their health benefits (e.g., Mediterranean and Okinawan diets) are being supplanted by versions that often reflect Western culture and that lead to worse not better health outcomes. For this reason, we focused on pre-transition dietary patterns. Third, with few exceptions, standardized assessment of diet is unavailable, making it difficult to compare diets.

Fourth, health outcomes are often unavailable and, when available, are not directly comparable across studies. Fifth, dietary patterns, even with proven health benefits, may not be ideal and could be improved. For example, traditional Japanese diets are associated with a low risk of coronary heart disease but a high risk of stroke, likely because of excessive sodium intake. Sixth, describing dietary patterns and evaluating their health outcomes often requires scoring systems based on adherence to specific aspects of the diets. This approach commonly relies on researchers who exercise best judgment in selecting biologically relevant aspects of

the diet and in developing a formula, which typically

weights each dimension as of equivalent importance. Seventh, in the interpretation of observational data, particularly ecologic data, it is difficult to separate the effects of diet from other factors, such as smoking and physical inactivity, that likely account for part of the observed differences in health outcomes.

Despite these caveats, the 2010 Dietary Guidelines Advisory Committee (DGAC) was able to identify dietary patterns that are associated with substantial beneficial health benefits (Table B2.5). Specifically, the Committee focused on the following dietary patterns for which there was research on health outcomes as well as information on nutrient and food group composition:

(1) Dietary Approaches to Stop Hypertension (DASH)- style dietary patterns, (2) Mediterranean-style dietary patterns, and (3) Vegetarian dietary patterns. The DASH dietary pattern is a Western-style dietary pattern for which a large and burgeoning literature documents its health benefits. The Committee also included Mediterranean and Japanese dietary patterns, which were associated with the lowest risk of coronary heart disease in the Seven Countries study (Keys, 1980). Subsequently, a substantial literature has documented the health benefits of Mediterranean-style diets. In contrast, while traditional Asian dietary patterns (e.g.,

Japanese and Okinawan dietary patterns) have also been associated with a reduced risk of coronary heart disease (Wilcox, 2007), documentation using contemporary research methods is scant. Finally, the Committee studied vegetarian diets, which have been associated with a reduced risk of coronary heart disease (Key,

1999).

DASH-style Dietary Patterns

DASH-style dietary patterns emphasize fruits, vegetables, and low-fat dairy products; include whole grains, poultry, fish and nuts; and are reduced in red meat, sweets, and sugar-containing beverages (Karanja,

1999; Craddick, 2003). The diets are rich in potassium, magnesium, calcium and fiber, and reduced in saturated fat and cholesterol. As originally tested, the DASH diet is reduced in total fat (27% kcal) with total protein

2010 Dietary Guidelines Advisory Committee Report 27

intake of 18 percent of calories and carbohydrate intake of 55 percent of calories. However, other versions of the DASH diet are available, in which carbohydrate is partially replaced with protein (about half from plant sources) or unsaturated fat (predominantly monounsaturated fat) (Appel, 2005; Swain, 2008). The latter version is noteworthy because nutrient adequacy and a reduced saturated fat intake (6% kcal) were both achieved in the setting of high monounsaturated fat intake (21% kcal). Each of these DASH-style diets lowers blood pressure, improves blood lipids, and reduces CVD risk. Blood pressure reduction is the greatest when the DASH diet is consumed with reduced sodium intake (Sacks, 2001).

As originally developed, the DASH diet was designed to provide a nutrient profile that might lower blood pressure. As such, it is a derived dietary pattern. Nonetheless, it is based on foods that are routinely available in U.S. and was studied using foods purchased at local stores. At present, few adults, even those with hypertension, eat a diet that is consistent with the

DASH dietary pattern (Mellen, 2008).

Mediterranean-style Dietary Patterns

In view of the large number of cultures and agricultural patterns of countries that border the Mediterranean Sea, the “Mediterranean” diet is not a single dietary pattern. Countries included those of southern-most Europe, the Middle East, and northern-most Africa. Interest in traditional Mediterranean-style diets is substantial because such diets have been associated with considerable health benefits. Because of the multiplicity of dietary patterns termed “Mediterranean,” it has been challenging to characterize these diets. Although a traditional Mediterranean diet has no well-accepted set of criteria, it can be described as one that emphasizes breads and other cereal foods usually made from wheat, vegetables, fruits, nuts, unrefined cereals, and olive oil; includes fish and wine with meals (in non-Islamic countries); and is reduced in saturated fat, meat, and

full-fat dairy products (Kris-Etherton, 2001; Trichopoulou, 2003; WCRF/AICR, 2007). Table B2.5 displays the nutrient profile and food group composition of Mediterranean-style diets, as reported in three cohort studies (one from Greece, one from Spain, and one from the U.S.) (Fung, 2009; Karanja, 1999; Lin, 2003;

Nunez-Cordoba, 2008; Trichopoulou, 2003; Wilcox,

2007).

Results from observational studies and clinical trials suggest that consumption of a traditional Mediterranean diet, similar to that of Crete in the 1960s, is associated with one of the lowest risks of coronary heart disease in the world. Over time, the diet of Crete has changed remarkably and is now characterized by higher intake of saturated fat and cholesterol, and reduced intake of monounsaturated fats. At the same time, total fat consumption has fallen. These trends have been accompanied by a steady rise in coronary heart disease risk (Menotti, 1999).

Vegetarian Dietary Patterns

In many observational studies, vegetarian diets and lifestyle have been associated with improved health outcomes. The types of vegetarian diets consumed in the U.S. vary considerably. Strict vegetarians (i.e., vegans), do not consume any animal products, while other types of vegetarians, such as lacto-ovo

vegetarians, consume milk and eggs. Although not strict vegetarians, many individuals consume small or

minimal amounts of animal products. On average, vegetarians consume fewer calories from fat than non- vegetarians, particularly saturated fat, and have a higher consumption of carbohydrates than non-vegetarians. In addition, vegetarians tend to consume fewer overall calories and have a lower body mass index than non- vegetarians. These characteristics, in addition to the dietary pattern per se, may contribute to the improved health outcomes of vegetarians.

Although no or minimal consumption of animal products is a hallmark of vegetarian diets, these diets have a clear potential for confounding, particularly from other dietary and non-dietary factors. Hence, the improved health experience of vegetarians may not only result from reduced consumption of saturated fats but also from greater consumption of vegetables, fruit, nuts, and grains or from other health attributes, such as not smoking cigarettes.

Other Dietary Patterns

In view of the increasing diversity of the U.S. population, interest in the health effects of non-Western diets is substantial. One group of diets with potential health benefits are those consumed in Asia. It is well- documented that in Southeast Asia, coronary heart disease rates have been among the lowest in the world.

28 2010 Dietary Guidelines Advisory Committee Report

Lifestyle factors, especially diet, appear to be a major reason. However, contemporary evidence (e.g., prospective cohort studies and clinical trials) similar to the evidence available for the other types of diets is sparse.

Traditional Japanese dietary patterns emphasize soybean products, fish, seaweeds, vegetables, fruit, and green tea, and are reduced in meats (Shimazu, 2007). Nonetheless, it should be recognized that this diet is high in salt, likely accounting for the high incidence of stroke in this population. Similar to other dietary patterns, Japanese dietary patterns have evolved over time.

The longevity of Okinawans is among the highest in the world. Researchers attribute the longevity and health of Okinawans, in large part, to diet composition or some other aspect of their diet, such as energy restriction (Willcox, 2007). The indigenous Satsamu sweet potato, which is rich in nutrients, is the food staple that

provides the bulk of energy intake. Other prominent foods are a wide variety of seaweeds, Okinawan tofu, and herbaceous plants. Okinawan food culture also includes a modest amount of fish and pork. The estimated carbohydrate content of this diet is extremely high, at more than 80 percent of calories. Salt intake is the lowest of all Japan. However, the traditional Okinawan diet has changed such that fast foods and processed foods are increasingly consumed.

What is the Effect of Different Dietary Patterns (DASH, Mediterranean, Vegetarian, and Other) on Blood Pressure in Adults?

The 2010 DGAC performed a literature search to identify research, with no date limits, on the effect of the above dietary patterns on blood pressure in adults. Some articles were reviewed that included dietary patterns that were characterized using dietary cluster or

factor analysis. The NEL search identified 146 potential articles (11 reviews/meta-analyses and 135 primary studies). Of these, 126 were excluded. A total of 20 articles, all of them primary studies, met the eligibility criteria and were reviewed (Table B2.6).

Of the 12 studies that evaluated a DASH-style dietary pattern (Appel, 2005, 1997, 2003; Azadbakht, 2005; Dauchet, 2007; Forman, 2009; Miller, 2002; Nowson,

2009, 2005, 2004; Sacks, 2001; Schulze, 2003), nine were randomized controlled trials (Appel, 2005, 1997,

2003; Azadbakht, 2005; Miller, 2002; Nowson, 2009,

2005, 2004; Sacks, 2001), and three were prospective cohort studies (Dauchet, 2007; Forman, 2009; Schulze,

2003). In aggregate, the DASH diet lowered systolic blood pressure in 12 studies (Appel, 2005, 1997, 2003; Azadbakht, 2005; Dauchet, 2007; Forman, 2009; Miller, 2002; Nowson, 2009, 2005, 2004; Sacks, 2001;

Schulze, 2003) and diastolic blood pressure in 10 of the

12 studies that reported diastolic blood pressure (Appel,

2005, 1997, 2003; Azadbakht, 2005; Dauchet, 2007; Forman, 2009; Miller, 2002; Nowson, 2005, 2004; Schulze, 2003). In several instances, blood pressure reduction occurred as part of a multi-factorial intervention that tested the DASH dietary pattern concomitantly with other interventions (Appel, 2003; Miller, 2002; Sacks, 2001).

Few studies examined the effects of a Mediterranean- style diet on blood pressure. In the one available study (Núñez-Córdoba, 2009) a cohort study, a Mediterranean-style diet lowered systolic and diastolic blood pressure.

Four trials tested the effects of vegetarian diets on blood pressure (Hakala and Karvetti, 1989; Margetts, 1986; Rouse, 1983; Sciarrone 1993). Vegetarian-style dietary patterns lowered systolic blood pressure in all four trials and diastolic blood pressure in three trials (Hakala and Karvetti, 1989; Rouse, 1983; Sciarrone, 1993).

One randomized, cross-over trial found that, within the context of a traditional Japanese diet, increased vegetables and fruit intake and decreased sodium intake significantly reduced systolic blood pressure in normotensive and hypertensive free-living rural Japanese (Takahashi, 2006).

What is the Effect of Different Dietary Patterns (DASH, Mediterranean, Vegetarian, and Other) on Cardiovascular Disease, Stroke, and Total Mortality in Adults?

The 2010 DGAC performed a literature search to identify research, with no date limits, on the effect of these dietary patterns on cardiovascular disease, stroke, and total mortality in adults. Some articles were reviewed that included dietary patterns that were characterized using dietary clusters or factor analysis. The search identified 197 potential articles (11 reviews/meta-analyses and 186 primary studies). Of

2010 Dietary Guidelines Advisory Committee Report 29

these, 168 were excluded. A total of 29 articles (27 primary studies, one systematic review/meta-analysis, and one systematic review), met the eligibility criteria and were reviewed. Of the 27 primary studies, two were randomized controlled trials, 20 were prospective

cohort studies (two were follow-up of RCTs and one was non-concurrent), three were case-control studies, one was a med adherence analysis, and one was a time series (Table B2.7).

Of the 10 studies that evaluated a DASH-style dietary pattern, nine were prospective cohort studies (Folsom,

2007; Fung, 2001, 2008; Heidemann, 2008; Hu, 2000; Levitan, 2009; Osler, 2001; Parikh, 2009; Singman,

1980) and one was a randomized trial in which estimated coronary heart disease risk was the outcome (Appel, 2005). Of the 10 that evaluated a relationship of a DASH-style dietary pattern with CVD, nine studies documented that consumption of a DASH-style diet was associated with a reduced risk of CVD (Appel, 2005; Fung, 2001, 2008; Heidemann, 2008; Hu, 2000;

Levitan, 2009; Osler, 2001; Parikh, 2009; Singman,

1980), and one (Folsom, 2007) found no such relationship. For total mortality, six of seven studies that reported data on mortality documented an inverse relation (Fung, 2008; Heidemann, 2008; Hu, 2000; Levitan, 2009; Osler, 2001; Parikh, 2009) and one (Folsom, 2007) found no such relationship. In the two available studies with stroke (Fung, 2008; Parikh,

2009), consumption of a DASH-style pattern prevented stroke.

Several studies examined the effects of a Mediterranean style diet on CVD and total mortality. Of the 13 studies, one was a systematic review/meta-analysis (Mente,

2009), one was a meta-analysis (Sofi, 2008), nine were prospective cohort studies (Fidanza, 2004; Fung, 2009; Harriss, 2007; Knoops, 2004; Mitrou, 2007; Panagiotakos, 2009; Trichopoulou, 2003, 2009; Waijers, 2006), one was an adherence analysis (Alberti,

2008), and one was a case-control study (Panagiotakos,

2005). Of the 10 studies that evaluated a relationship of a Mediterranean-style dietary pattern with CVD, each documented a beneficial effect (Fidanza, 2004; Fung,

2009; Harriss, 2007; Knoops, 2004; Mente, 2009; Mitrou, 2007; Panagiotakos, 2009, 2005; Sofi, 2008; Trichopoulou, 2003). Likewise, of the 10 studies with data on total mortality, each documented an inverse relation (Alberti, 2008; Fidanza, 2004; Fung, 2009; Harriss, 2007; Knoops, 2004; Mitrou, 2007; Sofi, 2008; Trichopoulou, 2003, 2009; Waijers, 2006). In the one available study with stroke, consumption of a

Mediterranean-style pattern prevented stroke (Fung,

2009).

Five studies examined the effects of a vegetarian diet on CVD and total mortality. Of the five studies, three were prospective cohort studies (Chang-Claude, 2005; Key,

1996; Mann, 1997), one was a meta-analysis (Key,

1998), and one was a time series analysis (Fraser,

2005). Of the five studies with CVD as the study outcome, all found that vegetarian diets were associated with a reduced risk of CVD compared to non-vegetarian diets (Chang-Claude, 2005; Fraser, 2005; Key, 1998,

1996; Mann, 1997). For total mortality, four studies (Fraser, 2005; Key, 1998, 1996; Mann, 1997) documented that a vegetarian diet was associated with a reduced risk of death, and one study (Chang-Claude,

2005) did not detect an association.

One prospective cohort study (Shimazu, 2007) assessed the association between dietary patterns among the Japanese and CVD mortality. Three diet patterns were identified: (1) Japanese pattern including soybean products, fish, seaweed, vegetables, fruit and green tea, (2) animal food pattern, and (3) high-dairy, high-fruit and vegetable, low alcohol (DFA) pattern. The Japanese pattern was associated with a decreased risk of CVD mortality, while the animal food pattern was associated with increased risk. The DFA pattern was not significantly associated with a change in CVD risk.

Conclusion

The totality of evidence documenting a beneficial impact of plant-based, lower-sodium dietary patterns on CVD risk is remarkable. Indeed, several distinct dietary patterns are associated with lower blood pressure and a reduced risk of CVD and total mortality. When explicitly tested, a reduced sodium intake further lowers blood pressure. A common feature of these diets is an emphasis on plant-based foods. Accordingly, fiber

intake is high while saturated fat typically low. When total fat intake is high, that is, over 30 percent of calories, the predominant fat is monounsaturated or polyunsaturated fat. Carbohydrate intake is often, but not necessarily high; the predominant forms appear to be complex carbohydrates, often from whole grain products with minimal processing.

30 2010 Dietary Guidelines Advisory Committee Report

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34 2010 Dietary Guidelines Advisory Committee Report

Table B2.5. Selected dietary patterns with documented cardiovascular health benefits (adjusted to 2000 calories)

Dietary Pattern	DASH with Reduced Sodium	Mediterranean Diet (Greece)	Mediterranean Diet (Spain)	Mediterranean Diet (U.S.)	Japanese	Okinawan
Citation	Karanja et al, 1999	Trichopoulou et al,	Nunez-Cordoba	Fung et al, 2009	Wilcox et al, 2007	Wilcox et al, 2007
	and Lin et al, 2003	NEJM 2003	2008 (SUN Study;		(Circa 1950)	(Circa 1949)
			MAI high score)
Qualitative
Description Emphasizes	Potassium-rich	Plant- foods,	Plant- foods,	Plant foods,	Rice, legumes, soy	Plant-foods,
	vegetables, fruits,	vegetables, fruits,	vegetables, fruits,	vegetables, fruits,	foods, vegetables,	primarily
	and low-fat dairy	grains, beans, nuts	breads, other cereals	whole grains,	seaweed, and fish	Okinawan sweet
	products	and seeds, olive oil,	potatoes, beans, nuts	legumes,		potatoes, rice,
		and fish	and seeds, olive oil,	fish		legumes, soy foods,
			and fish			other vegetables,
						and nutrient rich
						foods of low energy
						density
Includes	Whole grains,	Lean meat	Cheese, yogurt	Lean meat	Fruit
	poultry, fish, and	Red wine	Red wine		Meat and eggs
	nuts
Limits (small	Red meats, sweets,		Red meat	Potatoes	Milk products	Fruit
amount)	and sugar-		Sweets			Meat, eggs
	containing					Milk products
	beverages
Nutrients Calories (kcal)	2000	2000	2000	2000	2000	2000
Carbohydrates	58%	nd	47%	39.1%	79%	85%
(% total kcal)
Protein	18%	nd	18%	15.1%	13%	9%
(% total kcal)
Total Fat	27%	~42.7 (summed)	33%	nd	8%	6%
(% total kcal)
Saturated Fat	7%	13.1 %	10%	10% (Incl. trans)	2.0%	1.9%
(% total kcal)
Monounsaturated	10%	22.7%	15 %	9.5%	2.3%	1.8%

(% total kcal)

Table B2.5 (continued). Selected dietary patterns with documented cardiovascular health benefits (adjusted to 2000 calories)

Dietary Pattern	DASH with Reduced Sodium	Mediterranean Diet (Greece)	Mediterranean Diet (Spain)	Mediterranean Diet (U.S.)	Japanese	Okinawan
Polyunsaturated	8%	6.9%	5.1 %	nd	3.5%	2.4%
(% total kcal)
Cholesterol (mg)	143	nd	nd	nd	nd	nd
Fiber (g)	29	nd	29	20	22	26
Potassium (mg)	4371	nd	4589	nd	2623	5826
Sodium (mg)	1095	nd	2532	nd	2370	1269
Food Groups
Vegetables: total	2.1	4.1	1.2	2.2	nd	nd
(c)
– Dark Green (c)	nd	nd	nd	nd	<0.1 (seaweed)	<0.1 (sea weed)
– Legumes2(c)	nd	<0.1	0.4	0.3	0.3	0.5
– Red Orange (c)	nd	nd	nd	nd	0.5 (Asian sweet	6.6 (Asian sweet
					potatoes)	potatoes)
– Other Veg (c)	nd	nd	nd	nd	1.3;	0.9
					+ 0.3 (pickled veg)
– Starchy Veg (c)	nd	0.6	nd	No potatoes	0.3 (other potatoes)	<0.1 (other
						potatoes)
Fruit & juices (c)	2.5	1.0 (fruit & nuts)	1.3 (fruit & juice)	1.6	0.2 (papaya & tomato	<0.1 (papaya &
		1.5 (juice & other	0.1 (dried fruit &		= veg)	tomato = veg)
		bev)	nuts)
Grains: total (oz)	7.3	5.4	2.0	nd	2.4;	1.1;
					1.7 (rice)	0.9 (rice)
– Whole grains	3.9	nd	nd	1.6	nd	nd
(oz)
Milk & milk	0.7	1.0	0.8	nd	<0.1	<0.1
products, Whole
– Low-fat (c)	1.9	nd	1.3	nd	nd	nd

Table B2.5 (continued). Selected dietary patterns with documented cardiovascular health benefits (adjusted to 2000 calories)

Dietary Pattern	DASH with Reduced Sodium	Mediterranean Diet (Greece)	Mediterranean Diet (Spain)	Mediterranean Diet (U.S.)	Japanese	Okinawan
Animal Proteins: – Meat (oz)	1.4	3.5	3.6	2.4	0.4	0.1
– Poultry (oz)	1.7	nd	nd	nd	nd	nd
– Eggs (oz)	nd	nd	1.9	nd	0.3	<0.1
– Fish (total) (oz)	1.4	0.8	2.4	1.5	2.1	0.6
— Hi n3 (oz)	nd	nd	nd	nd	nd	nd
— Low n3 (oz)	nd	nd	nd	nd	nd	nd
– Legumes (oz)	0.4	nd	0.4	nd	0.4 (Incl soy)	0.3 (Incl soy)
– Nuts & seeds	0.9	See fruit above.	See fruit above.	0.5	< 1 g	<0.1
– Soy products (oz)	nd	nd		nd	See legumes.	See legumes.
Oils (g)	24.8	40.3 (olive oil)	19.0 (olive oil)	nd	nd	nd
Solid Fats (g)	nd	nd	nd	nd	nd	nd
Added Sugar (g)	12	24.3	nd	nd	7.7	3.4
Alcohol (g)	Nd	7.92	7.1 (red wine)	7.3	30.0 (flavors and alcohol)	7.8 (flavors and alcohol)

Plant Proteins:

(oz)

Table B2.6. Dietary patterns and blood pressure in adults

Author and Year	Study Type	Quality	Population/Location	Sig SBP Reduction	Sig DBP Reduction	Caveats
DASH	N = 12 (9 RCT, 3 prospective cohort)	12 Positive 2 Neutral		12 +	10 + 1 Ø 1 n/d
Appel LJ et al., 2005	RCT (OmniHeart)	Positive	N = 164 adult with prehypertension or stage 1 hypertension U.S.	+	+	Overall Between Diet Differences – SBP: Pro vs.Cho diet: P =0.002; Unsat Fat vs. Cho: P = 0.005 DBP: Pro vs.Cho diet: P <0.001; Unsat Fat vs. Cho: P = 0.02
Appel LJ et al., 1997	RCT	Positive	N = 459; 234 males; 225 females Normo and hypertensive subjects U.S.	+	+	SBP: P< 0.001 DBP: Males P <0.001; Females P = 0.003
Appel LJ et al., 2003	RCT	Positive	N = 810 free living adults Normo and Hypertensive U.S.	+	+	SBP and DBP: P <0.001
Azadbakht L et al., 2005	RCT	Neutral	N =116 subjects with metabolic syndrome BP > 130/85 Iran	+	+	For both men and women P<0.001
Dauchet L et al., 2007	Longitudinal and cross- sectional analysis	Positive	N= 6,119 (2596 men, 3523 women); free living France	+	+	SBP: P <0.05 DBP: P < 0.01 Longitudinal results: DASH score: SBP: P<0.002; DBP: P<0.02

Table B2.6 (continued). Dietary patterns and blood pressure in adults

Author and Year	Study Type	Quality	Population/Location	Sig SBP Reduction	Sig DBP Reduction	Caveats
Forman JP et al., 2009	Prospective cohort study	Positive	N = 83,882 females; Nurse’s Health Study II Normotensive U.S.	+	+	Outcome in multivariate HR (95% CI) for incident HTN
Miller ER et al., 2002	RCT	Positive	N = 43 U.S.	+	+	SBP, DBP: P <0.001
Nowson CA et al., 2009	RCT	Positive	N = 111 females (menopausal) Australia	+ + **	Ø +**	SBP: P = 0.38, 0.21 DBP: P = 0.61, 0.27 ** With HTN meds
DASH	N = 12 (9 RCT, 3 prospective cohort)	12 Positive 2 Neutral		12 +	10 + 1 Ø 1 n/d
Nowson CA et al., 2004	RCT	Positive	N = 94 males and females Australia	+	+	SBP: P = 0.001 DBP: P = 0.05
Sacks FM et al., 2001	RCT (cross- over)	Positive	N = 390 (males, females; black and white) U.S.	+	n/d	SBP: P < 0.001
Schulze MB et al., 2003	Prospective cohort study	Positive	N = 8,552 females Normotensive Germany	+	+	HR (95% CI) for incident HTN

Table B2.6 (continued). Dietary patterns and blood pressure in adults

Author and Year	Study Type	Quality	Population/Location	Sig SBP Reduction	Sig DBP Reduction	Caveats
MEDITERRANEAN	N = 1 cohort	1 Positive		1+	1+
Núñez-Córdoba JM et al., AJE 2009	Prospective cohort study (6 yr f/u)	Positive	N = 9,408 adults; 3,583 males, 5,825 females Spain	+	+	SBP: P = 0.01 DBP: P = 0.05
VEGETARIAN	N = 4 RCT	3Positive 1 Neutral		4+	3 + 1 Ø
Hakala P and Karvetti RL, 1989	RCT	Positive	N = 110 adults Finland	+	+	SBP: P = 0.05 DBP: P = 0.01
Margetts BM et al., 1986	RCT (cross- over)	Neutral	N = 58; 42 males, 16 females Untreated mild hypertensives Australia	+	Ø	SBP: P , 0.05
Rouse IL et al., 1983	RCT (cross- over)	Positive	N = 59 males and females Australia	+	+	SBP, DBP: P <0.01
Sciarrone SE et al., 1993	RCT	Positive	N = 21 males Australia	+	+	Ovo-lacto vegetarian
JAPANESE/OKINAWAN	N = 1 RCT	1 Positive		1+	1 Ø
Takahashi Y 2006	RCT	Positive	N = 550 (202 males, 348 females) Japan	+	Ø	SBP: P = 0.007 Japanese diet with ↑Vitamin C, carotene, Fruits and vegetables ↓ Sodium intake

Table B2.7. Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/

Quality/Study Type

Population/

Location

CVD

Mortality

Outcomes

Comments/Caveats

DASH and DASH Variations

N=10

1 RCT

9 Cohort

Appel et al., 2005

Randomized, 3-period

Crossover Trial

Positive

N=164

(mean age = 53.6 yr; 45% women)

Omni-Heart

U.S.

Compared with baseline, all diets lowered estimated

CHD risk. Compared with the high carbohydrate

diet, estimated 10-yr CHD risk was lower and similar on the high protein and high unsaturated fat diets.

Compared to high carbohydrate diet, high UFA diet decreased SBP; increased HDL-C; decreased TG, no change in LDL-C

Addresses total fat question:

High UFA diet replaced 10% energy from CHO (total fat=37% E; 21% MUFA; 10% PUFA; 6% SFA). High UFA improved CHD risk, BP, and serum lipids, compared to high CHO (SFA constant).

Folsom et al., 2007

Prospective Cohort

Study

Neutral

N = 20,993, 55-

69 yrs at baseline

Iowa Women’s

Health Study

Non-hypertensive

Incidence of hypertension inversely associated w/

degree of concordance with DASH diet (P for trend

= 0.02),

After adjustment for additional risk factors, little evidence that any endpoint assoc w/ DASH score

DASH diet concordance score

calculated w/ baseline FFQ in

1986, subjects followed through

2002.

Fung et al., 2001

Prospective Cohort

Study

Positive

N = 69,017, 38 –

63 yrs at baseline

Nurses’ Health

Study

U.S.

Higher Prudent-pattern score assoc w/ lower risk total CHD (RR Q5 vs Q1=0.61, 95% CI: 0.49-0.76, P for trend <0.001); after adjustment for BMI, smoking, caloric intake, supplemental use, hormone replacement therapy, and other coronary risk factors (RR=0.76, 95% CI: 0.60-0.98, P for trend = 0.03). Higher Western-pattern score assoc w/ higher risk total MI after adjusting for age (RR Q5 versus Q1=

1.44, 95% CI: 1.16-1.78, P for trend <.001);

remained sig. after multivariate adjustment

(RR=1.46, 95% CI: 1.07-1.99).

12 y follow-up: 1984-1996

Baseline=1984

All FQQs using 1984 format

(116 item)

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/

Quality/Study Type

Population/

Location

CVD

Mortality

Outcomes

Comments/Caveats

Fung et al., 2008

Prospective Cohort

Study

Positive

N = 88,517, 34 –

59 yrs at baseline

Nurses’ Health

Study

U.S.

and

Stroke

RR of CHD across quintiles of DASH score = 1.0,

0.99, 0.86, 0.87 and 0.76 (95% CI: 0.67 – 0.85, P for trend <0.001)

Magnitude of risk difference was similar for nonfatal

MI and fatal CHD

DASH score assoc w/ ↓ risk of stroke

24y follow-up: 1980-2004

Baseline=1980

Included data from older 1980

FFQ (61 item) and 1984 FFQ

Heidemann et al.,

2008

Prospective Cohort

Study

Positive

N = 72,113

Nurses’ Health

Study

U.S.

Prudent pattern assoc w/ 28% lower risk of

cardiovascular mortality and 17% lower risk of all- cause mortality,

Western pattern assoc w/ 22% higher risk of cardiovascular mortality, 16% higher risk of cancer, and 21% higher risk of all-cause mortality.

18 y follow-up: 1984-2002

Baseline=1984

All FQQs using 1984 format

(116 item)

DASH and DASH

Variations

N=10

1 RCT

9 Cohort

Hu et al., 2000

Prospective Cohort

Study

Positive

N=44,875 men,

40-75 y at baseline

Health Professionals Follow-up Study

Two patterns explaining < 20% of the variance identified by factor analysis: Prudent and Western

Higher Prudent score assoc w/ monotonic lower risk of CHD (RR across quintiles: 1.0, 0.84, 0.76,

0.71, 0.66 (95% CI: 0.54-0.80, P for trend < 0.0001

For fatal CHD after adjustment for age, smoking, BMI, and other CHD risk factors (RR across increasing quintiles: 1.0, 0.83, 0.78, 0.81, 0.70 (95% CI: 0.54, 0.91, P for trend=0.03

Higher Western score assoc w/ monotonic higher risk of CHD (RR across quintiles (P<0.0001)

CHD RR (highest Prudent vs lowest Western) = 0.50 (95% CI: 0.34, 0.74).

8 y follow-up from 1986

Authors conclude dietary patterns derived from their FFQ predict CHD risk independent of other lifestyle factors.

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/

Quality/Study Type

Population/

Location

CVD

Mortality

Outcomes

Comments/Caveats

Levitan et al., 2009

Prospective Cohort

Study

Neutral

36,019 women,

48-83 y at baseline

Swedish Mammography Cohort

Top quartile of DASH score had 37% lower rate of

heart failure (HF); rate ratios across quartiles = 1 (ref), 0.85 (95% CI: 0.66-1.11), 0.69 (95% CI: 0.54-

0.88), and 0.63 (95% CI: 0.48-0.81), P for trend

<0.001.

Both HF-assoc hospitalization and death were determined

7 y follow-up; dietary intake

only measured at baseline

Hypertension was based on self-report.

Osler et al., 2001

Prospective Cohort

Study

Neutral

N= 5,872 (2,994

men, 2,878 women) Random equal- sized samples

30,40,50, 60-y at baseline

Danish World Health Organization MONICA survey

Prudent pattern inversely assoc w/ all-cause (hazard

ratios =0.63 in women =0.75 in men) and cardiovascular mortality

Western pattern not associated w/ mortality

Parikh et al., 2009

Prospective Cohort

Study

Neutral

N=5532 adults w/

hypertension NHANES III (1988-1994) U.S.

and

Stroke

DASH-like group had lower unadjusted mortality

rates per 1,000 person-yrs for all-cause mortality (P=0.02), stroke mortality (P<0.001), and cancer mortality (P=0.05).

DASH-like group, after adjusting for multiple confounders, assoc w/ lower mortality from all causes (HR=0.69, 95% CI 0.52-0.92, P=0.01) and stroke (HR=0.11, 95% CI 0.03-0.47, P=0.003).

CVD mortality risk (HR=0.92, 95% CI 0.63-1.35, P=0.67), IHD (HR=0.77, 95% CI 0.47-1.14, P=0.28), and cancer (HR=0.51, 95% CI 0.23-1.10, P=0.09) not stat significant

8.2 person-years follow-up

Secondary outcomes included specific causes of mortality CVD, ischemic heart disease, stroke, and cancer

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/ Quality/Study Type	Population/ Location	CVD	Mortality	Outcomes	Comments/Caveats
DASH and DASH Variations	N=10 1 RCT 9 Cohort
Singman et al., 1980 Prospective Cohort Study Neutral	N=1,113 men experimental and 467 men control U.S.	+	nd	Prudent diet group in both age categories (40-49 y & 50-59 y) had lower CHD incidence rates
MEDITERRANEAN	N=13 1 Index 1 Systematic Rev 1 Meta Analysis 9 Cohort 1 Case Control
Alberti et al., 2008 Analysis of Mediterranean Adequacy Index (MAI) Neutral	5 data sets on 23 populations	ND	+	Inverse correlation between MAI and 25 y CHD death rate and total mortality	MAI: divide the sum of the percentages of dietary energy from food groups typical of a healthy reference Mediterranean diet, by the sum of the percentages of dietary energy of food groups that are not characteristic of a healthy reference Mediterranean diet
Fidanza et al., 2004 Prospective Cohort Study Neutral	N=12,763 men, 40-59 yrs at baseline U.S.	+	+	The coefficient of linear correlation between the MAI and CHD death rates in the 16 cohorts was – 0.72 (P=0.001)	MAI Index

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/

Quality/Study Type

Population/

Location

CVD

Mortality

Outcomes

Comments/Caveats

Fung et al., 2009

Prospective Cohort

Study

Neutral

N = 76,522 , 38 –

63 yrs at baseline

Nurses’ Health

Study

U.S.

and

Stroke

Top aMed quintile ↓risk CHD and stroke: RR CHD

= 0.71, 95% CI: 0.62-0.82, P for trend < 0.0001, RR

stroke = 0.87, 95% CI: 0.73-1.02, P for trend = 0.03

CVD mortality ↓: top quintile RR=0.61, 95%

CI:0.49-0.76, P for trend <0.0001

20 y follow-up: 1984-2004

Baseline=1984

All FQQs using 1984 format

Harriss et al., 2007

Prospective Cohort

Study

Neutral

N= 40,653

(16,673 men,

23,908 women)

Melbourne Collaborative Study

Mediterranean dietary factor inversely assoc w/ CVD

and IHD mortality

IHD, HR (highest compared w/ lowest quartile) =

0.59 (95% CI: 0.39-0.89, P for trend=0.03)

Excluding subjects w/ prior CVD (HR=0.51, 95% CI: 0.30-0.88, P for trend = 0.03)

Mean follow-up = 10.4 y

Involved migrants to Australia from Mediterranean countries (24% of subjects were Mediterranean born)

MEDITERRANEAN

N=13

1 Index

1 Systematic Rev

1 Meta Analysis

9 Cohort

1 Case Control

Knoops et al., 2004

Prospective Cohort

Study

Neutral

N= 40,653 (1,507

men, 832 women)

HALE cohort

Netherlands

Mediterranean diet (HR = 0.77, 95% CI: 0.68 – 0.88)

assoc w/ ↓ risk all-cause mortality

Similar results were observed for mortality from coronary heart disease, cardiovascular diseases, and cancer

10 y mortality from all causes

(CVD, CHD, and Cancer)

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/

Quality/Study Type

Population/

Location

CVD

Mortality

Outcomes

Comments/Caveats

Mente et al., 2009

Systematic Review/ Meta-analysis

Positive

146 prospective

cohort studies

+ 43 RCTs

(pub1950-2007)

Europe, Asia, U.S.

Among the dietary exposures with strong evidence of

causation from cohort studies, only the Mediterranean dietary pattern is related to CHD in RCTs

Used Bradford Hill guidelines

to derive causation score based on 4 criteria (strength, consistency, temporality, and coherence) for each dietary exposure in cohort studies and examined for consistency with the findings of RCTs.

Mitrou et al, 2007

Prospective Cohort

Study

Positive

N= 352,497

(196,158 men,

156,339 women)

median age = 62

NIH-AARP Diet and Health Study

U.S.

Men: multivariate HR all-cause mortality = 0.79

(95% CI: 0.76 – 0.83), CVD mortality = 0.78 (95% CI: 0.69 – 0.87), cancer mortality = 0.83 (95% CI:

0.76 – 0.91).

Women: ↓ risks = 12% cancer mortality (P for trend

= 0.04); = 20% all-cause mortality (P for trend <

0.001).

5 y follow-up

Used 9-point score to assess conformity with Mediterranean dietary pattern (components included vegetables, legumes, fruits, nuts, whole grains, fish,

monounsaturated fat-saturated fat ratio, alcohol, and meat)

Panagiotakos et al.,

2005

Case-control Study

Positive

N= 848 w/ 1st

CHD event and

1,078 age- and sex-matched controls (aged 49

– 75)

CARDIO2000

Study

Greece

10-unit increase in Mediterranean diet score assoc w/

27% (95% CI: 0.66 – 0.89) decrease odds of non- fatal acute coronary syndromes

Secondary prevention

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/

Quality/Study Type

Population/

Location

CVD

Mortality

Outcomes

Comments/Caveats

Panagiotakos et al.,

2009

Prospective Cohort

Study

Neutral

N = 2,101

ATTICA Study

Greece

Pattern characterized by cereals, small fish, and olive

oil assoc w/ ↓ CVD risk (HR = 0.72, 95% CI: 0.52 –

1.00)

Pattern characterized by fruit and vegetables using olive oil in cooking (HR = 0.80, 95% CI: 0.66 –

0.97)

Patterns characterized by sweets, red meat, margarine, salty nuts, hard cheese and alcohol assoc w/ ↑ CVD risk

5 y follow-up

Exclusion of CVD done by detailed clinical evaluation

Trichopoulou et al.,

2003

Prospective Cohort

Study

Neutral

N = 22,043, 38-

63 yrs at baseline EPIC Study Greece

Higher adherence to Med diet assoc w/ ↓ total

mortality (adjusted HR =0.75, 95% CI: 0.64 – 0.87);

inverse assoc w/ CHD death (adjusted HR = 0.67,

95% CI: 0.47 – 0.94) and cancer death (adjusted HR

= 0.76, 95% CI: 0.59 – 0.98).

44 month follow-up

Trichopoulou et al.,

2009

Prospective Cohort

Study

Neutral

N = 23,349

EPIC Study

Greece

Higher adherence to a Med diet assoc w/ ↓ total

mortality (adjusted mortality ratio = 0.864, 95% CI:

0.802 – 0.932).

8.5 y follow-up

Waijers et al., 2006

Prospective Cohort

Study

Neutral

N = 5,427 women

(aged >60 years) EPIC Study

Netherlands

Principal component analysis identified 3 diet

patterns: Mediterranean, Traditional Dutch, and

Healthy Dutch

Healthy trad Dutch pattern assoc w/ ↓ mortality rate;

women in highest tertile 30% ↓mortality risk

8.2 y follow-up

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/

Quality/Study Type

Population/

Location

CVD

Mortality

Outcomes

Comments/Caveats

VEGETARIAN

N=5

4 Cohort

1 Time series

Chang–Claude et al.,

2005

Prospective Cohort

Study

Neutral

N = 1,904 ; 858 males, 1,046 females

1,165 lacto-ovo,

679 non-veg, 60 vegans.

Germany

↓ risk ischemic heart disease (RR = 0.70, 95% CI:

0.41 – 1.18)

No effect on mortality (RR = 1.10, 95% CI: 0.89 –

1.36)

A cohort study of vegetarians and health-conscious persons in Germany was followed-up prospectively for 21 years, including 1,225 vegetarians and 679 health-conscious nonvegetarians

Fraser et al., 2005

Time series

Neutral

(N=30,292 males,

N=50,562 females) California Seventh Day Adventists

(N=297,126 male,

344,401 female) Stanford Five- City Project

U.S.

Rate ratio (RR) (Adventist/Stanford study)

1st event fatal CHD = 0.59 (95% CI, 0.43-0.80) men and 0.49 (0.32-0.76) women.

Vegetarian Adventists, RR = 0.45 (0.24-0.84) and

0.20 (0.06-0.63) men and women, respectively.

1st event MI RR = 0.60 (0.47-0.78) and 0.46 (0.33-

0.65).

Vegetarian Adventists RR = 0.37 (0.20-0.66) and

0.62 (0.35-1.09) men and women, respectively.

Two concurrent California

observational studies, one with unusual dietary habits, are compared. Similar diagnostic criteria were used in both the Adventist Health Study and

the Stanford Five-City Project.

VEGETARIAN

N=5

4 Cohort

1 Time series

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/

Quality/Study Type

Population/

Location

CVD

Mortality

Outcomes

Comments/Caveats

Key et al., 1996

Prospective Cohort

Study

Neutral

N = 10,771;

4,336 males,

6,435 females

Daily consumption of fresh fruit assoc w/ ↓

mortality ischemic heart disease (rate ratio = 0.76,

95% CI: 0.60 – 0.97), cerebrovascular disease (rate ratio = 0.68, 95% CI: 0.47 – 0.98), and all causes (rate ratio = 0.79, 95% CI: 0.70 – 0.90)

Mortality ratios measured for

vegetarianism and for daily versus less than daily consumption of wholemeal bread, bran cereals, nuts or dried fruit, fresh fruit, and raw salad in relation to all cause mortality and mortality from ischemic heart disease, cerebrovascular disease, all malignant neoplasms, lung cancer, colorectal cancer, and breast cancer.

Key et al., 1998

Meta-analysis: 5

Prospective Cohort

Studies

Neutral

N = 76,172 men

and women

U.S.

Compared to non-vegetarians, vegetarians had 24% ↓

IHD mortality (rate ratio = 0.76, 95% CI:0.62-0.94)

Reduction in mortality among vegetarians varied significantly with age at death.

Regular meat consumers compared to semi- vegetarians (fish or meat <1X/wk), IHD rate ratios=0.78 (95% CI:0.68-0.89) in semi-vegetarians and 0.66 (95% CI:0.53-0.83) in vegetarians (P for trend <0.001).

Vegetarians were those who

did not eat any meat or fish (n

= 27,808). Non-vegetarians were from a similar background to the vegetarians within each study.

Mann et al., 1997

Prospective Cohort

Study

Neutral

N = 10,802;

4,102 males,

6,700 females

Health conscious, mean age=33-34

United Kingdom

An increase in mortality for IHD was observed with

increasing intakes of total and saturated animal fat and dietary cholesterol-death rate ratios in the third tertile compared with the first tertile: 329, 95% confidence interval (CI) 150 to 721; 277, 95% CI

125 to 613; 353, 95% CI 157 to 796, respectively.

No protective effects for dietary fiber, fish or alcohol

13.3 y follow-up

Prospective observation of vegetarians, semi-vegetarians, and meat eaters

Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults

Author and Year/

Quality/Study Type

Population/

Location

CVD

Mortality

Outcomes

Comments/Caveats

JAPANESE/ OKINAWAN

N=1 Cohort

Shimazu et al., 2007

Prospective Cohort

Study

Neutral

N=40,547, 40-79 yrs at baseline Japan

3 patterns identified by principal components analysis: i) a Japanese dietary pattern highly correlated with soybean products, fish, seaweeds, vegetables, fruits and green tea, (ii) an ‘animal food’ dietary pattern and (iii) a high-dairy, high-fruit-and- vegetable, low-alcohol (DFA) dietary pattern.

Japanese pattern assoc w/ ↓ risk CVD mortality (HR

= 0.73, 95% CI 0.59-0.92, P for trend=0.003)

7 y follow-up

ND = Not determined.

Part B. Section 2: The Total Diet Combining Nutrients, Consuming Food June 8, 2011

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Part B. Section 2: The Total Diet Combining

Nutrients, Consuming Food

Introduction

The 2010 Dietary Guidelines Advisory Committee (DGAC) supports a total diet approach to achieving dietary goals. The purpose of this chapter is to demonstrate how the scientific evidence presented in each of the topic-specific chapters in Part D: The Science Base—Energy Balance and Weight Management; Nutrient Adequacy; Fatty Acids and Cholesterol; Protein; Carbohydrates; Sodium, Potassium, and Water; Alcohol; and Food Safety and Technology—can be incorporated into an overall eating pattern that optimizes health outcomes.

Until recently, data were insufficient to document the impact of whole diets and eating patterns on health outcomes. The state of the evidence and the methodologic rigor regarding such questions have improved tremendously and the data can now be incorporated into this Report.

This chapter synthesizes the evidence on dietary components that contribute to excess energy and inadequate nutrient intakes in the United States (U.S.), and the foods that can provide these missing essential nutrients and other health benefits. It presents a brief, evidence-based comparison of worldwide eating patterns, including the Dietary Approaches to Stop Hypertension (DASH), Mediterranean, and other patterns, along with a description of the U.S. Department of Agriculture (USDA) Food Patterns with vegetarian variations.

A nutrient-dense total diet has multiple health benefits and can be implemented in various ways. The U.S. is comprised of individuals of all ages who come from many cultures and have a variety of food and taste preferences. All of these factors were considered in developing a recommended total diet that is flexible while meeting nutrient needs without exceeding energy requirements.

The Catalyst for the Total Diet Approach

Although there is no single “American” or “Western” diet, average American food patterns currently bear little resemblance to the diet recommended in the 2005

Dietary Guidelines for Americans. As documented by the latest data from the National Health and Nutrition Examination Survey (NHANES), Americans eat too many calories and too much solid fats, added sugars, refined grains, and sodium. Americans also eat too little dietary fiber, vitamin D, calcium, potassium, and unsaturated fatty acids (specifically omega-3s), and other important nutrients that are mostly found in vegetables, fruits, whole grains, low-fat milk and milk products, and seafood (see Part D. Section 2: Nutrient Adequacy).

Overweight and obesity are highly prevalent in the U.S. in both adults and children. This is of great public health concern because excess body fat is associated with a much higher risk of premature death and many serious disorders, as identified in Part D. Section 1: Energy Balance and Weight Management. Preventing overweight is highly preferable to initiating weight loss treatment after weight gain occurs, because the failure rate in achieving and maintaining weight loss is very high. Furthermore, the behaviors required to prevent

overweight are less daunting than the behaviors necessary to lose and sustain weight loss. Currently, the average American gains about a pound a year between the ages of

20 to 60 years. Some persons gain much more. Remaining conscious of one’s body weight throughout life and adopting a lifestyle early on that will achieve and sustain weight control across the lifespan are paramount to maintaining good health and quality of life.

A Special Focus on Children and Adolescents The single most significant adverse health trend among U.S. children in the past 40 years has been the dramatic increase in overweight and obesity (see Part D. Section

1: Energy Balance and Weight Management). Since the early 1970s, the prevalence of overweight and obesity has approximately doubled among children ages 2 to 11 years, and tripled among adolescents ages 12 to 19

years. Not only is obesity associated with adverse health

2010 Dietary Guidelines Advisory Committee Report 11

effects during childhood, but evidence documents increased risk of future chronic disease in adult life.

Childhood obesity results from poorly regulated energy balance. Ideally, children and adolescents should consume foods that provide an adequate intake of all essential nutrients needed for normal growth and development, metabolism, immunity, and cognitive function, without exceeding caloric requirements. Factors associated with preventing excess adiposity in children are incorporated into the total diet described here, and include:

Energy intake balanced with expenditure

Greatly reduced intake of sugar-sweetened beverages

Increased intake of vegetables and fruits

Smaller amounts of fruit juice, especially for overweight children

Smaller portions of foods and beverages

Infrequent consumption of meals from quick service (i.e., fast food) restaurants

Habitual consumption of breakfast

Fewer hours of screen time (e.g., television, computer)

More hours of active play

Blending Science-based Recommendations into a Healthful Total Diet

The DGAC defines “total diet” as the combination of foods and beverages that provide energy and nutrients

and constitute an individual’s complete dietary intake, on average, over time. This encompasses various foods and food groups, their recommended amounts and frequency, and the resulting eating pattern. To achieve dietary goals and energy balance, Americans must become mindful, or “conscious,” eaters, that is, attentively choosing what and how much they eat. Since the mid-1980s, the USDA has provided recommended food patterns that represent a

total diet approach to dietary guidance (Britten, 2006). The most recent USDA Food Patterns have been visually conveyed as the MyPyramid Food Guidance System (Haven, 2006). This approach was intended to help people personalize dietary recommendations and offer flexibility based on individual preferences. The key core components of a nutrient-dense total diet for all Americans are presented below.

Moderate Energy Intake

The DGAC encourages Americans to achieve their recommended nutrient intakes by consuming foods within a total diet that meets but does not exceed energy needs. Overweight and obesity result from energy imbalance (intake exceeding expenditure) (see Part D. Section 1: Energy Balance and Weight Management). The increased incidence and current high proportion of overweight and obesity in the U.S. illustrates an energy imbalance across virtually all subgroups of the population. People consume too many calories (i.e., energy) relative to the calories they expend. As a start, all Americans are encouraged to know their energy needs in order to avoid inappropriate weight gain. Table B2.1 (see the end of this chapter) can help individuals identify their energy needs based on their age, sex, and level of activity. Self-monitoring of both calorie intake and time spent in physical activity is one of the most useful tools a person can use to engage in and maintain behaviors that sustain a healthy weight.

Because levels of leisure time physical activity in U.S. adults have remained stable or increased only slightly between 1990 and 2004, it is clear that an increased calorie intake has been the primary cause of the obesity problem. Hence, even though one can achieve a calorie deficit by increasing physical activity, the primary focus should be on reducing excessive calorie intake.

Overall, the top food sources of energy, and mean energy intake from each, for the U.S. population, as reported in the National Health and Nutrition Examination Survey (NHANES) 2005-2006, are (National Cancer Institute [NCI], 2010a):

Grain-based desserts (cakes, cookies, doughnuts, pies, crisps, cobblers, and granola bars; 139 calories per day)

Yeast breads (129 calories per day)

Chicken and chicken mixed dishes (121 calories per day)

Soda/energy/sports drinks (114 calories per day)

Pizza (98 calories per day)

While the top sources of energy intake vary by age group, many of these sources are foods and beverages that are not in nutrient-dense forms. For example, the

top energy source for adults ages 19 years and older and for children ages 4 to 13 years is grain-based desserts. These desserts are also among the top five sources of energy for teens and younger children. For teens ages 14

12 2010 Dietary Guidelines Advisory Committee Report

to 18 years, the top energy source is soda/energy/sports drinks, and these beverages are also among the top five energy sources for adults ages 19 years and older and for children ages 9 to 13 years. For children ages 2 to 3 years only, the top energy source is whole milk (rather than low-fat milk). Other foods that are among the top five sources of energy for various age groups are yeast breads, chicken and chicken mixed dishes, pizza, and, for adults only, alcoholic beverages (NCI, 2010a; see Table B2.2 at the end of this chapter for the top five sources of energy for each age group, and Tables D1.1, D1.6, and D1.7 in Part D. Section 1: Energy Balance and Weight Management for more detailed lists of food sources of energy).

Total diets that are high in energy but low in nutrients can paradoxically leave a person overweight but undernourished and thus, at higher risk of cardiovascular disease (CVD), type 2 diabetes (T2D), and certain types of cancers. Of urgent concern is America’s youth, most of whom currently fit this pattern. Many children consume nutrient-poor sources of energy at the highest end of their respective energy ranges (see Figure D1.1 in Part D. Section 1: Energy Balance and Weight Management) and they are increasingly sedentary.

Beverages also contribute substantially to overall dietary and energy intake. Although they provide needed fluid, beverages often add calories to the diet without providing nutrients. Their consumption should

be planned in the context of total calorie intake and how they can fit into the total diet of each individual. Currently, U.S. adults ages 19 years and older consume an average of 394 calories per day as beverages. The major types of beverages consumed, and the mean caloric intake from each, are (NCI, 2010b):

Soda (112 calories per day)

Coffee and tea (26 calories per day)

Fluid milk (83 calories per day)

100 percent fruit juice and fruit drinks (66 calories per day)

Alcoholic beverages (106 calories per day)

Children (ages 2 to 18 years) consume an average of

400 calories per day as beverages. The major beverages for children and calories from each are somewhat different:

Fluid milk (160 calories per day)

Soda (118 calories per day)

100 percent fruit juices and fruit drinks (108 calories per day)

In children, the amount and source of calories from beverages differs by age. For example, 100 percent fruit juice is a prominent source of energy in children ages 2 to 3 years, while soda/sports/energy drinks are the most common source of energy among beverages (and energy overall) in children ages 14 to 18 years.

Portion control and the quantity of foods and beverages consumed within the total diet also are important considerations in moderating energy intake (see Part D. Section 1: Energy Balance and Weight Management). Excessive portion sizes are very common in the U.S.

and are linked to higher energy intakes and weight gain over time. This is particularly true when large portions of foods high in solid fats and added sugars (SoFAS) and refined grains are consumed.

Reduce Solid Fats and Added Sugars (SoFAS)

SoFAS contribute substantially (approximately 35% of calories) to total energy intakes of Americans, thereby leading to excessive saturated fat and cholesterol intakes and insufficient intake of dietary fiber and other

nutrients (see Part D. Section 2: Nutrient Adequacy; Part D. Section 3: Fatty Acids and Cholesterol; and Part D. Section 5: Carbohydrates).

The 2005 DGAC defined the term “discretionary calorie allowance” as “the difference between total energy requirements and the energy consumed to meet recommended nutrient intakes” (DGAC, 2004). Discretionary calories were intended to represent the calories available for consumption only after meeting nutrient recommendations and without exceeding total energy needs. Unfortunately, this concept has been difficult to translate into meaningful consumer education. To clarify translation, the 2010 DGAC focused specifically on reducing the intake of SoFAS which provide most of the non-essential or extra

calories that Americans consume. Major food sources of the two components of SoFAS are (Bachman, 2008):

Solid fats (percent of solid fat intake)

— Grain-based desserts, including cakes, cookies, pies, doughnuts, and granola bars (10.9%)

— Regular cheese (7.7%)

— Sausage, franks, bacon, and ribs (7.1%)

— Pizza (5.9%)

— Fried white potatoes, including French fries and hash browns (5.5%)

2010 Dietary Guidelines Advisory Committee Report 13

— Dairy-based desserts, such as ice cream (5.1%)

Added sugars (percent of added sugars intake)

— Soda (36.6%)

— Grain-based desserts (11.7%)

— Fruit drinks (11.5%)

— Dairy-based desserts (6.4%)

— Candy (6.2%)

Maximum limits on SoFAS are meant to be estimates and not necessarily daily targets (see limits from USDA Food Patterns, Table B2.3, end of this chapter). These foods should constitute a very small proportion of total energy intake in the total diet. Figure B2.1 contrasts the current disproportionately high intake of SoFAS with what is more appropriate from a healthy eating pattern.

Figure B2.1. What we eat versus recommended limits: calories from solid fats and added sugars (SoFAS)

What We Eat Recommended Limits

Note: The depiction of the proportionate amounts of total calories consumed and the recommended limits are illustrative only. The figure illustrates about 35 percent of total calories consumed as SoFAS, on average, in contrast to a recommended limit of no more than about 5 to 15 percent of total calories for most individuals.

Americans currently consume 35 percent of their total calories from SoFAS. This is too high. They should reduce intake of calories from SoFAS by 20 to 30 percent. This means that no more than 5 to 15 percent of total calories should be derived from SoFAS. For example, the USDA Food Patterns limit SoFAS to about 120 calories in the 1600-calorie pattern, 160 calories in the 1800-calorie pattern, and 260 calories in the 2000-calorie pattern (Table B2.3, at the end of the chapter, lists SoFAS limits for all calorie levels). Reduction of calories from SoFAS to these amounts allows for increased intakes of nutrient-dense foods such as vegetables (including cooked dry beans and

peas), fruits, whole grains, and fat-free and low-fat fluid

milk and milk products, without exceeding overall calorie needs.

Consume Nutrient-dense Foods (But Not Too

Much of Them)

Currently, Americans consume less than 20 percent of the recommended intakes for whole grains, less than 60 percent for vegetables, less than 50 percent for fruits, and less than 60 percent for milk and milk products (Figure B2.2). Inadequate intakes of nutrient-dense foods from these basic food groups place individuals at risk for lower than recommended levels of specific nutrients, namely vitamin D, calcium, potassium, and dietary fiber.

14 2010 Dietary Guidelines Advisory Committee Report

Figure B2.2. Dietary intakes in comparison to recommended intake levels or limits

Note: Bars show average intakes for all individuals (ages 1 or 2 years or older) as a percent of the recommended intake level or limit. Recommended intakes for food groups and limits for refined grains, SoFAS, solid fats, and added sugars are based on the USDA 2000-calorie food patterns. Recommended intakes for fiber, potassium, vitamin D, and calcium are based on the highest Adequate Intakes (AI) for ages 14 to 70 years. Limits for sodium are based on the AI and for saturated fat on 7 percent of calories.

Data source: What We Eat in America, National Health and Nutrition Examination Survey (WWEIA, NHANES)

2001-2004 or 2005-2006.

Food from all food groups are composed of a combination of the macronutrients carbohydrates, fats, and protein in varying proportions. These are the major sources of energy in any food or diet. Understanding their role in the diet will help Americans make appropriate food choices.

Carbohydrates (4 kcal/g) are the primary source of energy intake, and higher intakes of carbohydrates, especially complex sources, are recommended for active people. Sedentary individuals, and thus most

Americans, should lower their intakes of refined carbohydrates, greatly reducing intakes of sugar and sugar-sweetened beverages and refined grains that are high in calories, but relatively low in certain nutrients. Whole-grain versions of many grain products (such as plain white bread, rolls, bagels, muffins, pasta, breakfast cereals) should be substituted to meet the

recommendation that half of grains consumed be whole grains, also assisting in meeting dietary fiber recommendations (see Part D. Section 5: Carbohydrates).

Dietary fats (both solid fats and oils) are high in calories (9 kcal/g). Unsaturated fats, including omega-3 from seafood sources, should be increased and saturated fat and trans fatty acid intake should be minimized. Given typical patterns of consumption in the U.S., dietary saturated fat intake is highly correlated with total fat intake. Consuming the recommended intake of saturated fat (less than 10% of calories immediately as an interim step toward an eventual goal of less than 7% of calories) is more likely achievable when total fat intake is less than 30 percent of total calories. It is recommended that total fat should be in the range of 20 to 35 percent of total calories but derived mostly from oils within a

2010 Dietary Guidelines Advisory Committee Report 15

nutrient-rich, energy-balanced dietary pattern. These oils should replace solid fats and not add calories to the total diet (see Part D. Section 3: Fatty Acids and Cholesterol).

Dietary protein (4 kcal/g) provides essential amino acids and energy, and assists in building and preserving body proteins. Both plant-based sources of protein (i.e., cooked dry beans and peas, nuts, seeds, and soy products) and animal-based sources (i.e., meat, poultry, seafood, eggs, and low-fat and fat-free milk) can be incorporated into the total diet, with further emphasis on increasing seafood (rich in omega-3 fatty acids as well

as protein) and cooked dry beans and peas (rich in dietary fiber as well as vegetable protein) (see Part D. Section 4: Protein).

Consumption of alcoholic beverages also contributes to calories (7 kcal/g), from the alcohol itself as well as accompanying mixers (e.g., soda, juice, or sweetened mixer). In many cases, the accompanying mixer (see Table D1.9 in Part D. Section 1: Energy Balance and Weight Management) has more calories than the alcohol itself, so careful attention to portion size is important for alcoholic beverages. Based on individual preferences among adults, a moderate amount of alcohol may be included in the total diet if calorie allowances are not exceeded and essential nutrient needs are met. For

adults who are attempting to reduce calorie intake, alcohol could be one of the energy sources that is reduced to lower total calorie intake. Pregnant women or individuals with certain medical conditions or on

certain medications as well as individuals who will take part in activities that require attention or skill should not consume alcohol (see Part D. Section 7: Alcohol).

Vegetables, fruits, high-fiber whole grains, seafood, eggs, and nuts prepared without added SoFAS are considered “nutrient-dense foods,” as are low-fat forms of milk and lean meat and poultry prepared without added SoFAS. Nutrient-dense foods are found in a variety of forms but ideally are minimally processed and minimize or exclude added SoFAS, starches, and sodium. Combined into a total diet, these foods should provide a full range of essential nutrients, including those of special concern (e.g., vitamin D, calcium, potassium, and dietary fiber).

Finally, the nutrient-dense total diet should be prepared using best practices for food safety to ensure that foods consumed do not induce foodborne illnesses (see Part

D. Section 8: Food Safety and Technology). A balanced grouping of a variety of foods among all the food

groups, consumed in moderation, that are culturally appealing will offer pleasurable eating experiences and promote health among Americans.

Reduce Sodium Intake

Even a nutrient-dense total diet that remains excessive in sodium can lead to health consequences such as elevated blood pressure. Excessive sodium intake raises blood pressure, a well-documented and extraordinarily common risk factor for heart disease, stroke, and kidney disease. Although most research has been conducted in adults, the adverse effects of sodium on blood pressure begin early in life, and reducing sodium intake has substantial health benefits. Given the fact that a higher potassium intake attenuates the adverse effects of sodium on blood pressure, ensuring increased intakes of dietary potassium also would have health benefits.

The current food supply is replete with excess sodium. In this setting, virtually all Americans exceed the recommended upper limit of sodium intake. Because approximately 75 percent of dietary sodium is added during food processing, food manufacturers and restaurant industries have a critically important role in reducing the sodium intake. In addition, individuals should choose and prepare foods with little or no

sodium (see Part D. Section 6: Sodium, Potassium, and

Water).

A Flexible Approach to Applying Total Diet

Recommendations

A healthful total diet is not a rigid prescription, but rather is a flexible approach that incorporates a wide range of individual tastes and preferences. Just as there is no one “American” or “Western” diet, there is no one recommendation for a healthful diet. As is evident in

the following sections, data are accumulating that certain dietary patterns consumed around the world are associated with beneficial health outcomes. Likewise,

the Food Patterns developed by the USDA illustrate that both nutrient and moderation goals can be met in a variety of ways.

Worldwide Dietary Patterns Provide Support for a Nutrient-dense Total Diet

Across the world and within the U.S., there are striking differences in diets and also in diet-related health outcomes. Although research on dietary patterns is complex, and many methodological issues remain in

16 2010 Dietary Guidelines Advisory Committee Report

synthesizing data across studies, a consensus is emerging that consumption of certain dietary patterns is associated with a reduced risk of several major chronic diseases. The 2010 DGAC focused on the effects of dietary patterns on total mortality, CVD, and blood pressure (a major diet-related cardiovascular risk

factor). The World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR, 2007) recently reviewed the available evidence of the relationship of cancer with specific dietary factors and overall dietary patterns. While several dietary factors were associated with specific types of cancer, it concluded that no firm judgment can be made on the relationship of dietary patterns with cancer.

The 2010 DGAC focused on the DASH-style dietary patterns and Mediterranean-style dietary patterns

because considerable research exists on health outcomes as well as information on nutrient and food group composition. It also examined traditional Asian dietary patterns and vegetarian diets. Traditional Asian dietary patterns (e.g., Japanese and Okinawan dietary patterns) have been associated with a reduced risk of coronary heart disease, but documentation using contemporary research methods is scant. Most traditional dietary patterns provide for health at least moderately well, and their variety demonstrates that a person can eat healthfully in a number of ways. Vegetarian diets have been associated with a reduced risk of CVD, but information on nutrient content and food group composition is sparse.

Dietary patterns with health benefits are summarized below. An Appendix at the end of this chapter provides further detail on these dietary patterns as well as several summary tables.

DASH-style Dietary Patterns

DASH-style dietary patterns emphasize vegetables, fruits, and low-fat milk and milk products; include whole grains, poultry, seafood, and nuts; and are reduced in red meat, sweets, sodium, and sugar- containing beverages. As originally tested, the DASH diet is reduced in total fat (27% of kcal) with total protein intake of 18 percent of calories and

carbohydrate intake of 55 percent of calories. However, other versions of the DASH diet are available, in which carbohydrate is partially replaced with protein (about half from plant sources) or unsaturated fat (predominantly monounsaturated fat). The latter version is noteworthy because nutrient adequacy and a reduced saturated fat intake (6% of kcal) were both achieved in the setting of high monounsaturated fat (21% of kcal)

and total fat (37% of kcal) intake. In a free-living setting, care is needed to meet but not exceed energy needs in order to avoid weight gain.

Each of these DASH style diets lowers blood pressure, improves blood lipids, and reduces CVD risk. Blood pressure reduction is the greatest when the DASH diet is consumed with reduced sodium intake. At present, few adults, even those with hypertension, eat a diet that is consistent with the DASH dietary pattern.

Mediterranean-style Dietary Patterns

In view of the large number of cultures and agricultural patterns of countries that border the Mediterranean Sea, the “Mediterranean” diet is not a single dietary pattern. Although no well-accepted set of criteria exist, a traditional Mediterranean diet can be described as one that emphasizes breads and other cereal foods usually made from wheat, vegetables, fruits, nuts, unrefined cereals, and olive oil; includes fish and wine with meals (in non-Islamic countries); and is reduced in saturated fat, meat, and full-fat dairy products. Results from observational studies and clinical trials suggest that consumption of a traditional Mediterranean diet, similar to that of Crete in the 1960s, is associated with one of the lowest risks of coronary heart disease in the world. Over time, the diet of Crete has changed remarkably

and is now characterized by higher intake of saturated fat and cholesterol, and reduced intake of monounsaturated fats. At the same time, total fat consumption has fallen. These trends have been accompanied by a steady rise in heart disease risk.

Vegetarian Dietary Patterns

In some observational studies, vegetarian diets and lifestyle have been associated with improved health outcomes. The types of vegetarian diets consumed in the U.S. vary widely. Vegans do not consume any animal products, while lacto-ovo vegetarians consume milk and eggs. Although not strict vegetarians, many individuals consume small or minimal amounts of animal products. On average, vegetarians consume fewer calories from fat than non-vegetarians, particularly saturated fat, and have a higher consumption of carbohydrates than non-vegetarians. In addition, vegetarians tend to consume fewer overall calories and have a lower body mass index than non- vegetarians. These characteristics, in addition to the dietary pattern per se, may contribute to the improved

health outcomes of vegetarians (see the Appendix at the end of this chapter and Part D. Section 4: Protein for additional information on vegetarian diets).

2010 Dietary Guidelines Advisory Committee Report 17

Other Dietary Patterns

In view of the increasing diversity of the U.S. population, interest in the health effects of non-Western diets is substantial. One group of diets with potential health benefits are those traditionally consumed in Asia, which has experienced some of the lowest rates of coronary heart disease in the world. Both traditional Japanese and Okinawan dietary patterns have been associated with a low risk of coronary heart disease. Nonetheless, compared to the evidence supporting DASH and Mediterranean diets, detailed information on diet composition as well as epidemiologic and clinical trial evidence on health benefits, similar to that

available for the other types of diets, is sparse. Also, over time, dietary intakes in these countries have changed and may no longer reflect the healthiest choices.

USDA Food Patterns Provide Guidance for

Meeting Dietary Guideline Recommendations

Applying results from carefully conducted studies of nutrition and health, the USDA has developed a number of different food guides over the past century. These guides have identified eating patterns that meet known nutrient needs and balance intake from various food groups. Based upon the Nation’s dietary intake at the time, early USDA food guides focused on nutrient adequacy only. Due to the health risks associated with overconsumption of specific dietary components, including the increasing obesity problem, recent guides have encompassed moderation goals while meeting nutrient adequacy goals. The current USDA Food Patterns also are aimed at primary disease prevention. For example, Table B2.4 (see end of chapter) compares the 2000-calorie USDA food pattern with the DASH

diet and with current consumption patterns. The types and amounts of foods recommended in the USDA patterns are very similar to the DASH diet, and both are very different from current intakes.

The USDA Food Patterns recommend the amounts of foods to eat each day from the five major food groups and subgroups, specifically in nutrient-dense forms. The Patterns allow for oils and limit the maximum number of calories that should be consumed from SoFAS. Table B2.3 (see end of chapter) shows recommended amounts and limits in the USDA Food Patterns at all 12 energy levels (Part D. Section 2: Nutrient Adequacy, Table D2.1 provides the specific nutritional goals for each pattern).

The USDA Food Patterns incorporate several important assumptions:

A variety of foods are used to meet recommended intakes from each food group or subgroup, in amounts proportionate to current consumption by the population.

Food choices selected for use in the analysis are in nutrient-dense forms, that is, with little or no SoFAS, and in most cases without added salt.

For each age-sex group, the pattern developed to meet nutrient needs is at a caloric level that meets but does not exceed energy needs for sedentary individuals.

The online Appendix E3.1: Adequacy of the USDA

Food Patterns, available at www.dietaryguidelines.gov, provides details of the analysis conducted for the

DGAC to determine whether the USDA Food Patterns meet nutritional goals for adequacy and moderation while staying within established calorie targets.

Recommended intake amounts in the USDA Food Patterns remain unchanged from 2005 with the exception of the vegetable subgroups. Several changes were made to decrease the wide discrepancy in number and amounts of vegetables consumed between the largest and the smallest subgroups. This resulted in moving tomatoes and red peppers from “other vegetables” to a new “red-orange vegetable” subgroup, which provided a greater focus on tomatoes without compromising the nutrient adequacy of the patterns (see the online Appendix E3.2: Realigning Vegetable Subgroups report at www.dietaryguidelines.gov, for details). The USDA Food Patterns meet almost all of their nutritional goals for adequacy and moderation, when evaluated using current food composition and consumption data.

USDA also developed and evaluated several variations on the base patterns, applying the same principles but modifying food choices to accommodate those wanting to eat a plant-based or vegetarian diet. An additional analysis investigated a possible modification of the patterns for those tracking carbohydrate intake, such as people with diabetes. The results of these analyses are presented below (see Part C: Methodology for a description of the methods used and a list of all food pattern modeling analyses).

18 2010 Dietary Guidelines Advisory Committee Report

Vegetarian Patterns Based on USDA Food

Patterns

The USDA Food Patterns include two animal-based food groups: the “meat, poultry, seafood, eggs, soy products, nuts, and seeds” group and the “milk, yogurt, and cheese” group. Although the groups contain some plant foods, the majority of consumption from them is from animal products. As is true in American diets, these two food groups in the Food Patterns are the major sources of protein, calcium, vitamin D, vitamin B12, riboflavin, choline, selenium, zinc, and the omega-

3 fatty acids eicosapentaenoic acid (EPA) and

docosahexaeonic acid (DHA).

The USDA Food Patterns were modified to replace some or all animal products with plant products (see the online Appendix E3.3: Vegetarian Food Patterns report at www.dietaryguidelines.gov for details). The plant- based (at least 50% of all protein from plant sources), lacto-ovo vegetarian (no meat, poultry, or seafood), and vegan (no meat, poultry, seafood, eggs, fluid milk or milk products) food patterns, collectively referred to as the “vegetarian patterns,” meet almost all goals for nutrient adequacy. Amounts of protein, including all essential amino acids, were adequate in all vegetarian patterns. Amounts of calcium and vitamins D and B12 were adequate because fortified sources of these nutrients were selected to replace milk and meat products. The estimated bioavailable iron in the vegan patterns was less than the RDA for some children and women. While no dietary standards exist for omega-3 fatty acids, levels of EPA and DHA are substantially lower than the base Food Patterns, especially in the vegan patterns. All moderation goals are met in the vegetarian patterns. If only plant foods are consumed, choices should include foods fortified with vitamin B12, vitamin D, and calcium. Other nutrients of potential concern include iron, choline, EPA, and DHA.

Considering an Alternative Placement for

Starchy Vegetables

To offer flexibility in selecting a food pattern that meets nutrient needs and accommodates food preferences, USDA evaluated a nutritionally adequate option that considers starchy vegetables as a grain alternative (see the online Appendix E3.4: Starchy Vegetables report at www.dietaryguidelines.gov for details). This pattern may be useful for individuals who wish to track the amount of carbohydrates they consume, who prefer a dietary pattern that groups all major sources of starch together, or who wish to integrate the USDA recommendations with other diet plans. In this pattern, individuals can substitute starchy vegetables for a

portion of the recommended grains, as long as they eat additional vegetables from other subgroups to replace the starchy vegetables. As with all of the modeling analyses, the vegetables and grains selected should be nutrient-dense forms, not forms with added fats, sugars, or salt. Although starchy vegetables remain part of the vegetable group in the USDA Food Patterns, this analysis identified an option for flexibility to help some individuals integrate the USDA recommendations with other dietary plans.

The Importance of Nutrient-dense Choices The USDA Food Patterns assume that foods in each food group will be consumed in the same relative proportions as they appear in the average American diet, but that most will be in nutrient-dense forms. Nutrient-dense choices are available to consumers, but they are not the forms most typically consumed. Consuming recommended amounts of foods, but in

forms that represent typical food choices rather than the “ideal” nutrient-dense choices, has a major impact on energy and nutrient intake. Excess intake of energy, sodium, saturated fat, and cholesterol results from using typical food choices in the recommended amounts for the patterns. For example, assuming typical food choices, the calorie intake in the 2000-calorie pattern is

almost 400 calories more per day than the target (see the online Appendix E3.5: “Typical Choices” Food

Patterns report at www.dietaryguidelines.gov for details of an analysis of the effect of typical versus ideal choices). If consumers act on the message about quantities to eat from each food group or subgroup, but fail to implement the moderation messages about choosing most foods in low-fat, no-added-sugars, and low-sodium forms, they will not meet the important moderation goals.

Chapter Summary

Good health and vitality across the lifespan are what Americans desire. The 2010 DGAC Report concludes that this is achievable but requires a lifestyle approach that includes a total diet that is:

Energy balanced, limited in total calories, and portion controlled

Nutrient-dense and includes:

— Vegetables, fruits, high-fiber whole grains

— Fat-free or low-fat fluid milk and milk products

— Seafood, lean meat and poultry, eggs, soy products, nuts, seeds, and oils

2010 Dietary Guidelines Advisory Committee Report 19

Very low in solid fats and added sugars (SoFAS)

Reduced in sodium

Physical activity will assist in the helping to achieve a balance between calorie intake and expenditure, leading to body weight maintenance. Children and adolescents are of particular concern because the dietary habits that they form during their youth will set the foundation for their choices and behaviors as adults.

Several distinct dietary patterns are associated with health benefits, including lower blood pressure and a reduced risk of CVD and total mortality. A common feature of these diets is an emphasis on plant foods. Accordingly, fiber intake is high and saturated fat is typically low. When total fat intake is high, that is, more than 30 percent of calories, the predominant fats are monounsaturated and polyunsaturated fats.

Carbohydrate intake is typically in the range of 50 to 60 percent of calories, but these often include whole grain products with minimal processing, as well as cooked

dry beans and peas. The totality of evidence documenting a beneficial impact of plant-based dietary patterns on CVD risk is remarkable and worthy of recommendation.

Americans have considerable flexibility in selecting a diet that includes foods they enjoy, meets nutrient requirements, reduces risk of preventable disease, and controls weight. No one specific dietary pattern provides the only way to incorporate the principles

listed above into a total diet. The daunting public health challenge is to accomplish population-wide adoption of healthful dietary patterns within the setting of powerful influences that currently promote unhealthy lifestyles. The 2010 DGAC is united in advocating that policy makers, stakeholders, and health-care providers

embrace and support these important, evidence-based guidelines for the benefit of all Americans.

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Energy Among U.S. Children and Adolescents, 2005-

2006. Risk Factor Monitoring and Methods Branch

Website. Applied Research Program. National Cancer Institute, 2010a. http://riskfactor.cancer.gov/diet/foodsources/. Updated May 21, 2010. Accessed May 21, 2010.

National Cancer Institute (NCI). Distribution of Intake across Beverage Types, U.S. Population, 2005-2006. Risk Factor Monitoring and Methods Branch Website. Applied Research Program. National Cancer Institute,

2010b. http://riskfactor.cancer.gov/diet/foodsources/. Updated May 21, 2010. Accessed May 21, 2010.

2007.

20 2010 Dietary Guidelines Advisory Committee Report

Sex/Activity Level	Male/ Sedentary	Male/ Moderately Active	Male/ Active	Female/ Sedentary	Female/ Moderately Active	Female/ Active
Age
2	1000	1000	1000	1000	1000	1000
3	1000	1400	1400	1000	1200	1400
4	1200	1400	1600	1200	1400	1400
5	1200	1400	1600	1200	1400	1600
6	1400	1600	1800	1200	1400	1600
7	1400	1600	1800	1200	1600	1800
8	1400	1600	2000	1400	1600	1800
9	1600	1800	2000	1400	1600	1800
10	1600	1800	2200	1400	1800	2000
11	1800	2000	2200	1600	1800	2000
12	1800	2200	2400	1600	2000	2200
13	2000	2200	2600	1600	2000	2200
14	2000	2400	2800	1800	2000	2400
15	2200	2600	3000	1800	2000	2400
16	2400	2800	3200	1800	2000	2400
17	2400	2800	3200	1800	2000	2400
18	2400	2800	3200	1800	2000	2400
19-20	2600	2800	3000	2000	2200	2400
21-25	2400	2800	3000	2000	2200	2400
26-30	2400	2600	3000	1800	2000	2400
31-35	2400	2600	3000	1800	2000	2200
36-40	2400	2600	2800	1800	2000	2200
41-45	2200	2600	2800	1800	2000	2200
46-50	2200	2400	2800	1800	2000	2200
51-55	2200	2400	2800	1600	1800	2200
56-60	2200	2400	2600	1600	1800	2200
61-65	2000	2400	2600	1600	1800	2000
66-70	2000	2200	2600	1600	1800	2000
71-75	2000	2200	2600	1600	1800	2000
76 and up	2000	2200	2400	1600	1800	2000

Table B2.1. Estimated energy needs1 in calories per day, for reference-sized individuals by age, sex, and activity level

1Based on Estimated Energy Requirements (EER) equations, using reference heights (average) and reference weights (healthy) for each age/sex group, rounded to the nearest 200 calories. EER equations are from the Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington DC: National Academies Press, 2002.

Source: Britten et al., 2006.

2010 Dietary Guidelines Advisory Committee Report 21

Table B2.2. Top five sources of energy among U.S. children, adolescents, and adults by age, NHANES 2005-061

Mean Energy Intake (kcal)	Overall, Ages 2+ years 2157	Ages 2–18 years 2027	Ages 2–3 years 1471	Ages 4–8 years 1802	Ages 9–13 years 2035	Ages 14–18 years 2427	Ages 19+ years 2199
Rank
1	Grain-based	Grain-based	Whole milk	Grain-based	Grain-based	Soda/energy	Grain-based desserts
	desserts1	desserts	(104 kcal)	desserts	desserts	/sports drinks2	(138 kcal)
	(138 kcal)	(138 kcal)		(136 kcal)	(145 kcal)	(226 kcal)
2	Yeast breads	Pizza	100% fruit juice	Yeast breads	Pizza	Pizza	Yeast breads
	(129 kcal)	(136 kcal)	(not orange or	(98 kcal)	(128 kcal)	(213 kcal)	(134 kcal)
			grapefruit)
			(93 kcal)
3	Chicken and	Soda/energy/	Reduced fat	Pasta and	Chicken and	Grain-based	Chicken and chicken
	chicken mixed	sports drinks	milk	pasta dishes	chicken mixed	desserts	mixed dishes
	dishes	(118 kcal)	(91 kcal)	(97 kcal)	dishes	(157 kcal)	(123 kcal)
	(121 kcal)				(122 kcal)
4	Soda/energy/	Yeast breads	Pasta and pasta	Pizza	Yeast breads	Yeast breads	Soda/energy /sports
	sports drinks	(114 kcal)	dishes	(95 kcal)	(109 kcal)	(151 kcal)	drinks2
	(114 kcal)		(86 kcal)				(112 kcal)
5	Pizza	Chicken and	Grain-based	Reduced fat	Soda/energy/	Chicken and	Alcoholic beverages
	(98 kcal)	chicken	desserts	milk	sports drinks	chicken mixed	(106 kcal)
		mixed dishes	(68 kcal)	(95 kcal)	(105 kcal)	dishes
		(113 kcal)				(143 kcal)

1Foods ranked by mean contribution to overall energy intake. Table shows each food category and its mean caloric contribution for each age group.

2Includes cakes, cookies, doughnuts, pies, crisps, cobblers, granola bars.

3Includes sodas, energy drinks, sports drinks, and sweetened bottled water including vitamin water.

Note: For a more detailed listing of food sources of energy, see Part D. Section 1. Energy Balance, Tables D1.1, D1.6, and D1.7.

Source: National Cancer Institute (NCI). Food Sources of Energy Among U.S. Population, 2005-06. Risk Factor Monitoring and Methods Branch Website. Applied Research Program. National Cancer Institute, 2010a. http://riskfactor.cancer.gov/diet/foodsources/. Updated May 21, 2010. Accessed May 21,

2010.

Table B2.3. USDA Food Patterns—recommended daily intake amounts1 from each food group or subgroup at all calorie levels. Recommended intakes from vegetable subgroups are per week

Energy Level of

Pattern2 1000 1200 1400 1600 1800 2000 2200 2400 2600 2800 3000 3200

Fruits 1 c 1 c 1½ c 1½ c 1½ c 2 c 2 c 2 c 2 c 2½ c 2½ c 2½ c

Vegetables 1 c 1½ c 1½ c 2 c 2½ c 2½ c 3 c 3 c 3½ c 3½ c 4 c 4 c

Dark green vegetables ½ c/wk 1 c/wk 1 c/wk 1 ½ c/wk 1 ½ c/wk 1 ½ c/wk 2 c/wk 2 c/wk 2 ½ c/wk 2 ½ c/wk 2 ½ c/wk 2 ½ c/wk Red/Orange vegetables 2½ c/wk 3 c/wk 3 c/wk 4 c/wk 5 ½ c/wk 5 ½ c/wk 6 c/wk 6 c/wk 7 c/wk 7 c/wk 7½ c/wk 7½ c/wk Cooked dry beans and

peas ½ c/wk ½ c/wk ½ c/wk 1 c/wk 1 ½ c/wk 1 ½ c/wk 2 c/wk 2 c/wk 2 ½ c/wk 2 ½ c/wk 3 c/wk 3 c/wk Starchy vegetables 2 c/wk 3½ c/wk 3½ c/wk 4 c/wk 5 c/wk 5 c/wk 6 c/wk 6 c/wk 7 c/wk 7 c/wk 8 c/wk 8 c/wk Other vegetables 1½ c/wk 2½ c/wk 2½ c/wk 3½ c/wk 4 c/wk 4 c/wk 5 c/wk 5 c/wk 5½ c/wk 5½ c/wk 7 c/wk 7 c/wk Grains 3 oz eq 4 oz eq 5 oz eq 5 oz eq 6 oz eq 6 oz eq 7 oz eq 8 oz eq 9 oz eq 10 oz eq 10 oz eq 10 oz eq Whole grains 1½ oz eq 2 oz eq 2½ oz eq 3 oz eq 3 oz eq 3 oz eq 3½ oz eq 4 oz eq 4½ oz eq 5 oz eq 5 oz eq 5 oz eq Other grains 1½ oz eq 2 oz eq 2½ oz eq 2 oz eq 3 oz eq 3 oz eq 3½ oz eq 4 oz eq 4½ oz eq 5 oz eq 5 oz eq 5 oz eq Meat and beans 2 oz eq 3 oz eq 4 oz eq 5 oz eq 5 oz eq 5½ oz eq 6 oz eq 6 ½ oz eq 6 ½ oz eq 7 oz eq 7 oz eq 7 oz eq Milk 2 c 2 c 2 c 3 c 3 c 3 c 3 c 3 c 3 c 3 c 3 c 3 c

Oils 15 g 17 g 17 g 22 g 24 g 27 g 29 g 31 g 34 g 36 g 44 g 51g

Maximum SoFAS3 limit, 137

137

258

362

calories (%total calories) (14%)

(11%)

(10%) 121(8%) 161(9%)

(13%) 266 (12%) 330 (14%) (14%) 395 (14%)459 (15%) 596 (19%)

1Food group amounts shown in cup (c) or ounce equivalents (oz eq). Oils are shown in grams (g). Quantity equivalents for each food group are:

Grains, 1 ounce equivalent is: ½ cup cooked rice, pasta, or cooked cereal; 1 ounce dry pasta or rice; 1 slice bread; 1 small muffin (1 oz); 1 ounce ready- to-eat cereal.

Fruits and vegetables, 1 cup equivalent is: 1 cup raw or cooked fruit or vegetable, 1 cup fruit or vegetable juice, 2 cups leafy salad greens.

Meat and beans, 1 ounce equivalent is: 1 ounce lean meat, poultry, fish; 1 egg; ¼ cup cooked dry beans; 1 Tbsp peanut butter; ½ ounce nuts/ seeds.

Milk, 1 cup equivalent is: 1 cup milk or yogurt, 1½ ounces natural cheese such as Cheddar cheese or 2 ounces of processed cheese.

2Food intake patterns at 1000, 1200, and 1400 calories meet the nutritional needs of children ages 2 to 8 years. Patterns from 1600 to 3200 calories meet the nutritional needs of children 9 years of age and older and adults. If a child ages 2 to 8 years needs more calories and, therefore, is following a pattern at 1600 calories or more, the recommended amount from the milk group should be 2 cups per day. Children ages 9 years and older and adults should not use the

1000, 1200, or 1400 calorie patterns.

3SoFAS are calories from solid fats and added sugars.

Table B2.4. Dietary Pattern Comparison: Current U.S. intake, DASH-sodium diet, and USDA Food Patterns. Description, nutrient composition, and food group amounts (adjusted to 2000 calories)

Dietary Pattern	Usual U.S. Intake Adults	DASH with Reduced Sodium	USDA Base Pattern1	USDA Plant-based	USDA Lacto–ovo Vegetarian	USDA Vegan
Citation	NHANES 2001- 04; 2005-06; Ages 19+	Karanja et al., 1999 and Lin et al., 2003	Britten et al., 2006; Online Appendix E- 3.1	Online Appendix E- 3.3	Online Appendix E- 3.3	Online Appendix E- 3.3
Qualitative Description
Emphasizes		Potassium-rich vegetables, fruits, and low-fat milk products	Vegetables, fruits, and whole grains, low-fat milk products	Plant foods – vegetables, fruits, whole grains, legumes, low-fat milk products	Plant foods – vegetables, fruits, whole grains, legumes, nuts, seeds, soy foods, milk products	Plant foods – vegetables, fruits, whole grains, legumes, nuts, seeds, soy foods
Includes		Whole grains, poultry, fish, and nuts	Enriched grains, lean meat, fish, and oils	Lean meat, eggs, fish, and oils	Eggs, oils	Non-dairy milk alternatives
Limits (small amount)		Red meats, sweets, and sugar-containing beverages	Solid fats Added sugars	Solid fats Added sugars	No meat, poultry, fish Added sugars	No animal products Added sugars
Nutrients
Calories (kcal)	2000	2000	2000	2000	2000	2000
Carbohydrates (% total kcal)	48.4%	58%	56.7%	55.8%	56.7%	56.8%
Protein (% total kcal)	15.2%	18%	15.2%	16.3%	15.2%	13.3%
Total Fat (% total kcal)	33.5%	27%	32%	31%	31%	33%
Saturated Fat (% total kcal)	10.9%	6%	8.4%	7.8%	7.8%	6.8%
Monounsaturated (% total kcal)	12.5%	10%	12.0%	11.4%	11.8%	12.4%
Polyunsaturated (% total kcal)	6.8%	8%	9.0%	9.3%	9.4%	12.0%
Cholesterol (mg)	269	143	229	170	160	17

Table B2.4 (continued). Dietary Pattern Comparison: Current U.S. intake, DASH-sodium diet, and USDA Food Patterns. Description, nutrient composition, and food group amounts (adjusted to 2000 calories)

	Usual U.S. Intake	DASH with Reduced Sodium	USDA Base		USDA Lacto–ovo
Dietary Pattern	Adults 19 year+		Pattern1	USDA Plant-based	Vegetarian	USDA Vegan
Fiber (g)	15	29	30	37	39	43
Potassium (mg)	2909	4371	3478	3611	3610	3645
Sodium (mg)	2846	1095	1722	1582	1595	1224
Food Groups
Vegetables: total (c)	1.6	2.1	2.5	2.5	2.5	2.5
– Dark Green (c)	0.1	nd	0.2	0.2	0.2	0.2
– Legumes2(c)	0.1	nd	0.2	0.2	0.2	0.2
– Red Orange (c)	0.4	nd	0.8	0.8	0.8	0.8
– Other Veg (c)	0.5	nd	0.6	0.6	0.6	0.6
– Starchy Veg (c)	0.5	nd	0.7	0.7	0.7	0.7
Calories (kcal)	2000	2000	2000	2000	2000	2000
Food Groups
Fruit & juices (c)	1.0	2.5	2	2	2	2
Grains: total (oz)	6.4	7.3	6	6	6	6
– Whole grains (oz)	0.6	3.9	3	3	3	3
Milk & milk	1.5	0.7 (whole)	–	–	–	–
products incl whole
fat (c) – Low-fat milk (c)	nd	1.9	3	3	3	3 (non-dairy)3
Animal Proteins:
– Meat (oz)	2.5	1.4	2.5	0.6	–	–
– Poultry (oz)	1.2	1.7	1.5	0.4	–	–
– Eggs (oz)	0.4	nd	0.4	0.4	0.6	–
– Fish (total) (oz)	0.5	1.4	0.5	0.7	–	–
— Hi n3 (oz)	0.1	nd	0.1	nd	–	–
— Low n3 (oz)	0.4	nd	0.4	nd	–	–

Dietary Pattern	Usual U.S. Intake Adults 19 year+	DASH with Reduced Sodium	USDA Base Pattern1	USDA Plant-based	USDA Lacto–ovo Vegetarian	USDA Vegan
Plant Proteins:
– Legumes (oz)	nd	0.4	See vegetables.	1.4	1.4	1.9
– Nuts & seeds (oz)	0.5	0.9	0.6	1.1	1.9	2.1
– Soy products (oz)	0.0	nd	0.05	0.9	1.7	1.4
Oils (g)	17.7	24.8	27	23	19	18
Solid Fats (g)	43.2	nd	16	16	16	16
Added Sugar (g)	79.0	12 (snacks/sweets)	32	32	32	32
Alcohol (g)	9.9	–	–	–	–	–

1The USDA Base Food Pattern is slightly adapted from the 2000-calorie pattern presented in the 2005 Dietary Guidelines for Americans (DGA). Vegetable subgroups were realigned to include a Red/Orange subgroup. The base pattern and the vegetarian variations are subject to change as the 2010 DGA are developed. The measures are cup and ounce equivalents (Britten, 2006; Marcoe, 2006). Nutrient distribution updated with 2010 composites.

2On USDA patterns, total recommended legume amount is the sum of amounts recommended in the Vegetable and the Meat & Beans groups. An ounce equivalent of legumes in the Meat & Beans group is ¼ cup. For example, in the 2000-calorie pattern, total weekly legume recommendation is (13 oz eq /4) +

1.5 cups = 5 cups.

3Non-dairy options in Vegan pattern are calcium-fortified soymilk, rice milk, and tofu. All USDA patterns contain a small amount of soy milk. nd = Not described.

(-) = No recommendation.

Sources: Usual U.S. Intakes – WWEIA, NHANES 2001-2004 and WWEIA, NHANES 2005-2006, one-day mean intakes consumed per individual. Male and female intakes adjusted to 2000 calories, averaged, and rounded to one decimal point.

Part B: Section 1: Introduction June 8, 2011

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Part B: Section 1: Introduction

Since first published in 1980, the Dietary Guidelines for Americans have provided science-based advice to promote health and reduce risk of major chronic diseases through optimal diet and regular physical activity. The Dietary Guidelines have traditionally targeted the healthy general public older than age 2 years, but as data continue to accumulate regarding the importance of dietary intake during gestation and from birth on, it also will become important to consider those younger than age 2 years in future Guidelines. Because of their focus on health promotion and risk reduction, the Dietary Guidelines form the basis of Federal food, nutrition education, and information programs.

By law (Public Law 101-445, Title III, 7 U.S.C. 5301 et seq.), the most recent edition of the Dietary Guidelines is reviewed by a committee of experts, updated if necessary, and published every 5 years. The legislation also requires that the Secretaries of the U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) review all Federal publications for the general public containing dietary guidance information for consistency with the Dietary Guidelines for Americans. This Report presents the recommendations of the 2010 Dietary Guidelines Advisory Committee (DGAC) to the Secretaries of USDA and HHS for use in updating the Guidelines.

The 2010 DGAC Report is unprecedented in addressing an American public, two-thirds of whom are overweight or obese. Americans are making dietary choices in a highly obesogenic environment and at a time of burgeoning diet-related chronic diseases affecting

people of all ages, ethnic backgrounds, and socioeconomic levels. The DGAC considers the obesity epidemic to be the single greatest threat to public health in this century. This Report is therefore focused on evidence-based guidelines and recommendations that are considered effective and useful in halting and reversing the obesity problem through primary prevention and changes in behavior, the environment, and the food supply.

The Role of Diet and Physical Activity in Health Promotion: Attenuating Chronic Disease Risks

A large proportion of deaths each year in the United States (U.S.) result from a limited number of preventable and modifiable factors. The leading causes of death for the past two decades have been tobacco use and poor diet and physical inactivity (McGinnis, 1993; Mokdad, 2004). The number of deaths related to poor diet and physical inactivity is increasing and may soon overtake tobacco as the leading cause of death. As discussed in this Report, poor dietary intake has been linked to excess body weight and numerous diseases

and conditions, such as cardiovascular disease (CVD) and type 2 diabetes (T2D) and their related risk factors. Even if the overweight/obesity epidemic resolves, the problems of chronic disease would continue to be a major health problem because poor-quality diets, even in the absence of overweight/obesity, increase the risk some of our most common chronic diseases.

The reduction of chronic disease risk merits strong emphasis in our Nation for many reasons, especially because some groups in the population bear a disproportionate burden of chronic disease and

attendant risk factors. The present Report highlights the evidence that links diet and different chronic diseases. It also summarizes and synthesizes knowledge regarding many individual nutrients and food components into recommendations for an overall total pattern of eating that can be adopted by the public. Although adherence

to the Dietary Guidelines is low among the U.S. population, evidence is accumulating that selecting diets that comply with the Guidelines reduces the risk of chronic disease and promotes health. Ultimately, individuals choose the types and amount of food they

eat and the amount of physical activity they perform, but the current environment significantly enhances the overconsumption of calories and discourages the expenditure of energy. Both sides of this equation are discussed in greater detail throughout the Report.

6 2010 Dietary Guidelines Advisory Committee Report

Population Groups of Particular Concern

The Dietary Guidelines for Americans has traditionally provided guidance to healthy Americans. However, the

2010 DGAC recognizes that a large percentage of the American population now has diet-related chronic diseases or risk factors for them, and has accommodated this reality in its review of the evidence. Much of the evidence the Committee reviewed pertains to adults. However, given the importance of nutrition across the lifespan and the rapidly growing scientific literature on diet and children’s health, several sections of the Report focus particular attention on this important population group. In addition, the Committee presents reviews of evidence on several questions pertaining to pregnant

and lactating women and to older adults.

Children

Increasingly, studies are addressing the role of nutrition and physical activity in promoting health in children. A nutrient-dense, high-quality diet, sufficient but not excessive in calories, and regular daily physical activity are integral to promoting the optimal health, growth, and development of children. For example, the rapid rates of growth occurring during adolescence increase the need for dietary sources of iron and calcium during that period to higher amounts per 1000 calories than required at any other stage of life.

Evidence documents the importance of optimal nutrition starting during the fetal period through childhood and adolescence because this has a substantial influence on the risk of chronic disease with age (Warner, 2010). Eating patterns established during childhood often are carried into adulthood (Aggett,

1994). For example, those who consume fruits and vegetables or milk regularly as children are more likely to do so as adults (Aggett, 1994).

Today, too many children are consuming diets with too many calories and not enough nutrients, and they are not getting enough physical activity (less than half of children age 12 to 21 years exercise on a daily basis [HHS, 1996]). As a result, chronic disease risk factors, such as glucose intolerance and hypertension, which were once unheard of in childhood, are now increasingly common. T2D now accounts for up to 50 percent of new cases of diabetes among youths. One in

400 youths will have T2D by age 20 years. Excess weight, particularly around the abdomen, as well as too

little physical activity, appears to be the basis for developing this disease early in life.

Pregnant and Lactating Women

Both pregnancy and lactation are critical periods during which maternal nutrition is a key factor influencing the health of both child and mother. Energy as well as protein and several mineral and vitamin requirements increase substantially during pregnancy, making the pregnant woman’s dietary choices critically important (Christian, 2010; Institute of Medicine [IOM], 1991; IOM, 2002; Picciano, 2003).

However, excess energy intake during pregnancy has become a major concern. Growing evidence indicates that overnutrition leading to unhealthy weight gain during pregnancy may greatly predispose the child to obesity. Insufficient micronutrient intake also continues to be a concern. For example, sufficient intake of folic acid, which is especially important for normal development of the embryo and fetus, is critical during the entire periconceptional period. Dietary factors also may contribute to impaired glucose tolerance, a

common disorder of pregnancy that influences fetal growth and outcomes (Clapp, 1998; Saldana, 2004). Dietary contaminants, such as methyl mercury, may adversely affect fetal growth. Maternal diet, especially the intake of certain vitamins and alcoholic beverages, also may influence breast milk composition (Dewey,

1999; IOM, 1991).

Older Adults

The 65+ in the United States: 2005 Report noted that the U.S. population aged 65 years and older is expected to double in size within the next 25 years (He, 2005). By

2030, it is projected that one in five people will be older than age 65 years. Individuals age 85 years and older are the fastest growing segment of the older population. In

2011, the “baby boom” generation will begin to turn 65. As the number of older Americans increases, the role of diet quality and physical activity in reducing the progression of chronic disease will become increasingly important. The health of older Americans is improving, but many are disabled and suffer from chronic conditions. The proportion with a disability fell significantly from

26.2 percent in 1982 to 19.7 percent in 1999 (Manton,

2001), yet 14 million people age 65 years and older reported some level of disability in Census 2000, mostly linked to a high prevalence of chronic conditions, such as CVD, T2D, hypertension, or arthritis.

2010 Dietary Guidelines Advisory Committee Report 7

The process of aging can influence how nutrients are used and can exacerbate the effect of poor diet quality on health. For example, aging may reduce nutrient absorption, increase urinary nutrient loss, and alter

normal pathways of nutrient metabolism. These changes associated with aging can be compensated to some extent by a nutrient-dense diet that remains within calorie needs. Most important, modifications of diet and increases in physical activity have tremendous potential as a means to prevent or delay chronic disease in older persons. Older individuals achieve, in many instances, greater benefit from a given improvement in diet than

do younger individuals (e.g., older individuals tend to be more responsive to the blood pressure-lowering effects of reducing salt intake) or from an increase in physical activity. As with children, adolescents, and younger adults, data comparing people aged 65 to 74 years in 1988-1994 and 1999-2000 show a startling rise in the percentage of obese older adults. In men, the proportion grew from about 24 to 33 percent and in women from about 27 percent to 39 percent (He, 2005). Furthermore, available data have repeatedly

documented that older-aged persons can make and sustain behavior change, more so than their younger counterparts (The Diabetes Prevention Program [DPP],

2002, 2009; Whelton, 1997). Such results highlight the importance of encouraging dietary changes throughout the lifespan, including older-aged persons.

Changes in Diet and Physical Activity as a

Means to Reduce Health Disparities

Of substantial concern are disparities in health among racial and ethnic minorities and among different socioeconomic groups. For example, Blacks have a higher prevalence of elevated blood pressure and a greater incidence of blood pressure-related diseases, such as stroke and kidney failure, than do non-Blacks (DGAC, 2004). Also, several subgroups of the population (e.g., Mexican-Americans, American Indians, and Blacks) have a strikingly high prevalence of overweight and obesity, even beyond that of the already high prevalence rates observed in the general population. Furthermore, it is well-recognized that

individuals of lower socioeconomic status have a higher incidence of adverse health outcomes than do individuals of higher socioeconomic status. Dietary patterns differ among different groups, with individuals of lower education and income consuming fewer servings of vegetables and fruit than those with more education and higher income (USDA, 2004). While the

reasons for such disparities are complex and multi- factorial, available research is sufficient to advocate certain dietary changes and increased physical activity as a means to reduce disparities.

The effects on blood pressure of a reduced sodium intake, increased potassium intake, and an overall healthy dietary pattern provide an example of how dietary changes could reduce health disparities. Although both Blacks and non-Blacks consume excess sodium, Blacks tend to be more sensitive to the effects of sodium than are non-Blacks. Likewise, Blacks tend to be more sensitive to the blood pressure-lowering effects of increased potassium intake. Ironically, the average potassium intake of Blacks is less than that of non-Blacks. The Dietary Approaches to Stop Hypertension (DASH) diet, an example of a healthy dietary pattern that emphasizes vegetables and fruits,

has been shown in clinical trials to lower blood pressure to a greater extent in Blacks than in non-Blacks. Yet, Blacks tend to consume fewer fruits and vegetables than do non-Blacks.

Such evidence exemplifies important, yet underappreciated, opportunities to reduce health disparities through dietary changes.

From the 2010 DGAC Report to the Dietary

Guidelines for Americans

A major goal of the 2010 DGAC is to summarize and synthesize the evidence to support USDA and HHS in developing nutrition recommendations that reduce the risk of chronic disease while meeting nutrient requirements and promoting health for all Americans.

The U.S. Government uses the Dietary Guidelines as the basis of its food assistance programs, nutrition education efforts, and decisions about national health objectives. For example, the National School Lunch Program and the Elderly Nutrition Program incorporate the Dietary Guidelines in menu planning; the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) applies the Dietary Guidelines in its educational materials; and the Healthy People 2010

Objectives for the Nation include objectives based on the Dietary Guidelines. The evidence described here in the 2010 DGAC Report, which will be used to develop the 2010 Dietary Guidelines for Americans, will help policymakers, educators, clinicians, and others speak with one voice on nutrition and health and reduce the

8 2010 Dietary Guidelines Advisory Committee Report

confusion caused by mixed messages in the media. The DGAC also hopes that the 2010 Dietary Guidelines for Americans will encourage the food industry to grow, manufacture, and sell foods that promote health and contribute to appropriate energy balance.

A Guide to the 2010 DGAC Report

This report contains several major components. Part A provides an Executive Summary to the Report. Part B sets the stage for the Report through this Introduction. It also provides a synthesis of major findings in two complementary chapters. The first chapter describes a health-promoting total diet approach that combines the intake of foods, calories, and nutrients. The second chapter integrates the Report’s major cross-cutting findings and provides specific recommendations for

how Americans and different sectors throughout the Nation can put the Report’s evidence-based dietary recommendations into action.

Part C describes the methodology the DGAC used to conduct its work and review the evidence on diet and health. Part D is the Science Base. In this Part, the DGAC’s subcommittees present their specific findings in chapters focused on energy balance and weight management; nutrient adequacy; fatty acids and cholesterol; protein; carbohydrates; sodium, potassium, and water; alcohol; and food safety and technology.

The Report concludes with several Appendices, including a compilation of the Committee’s scientific conclusions, a glossary, a brief history of the Dietary Guidelines for Americans, a listing of the food pattern analyses conducted for the 2010 DGAC, a summary of the process used to collect public comments, biographical sketches of DGAC members, and acknowledgments.

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B, Lafeber H, Ormission A, Rey J, Tormo R. ESPGAN Committee on Nutrition Report: Childhood diet and prevention of coronary heart disease. J Pediatr Gastr and Nutr. 1994;19(3):261-9.

Clapp JF III. Effect of dietary carbohydrate on the glucose and insulin response to mixed caloric intake

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Diabetes Care. 1998;21(Suppl 2): B107-B112.

Christian P. Micronutrients, birth weight, and survival.

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Dewey KG, Schanler J, Koletzko B, eds. Nutrition and human lactation. J Mammary Gland Biology & Neoplasia. 1999;4:241-95.

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Diabetes Prevention Program Research Group, Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, Brenneman AT, Brown-Friday JO, Goldberg R, Venditti E, Nathan DM (DPP). 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Lancet.

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Manton KG, Gu X. Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999. Proc Natl Acad Sci USA. 2001;98(11):6354-9.

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McCullough ML, Feskanich D, Stampher MJ, Giovannucci EL, Rimm EB, Hu FB, Spiegelman D, Hunter DJ, Colditz GA, Willett WC. Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance. Am J Clin Nutr.

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10 2010 Dietary Guidelines Advisory Committee

DIETRY GUIDELINES FOR AMERICANS June 7, 2011

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Part A: Executive Summary

The 2010 Dietary Guidelines Advisory Committee (DGAC) was established jointly by the Secretaries of U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (HHS). The Committee’s task was to advise the Secretaries of USDA and HHS on whether revisions to the 2005

Dietary Guidelines were warranted, and if so, to recommend updates to the Guidelines. The DGAC immediately recognized that, on the basis of the vast amount of published research and emerging science on numerous relevant topics, an updated report was indeed needed.

The 2010 DGAC Report is distinctly different from previous reports in several ways. First, it addresses an American public of whom the majority are overweight or obese and yet under-nourished in several key nutrients. Second, the Committee used a newly developed, state-of-the-art, web-based electronic system and methodology, known as the Nutrition Evidence Library (NEL), to answer the majority of the scientific questions it posed. The remaining questions were answered by data analyses, food pattern modeling analyses, and consideration of other evidence-based reviews or existing reports, including the 2008 Physical Activity Guidelines for Americans. The 2005 Dietary Guidelines for Americans were the starting place for most reviews. If little or no scientific literature had been published on a specific topic since the 2005 Report was presented, the DGAC indicated this and established the conclusions accordingly.

A third distinctive feature of this Report is the introduction of two newly developed chapters. The first of these chapters considers the total diet and how to integrate all of the Report’s nutrient and energy recommendations into practical terms that encourage personal choice but result in an eating pattern that is nutrient dense and calorie balanced. The second chapter complements this total diet approach by integrating and translating the scientific conclusions reached at the individual level to encompass the broader

environmental and societal aspects that are crucial to full adoption and successful implementation of these recommendations.

The remainder of this Executive Summary provides brief synopses of these and all of the other chapters, which review current evidence related to specific topics and present the resulting highlights that comprise the fundamental essence of this report.

Major Cross-cutting Findings and

Recommendations

Total Diet: Combining Nutrients, Consuming

Foods

The 2010 DGAC Report concludes that good health and optimal functionality across the lifespan are achievable goals but require a lifestyle approach including a total diet that is energy balanced and nutrient dense. Now, as in the past, a disconnect exists between dietary recommendations and what Americans actually consume. On average, Americans of all ages consume too few vegetables, fruits, high-fiber whole grains, low- fat milk and milk products, and seafood and they eat too much added sugars, solid fats, refined grains, and sodium. SoFAS (added sugars and solid fats) contribute approximately 35 percent of calories to the American diet. This is true for children, adolescents, adults, and older adults and for both males and females. Reducing the intake of SoFAS can lead to a badly needed

reduction in energy intake and inclusion of more healthful foods into the total diet.

The diet recommended in this Report is not a rigid prescription. Rather, it is a flexible approach that incorporates a wide range of individual tastes and food preferences. Accumulating evidence documents that certain dietary patterns consumed around the world are associated with beneficial health outcomes. Patterns of eating that have been shown to be healthful include the Dietary Approaches to Stop Hypertension (DASH)-style dietary patterns and certain Mediterranean-style dietary patterns. Similarly, the USDA Food Patterns illustrate that both nutrient adequacy and moderation goals can

be met in a variety of ways. The daunting public health challenge is to accomplish population-wide adoption of healthful dietary patterns within the context of powerful influences that currently promote unhealthy consumer choices, behaviors, and lifestyles.

2010 Dietary Guidelines Advisory Committee Report 1

Translating and Integrating the Evidence: A Call to Action

Complementing the Total Diet chapter, this chapter describes the four major findings that emerged from the DGAC’s review of the scientific evidence and articulates steps that can be taken to help all Americans adopt health-promoting nutrition and physical activity guidelines:

Reduce the incidence and prevalence of overweight and obesity of the U.S. population by reducing overall calorie intake and increasing physical activity.

Shift food intake patterns to a more plant-based diet that emphasizes vegetables, cooked dry beans and peas, fruits, whole grains, nuts, and seeds. In addition, increase the intake of seafood and fat-free and low-fat milk and milk products and consume only moderate amounts of lean meats, poultry, and eggs.

Significantly reduce intake of foods containing added sugars and solid fats because these dietary components contribute excess calories and few, if any, nutrients. In addition, reduce sodium intake and lower intake of refined grains, especially refined grains that are coupled with added sugar, solid fat, and sodium.

Meet the 2008 Physical Activity Guidelines for

Americans.

The 2010 DGAC recognizes that substantial barriers make it difficult for Americans to accomplish these goals. Ensuring that all Americans consume a health- promoting dietary pattern and achieve and maintain energy balance requires far more than individual behavior change. A multi-sectoral strategy is imperative. For this reason, the 2010 DGAC strongly

recommends that USDA and HHS convene appropriate committees, potentially through the Institute of Medicine (IOM), to develop strategic plans focusing on the actions needed to successfully implement key 2010

DGAC recommendations. Separate committees may be necessary because the actions needed to implement key recommendations likely differ by goal.

A coordinated strategic plan that includes all sectors of society, including individuals, families, educators, communities, physicians and allied health professionals, public health advocates, policy makers, scientists, and small and large businesses (e.g., farmers, agricultural producers, food scientists, food manufacturers, and food retailers of all kinds), should be engaged in the

development and ultimate implementation of a plan to help all Americans eat well, be physically active, and maintain good health and function. It is important that any strategic plan is evidence-informed, action-oriented, and focused on changes in systems in these sectors.

Strategies to help Americans change their dietary intake patterns and be physically active also will go a long way to ameliorating the disparities in health among racial

and ethnic minorities and among different socioeconomic groups, which have been recognized as a significant concern for decades. While the reasons for these differences are complex and multifactorial, this Report addresses research indicating that certain dietary changes can provide a means to reduce health

disparities.

Change is needed in the overall food environment to support the efforts of all Americans to meet the key recommendations of the 2010 DGAC. To meet these challenges, the following sustainable changes must occur:

Improve nutrition literacy and cooking skills, including safe food handling skills, and empower and motivate the population, especially families with children, to prepare and consume healthy foods at home.

For all Americans, especially those of low income, create greater financial incentives to purchase, prepare, and consume vegetables and fruit, whole grains, seafood, fat-free and low-fat milk and milk products, lean meats, and other healthy foods.

Improve the availability of affordable fresh produce through greater access to grocery stores, produce trucks, and farmers’ markets.

Increase environmentally sustainable production of vegetables, fruits, and fiber-rich whole grains.

Ensure household food security through measures that provide access to adequate amounts of foods that are nutritious and safe to eat.

2 2010 Dietary Guidelines Advisory Committee Report

Develop safe, effective, and sustainable practices to expand aquaculture and increase the availability of seafood to all segments of the population. Enhance access to publicly available, user-friendly benefit/risk information that helps consumers make informed seafood choices.

Encourage restaurants and the food industry to offer health-promoting foods that are low in sodium; limited in added sugars, refined grains, and solid fats; and served in smaller portions.

Implement the U.S. National Physical Activity Plan, a private-public sector collaborative promoting local, state, and national programs and policies to increase physical activity and reduce sedentary activity (http://www.physicalactivityplan.org/index.htm). Through the Plan and other initiatives, develop efforts across all sectors of society, including health care and public health; education; business and industry; mass media; parks, recreation, fitness, and sports; transportation; land use; community design; and volunteer and non-profit. Reducing screen time, especially television, for all Americans also will be important.

Topic-specific Findings and Conclusions

Energy Balance and Weight Management

The prevalence of overweight and obesity in the U.S. has increased dramatically in the past three decades. This is true of children, adolescents, and adults and is more severe in minority groups. The American environment is conducive to this epidemic, presenting temptation to the populace in the form of tasty, energy- dense, micronutrient-poor foods and beverages. The macronutrient distribution of a person’s diet is not the driving force behind the current obesity epidemic. Rather, it is the over-consumption of total calories coupled with very low physical activity and too much sedentary time. The energy density of foods eaten is an important factor in overeating. Americans eat too many calories from foods high in SoFAS that offer few or no other nutrients besides calories. This is true not only for adults but also for children, who consume energy-dense SoFAS, especially in the form of sugar-sweetened

beverages, at levels substantially higher than required to maintain themselves at a normal weight as they grow.

With regard to special subgroups, maternal obesity before pregnancy and excessive weight gain during pregnancy are deleterious for the mother and the fetus.

One-fifth of American women are obese when they become pregnant, often put on much more weight than is healthy during pregnancy, and have trouble losing it

after delivery, placing their offspring at increased risk of obesity and type 2 diabetes (T2D) later in life. Breastfeeding has no sustained impact on maternal weight gain or loss, but has numerous benefits for mother and infant and should be encouraged.

Older overweight or obese adults can derive as much benefit from losing weight and keeping it off as do younger persons, with resulting improvements in quality of life, including diminished disabilities and lower risks of chronic diseases.

Selected behaviors that lead to a greater propensity to gain weight include too much TV watching, too little physical activity, eating out frequently (especially at quick service restaurants [i.e., fast food restaurants]), snacking on energy-dense food and drinks, skipping breakfast, and consuming large portions. Self- monitoring, including knowing one’s own calorie requirement and the calorie content of foods, helps make individuals conscious of what, when, and how much they eat. Mindful, or conscious, eating is an important lifestyle habit that can help to prevent inappropriate weight gain, enhance weight loss in those

who should lose weight, and assist others in maintaining a healthy weight.

Nutrient Adequacy

Americans are encouraged to lower overall energy intakes to match their energy needs. Energy-dense forms of foods, especially foods high in SoFAS, should be replaced with nutrient-dense forms of vegetables,

fruits, whole grains, and fluid milk and milk products to increase intakes of shortfall nutrients and nutrients of concern—vitamin D, calcium, potassium, and dietary fiber. Women of reproductive capacity should consume foods rich in folate and iron, and older individuals should consume fortified foods rich in vitamin B12 or

B12 supplements, if needs cannot be met through whole

foods. Nutritious breakfast consumption and in some

cases nutrient-dense snacking may assist in meeting nutrient recommendations, especially in certain subgroups.

A daily multivitamin/mineral supplement does not offer health benefits to healthy Americans. Individual mineral/vitamin supplements can benefit some population groups with known deficiencies, such as calcium and vitamin D supplements to reduce risk of

2010 Dietary Guidelines Advisory Committee Report 3

osteoporosis or iron supplements among those with deficient iron intakes. However, in some settings, mineral/vitamin supplements have been associated with harmful effects and should be pursued cautiously.

Fatty Acids and Cholesterol

Intakes of dietary fatty acids and cholesterol are major determinants of cardiovascular disease (CVD) and T2D, two major causes of morbidity and mortality in Americans. Fats contribute 9 calories per gram. The health impacts of dietary fats and cholesterol are mediated through levels of serum lipids, lipoproteins, and other intermediate markers. The U.S. consumption of harmful types and amounts of fatty acids and cholesterol has not changed appreciably since 1990.

In order to reduce the population’s burden from CVD and T2D and their risk factors, the preponderance of the evidence indicates beneficial health effects are associated with several changes in consumption of dietary fats and cholesterol. These include limiting saturated fatty acid intake to less than 7 percent of total calories and substituting instead food sources of mono- or polyunsaturated fatty acids. As an interim step

toward achieving this goal, individuals should first aim to consume less than 10 percent of energy as saturated fats and gradually reduce intake over time, while increasing polyunsaturated and monounsaturated sources. Other beneficial changes include limiting dietary cholesterol to less than 300 milligrams per day, but aiming at further reductions of dietary cholesterol to less than 200 milligrams per day in persons with or at high risk for CVD or T2D, and limiting cholesterol- raising fats (saturated fats exclusive of stearic acid and trans fatty acids) to less than 5 to 7 percent of energy.

Beneficial changes also include avoiding trans fatty acids from industrial sources in the American diet, leaving small amounts (<0.5% of calories) from trans fatty acids from natural (ruminant) sources, and consuming two servings of seafood per week (4 oz cooked, edible seafood per serving) that provide an average of 250 milligrams per day of n-3 fatty acids from marine sources (i.e., docosahexaenoic acid [DHA] and eicosapentaenoic acid [EPA]). Ensuring maternal dietary intake of long chain n-3 fatty acids, in particular DHA, during pregnancy and lactation through two or more servings of seafood per week also has benefits for the infant, especially when women emphasize types of seafood high in n-3 fatty acids and with low methyl mercury content.

Protein

Proteins are unique because they provide both essential amino acids to build body proteins and are a calorie source. Protein contributes 4 calories per gram. Because protein requirements are based on ideal body weight

(0.8 g protein/kg body weight/day for ages 19 years and older), lower-calorie diets result in a higher percentage of protein intake. Animal sources of protein, including meat, poultry, seafood, milk, and eggs, are the highest quality proteins. Plant proteins can be combined to form complete proteins if combinations of legumes and

grains are consumed. Plant-based diets are able to meet protein requirements for essential amino acids through planning and offer other potential benefits, such as sources of fiber and nutrients important in a health- promoting diet.

Carbohydrates

Carbohydrates contribute 4 calories per gram and are the primary energy source for active people. Sedentary people, including most Americans, should decrease consumption of energy-dense carbohydrates, especially refined, sugar-dense sources, to balance energy needs and attain and maintain ideal weight. Americans should choose fiber-rich carbohydrate foods such as whole grains, vegetables, fruits, and cooked dry beans and

peas as staples in the diet. Low-fat and fat-free milk and milk products are also nutrient-dense sources of carbohydrates in the diet and provide high-quality protein, vitamins, and minerals. High-energy, non- nutrient-dense carbohydrate sources that should be reduced to aid in calorie control include sugar- sweetened beverages; desserts, including grain-based desserts; and grain products and other carbohydrate foods and drinks that are low in nutrients.

Sodium, Potassium, and Water

At present, Americans consume excessive amounts of sodium and insufficient amounts of potassium. The health consequences of excessive sodium and insufficient potassium are substantial and include increased levels of blood pressure and its consequences (heart disease and stroke). In 2005, the DGAC recommended a daily sodium intake of less than 2300 milligrams for the general adult population and stated that hypertensive individuals, Blacks, and middle-aged and older adults would benefit from reducing their sodium intake even further to 1500 milligrams per day. Because these latter groups together now comprise nearly 70 percent of U.S. adults, the goal should be

4 2010 Dietary Guidelines Advisory Committee Report

1500 milligrams per day for the general population. Given the current U.S. marketplace and the resulting excessively high sodium intake, it will be challenging to achieve the lower level. In addition, time is required to adjust taste perception in the general population. Thus, the reduction from 2300 milligrams to 1500 milligrams per day should occur gradually over time. Because early stages of blood pressure-related atherosclerotic disease begin during childhood, both children and adults should reduce their sodium intake.

Individuals also should increase their consumption of dietary potassium because increased potassium intake helps to attenuate the effects of sodium on blood pressure. Water is needed to sustain life. However, there is no evidence, except under unusual circumstances,

that water intake among Americans is either excessive or insufficient.

Alcohol

An average daily intake of one to two alcoholic beverages is associated with the lowest all-cause mortality and a low risk of diabetes and coronary heart disease among middle-aged and older adults. Despite this overall benefit of moderate alcohol consumption, the DGAC recommends that if alcohol is consumed, it should be consumed in moderation, and only by adults. Moderate alcohol consumption is defined as average daily consumption of up to one drink per day for women and up to two drinks per day for men, with no

more than three drinks in any single day for women and no more than four drinks in any single day for men. One drink is defined as 12 fluid ounces of regular beer, 5 fluid ounces of wine, or 1.5 fluid ounces of distilled spirits.

The DGAC found strong evidence that heavy consumption of four or more drinks a day for women and five or more drinks a day for men has harmful health effects. A number of situations and conditions call for the complete avoidance of alcoholic beverages.

Food Safety and Technology

Since the release of the 2005 Dietary Guidelines, food safety concerns have escalated, with the apparent increase in voluntary recalls of foods contaminated with disease-causing bacteria and adulterated with non-food substances. These food safety issues affect commercial food products and food preparation in the home.

The basic four food safety principles identified to reduce the risk of foodborne illnesses remain unchanged. These principles are Clean, Separate, Cook, and Chill. Consumers must take more responsibility for carrying out these essential food safety practices. These actions, in tandem with sound government policies and responsible food industry practices, can help prevent foodborne illness. Even with current and future introductions of food safety technologies, food safety fundamentals in the home remain foundational.

The health benefits from consuming a variety of cooked seafood outweigh the risks associated with exposure to methyl mercury and persistent organic pollutants, provided that the types and sources of seafood to be avoided by some consumers are clearly communicated

to consumers. Overall, consumers can safely eat at least

12 ounces of a variety of cooked seafood per week provided they pay attention to local seafood advisories and limit their intake of large, predatory fish. Women who may become or who are pregnant, nursing mothers, and children ages 12 and younger can safely consume a variety of cooked seafood in amounts recommended by this Committee while following Federal and local advisories.

Conclusion

The 2010 DGAC recognizes the significant challenges involved in implementing the goals outlined in this Report. The challenges go beyond cost, economic interests, technological and societal changes, and agricultural limitations, but together, stakeholders and the public can make a difference. We must value preparing and enjoying healthy food and the practices of good nutrition, physical activity, and a healthy lifestyle. The DGAC encourages all stakeholders to take actions

to make every choice available to Americans a healthy choice. To move toward this vision, all segments of society—from parents to policy makers and everyone else in between—must now take responsibility and play a leadership role in creating gradual and steady change to help current and future generations live healthy and productive lives. A measure of success will be evidence that meaningful change has occurred when the 2015

DGAC convenes.

2010 Dietary Guidelines Advisory Committee Report

High-Fat Diets Won’t Harden Arteries Low-carbohydrate diets that require patients to fill up on fats won’t lead to harder arteries, researchers say June 3, 2011

Posted by ADAM PARTNERS in High Fat Low Carb Diet, Obesity.
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Those who lost 10 pounds after curbing their carb intake had no differences in arterial stiffness than those on a more traditional, low-fat diet, Dr. Kerry Stewart of Johns Hopkins and colleagues reported at the American College of Sports Medicine meeting in Denver. “Losing weight may be more important to [arterial] health than the diet you’re on,” Stewart said. Some researchers have raised concerns that replacing carbs with fats may have adverse effects on blood vessels, especially since promoting consumption of fats runs “counter to what the public has been told [about reducing fat intake] for the last 20 or so years,” Stewart said. Yet studies have shown that a low-carb diet can have positive effects on blood pressure, cholesterol, and other parameters that may reduce the risk of the artery disease atherosclerosis and subsequent heart disease. So to assess what the diets are actually doing to patients’ arteries, Stewart and colleagues enrolled 55 overweight or obese but healthy patients ages 30 to 65 in a lifestyle modification program. None had heart disease or other markers of cardiovascular risk at enrollment. In addition to a supervised exercise program — an hour-long regimen three days per week — patients were randomized to either a low-carb or low-fat diet for six months. The researchers monitored arterial stiffness and other measures of blood vessel health. For this analysis, the researchers had data on 23 of 28 patients who lost 10 pounds on the low-carb diet, and 23 of 27 who did so on the traditional diet. Those on the low-carb diet lost the 10 pounds sooner than the low-fat group did — just 45 days instead of 70 days. There were no changes in arterial stiffness or endothelial function in either diet group, and that didn’t change after the results were adjusted for the time it took to shed 10 pounds, Stewart said. “My theory is that if people can achieve weight loss, it will benefit vasculature in every other system of body,” he told “Weight loss, in the long run, will count more than the specific content of the diet.” Nor were there any acute effects on vascular function after a lone high-fat meal, the researchers found. In a companion study, 66 patients had no changes in endothelial function after eating a 900-calorie, 50-grams-of-fat meal from McDonald’s. In fact, arterial stiffness significantly improved by 16 percent after that feast, the researchers found. “It really seemed to make the arteries relax more, but we’re not entirely sure how,” Stewart said. “We’ll have to look more deeply into that.” Some researchers contacted for outside comment said longer-term follow up may be needed to confirm those benefits. And analyses of the diet study that include the type of fats eaten would be helpful, they said. “It would be nice to know what the fat consisted of, as some may be safer than others — i.e. monounsaturated fats and omega-3 fatty acids and even polyunsaturated fats would be better than saturated fats,” said Dr. Carl Lavie of the University of Queensland in New Orleans, who was not involved in the study. Stewart said that upcoming analyses will break down the type of fats consumed, and that the dieticians involved in the study advised patients to stick to these healthier fats. He added that the work should help allay physicians’ concerns about recommending a low-carbohydrate diet — something the medical community has largely been reluctant to do, he said.

CARBOHYDRATES May 27, 2011

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Carbohydrates are the principal source of the body’s energy and are divided into two types —simple and complex. Simple carbohydrates include the various sugars found in fruit (fructose), milk (lactose), and table sugar (sucrose). Complex carbohydrates are found in vegetables, whole grains, and legumes. Complex carbohydrates are preferable, as it takes longer for the body to break them down, releasing the sugar into the bloodstream slowly. Simple carbohydrates, especially table sugar, can flood the body and trigger an oversecretion of insulin by the isles of Langerhans, resulting in an initial surge of energy from the sugar followed by lethargy caused by the sudden rush of insulin. Foods should be unrefined, fresh, and natural; refined foods, canned goods, and snack foods should be avoided.

Food Sources: Fruits, whole grains, vegetables.

Effects: Carbohydrates help relax the brain and are necessary for good mental functioning. They act as an antidepressant for people with less sugarinduced serotonin in the brain than normal (such as those who suffer from seasonal affective disorder [SAD]), possibly by amplifying serotonergic neurotransmission. If consumption is timed right, they can increase the brain’s energy levels, as they are readily broken down into glucose, a simple sugar found in nature that is necessary for the brain’s functioning.

Precautions: Fructose does not have this calming effect. Simple sugars (table sugar, brown sugar, and honey, for instance) have no nutritional value except for calories, and can promote cavities, cause rapid changes in blood sugar and insulin, and lead to obesity, hypoglycemia, and diabetes, among other disorders. Some people are “carbohydrate cravers,” and need them to prevent drowsiness, restlessness, or boredom; instead of becoming sleepy, these people become more focused and alert, and better sustain concentration. Carbohydrates are safe and, to quote Dr. Stuart Berger, “They are the only food category not linked to any killer diseases.”

Dosage: 300 to 400 g/day from complex carbohydrates, or about 1200 to 1600 kilocalories/day (out of an average total of 1800 to 2200 kilocalories/day). Ideally, 65 percent of a person’s caloric intake should be carbohydrates —55 percent from complex carbohydrates and starches and 10 percent from natural sugars such as those found in fruit. A minimum of 50 g/day are needed to prevent ketosis, an acidic condition of the blood. For best effect, carbohydrates should be taken with as little protein and fat as possible, as these slow down or hinder serotonin on its way to the brain.

Can You Be Addicted to Foods? May 26, 2011

Posted by ADAM PARTNERS in Possible causes of Obesity Epidemic in USA.
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Many people tend to think that all obese people have to do to solve their problems is eat less and move more. Alcoholics, on the other hand, need treatment.

But are the two disorders really all that different? Is it possible that eating in today’s sweet and salty fast-food world is actually somewhat, well, addictive? Could people with a predilection to abusing alcohol and drugs just as easily abuse food?

A study published in The Archives of General Psychiatry this week is not the first to examine the neurobiological similarities between behaviors that drive obesity and those that drive substance abuse. The researchers, from Washington University School of Medicine in St. Louis, examined two large surveys of nationally representative samples of American adults questioned about alcoholism in their families. Each included about 40,000 adults; one survey was carried out in 1991 and 1992; the other was done a decade later, in 2001 and 2002.

The people surveyed were asked whether a relative had “been an alcoholic or problem drinker at any time in his/her life,” a question repeated for several types of relative — mother, father, brother, sister, half-sibling and children. Participants also reported their own weight and height, so body mass index could be calculated (B.M.I. is a calculation of weight in kilograms divided by height in meters squared, and a result of 30 or more is considered obese).

The first survey, from the early 1990s, found no link between a family history of alcoholism and obesity. “There was an almost perfect overlap between the B.M.I. distribution of people without a family history of alcoholism and people with a family history of alcoholism,” said Richard A. Grucza, assistant professor of psychiatry at Washington University and lead author of the new paper.

Ten years later the survey told a different story. In 2001 and 2002, adults with a family history of alcoholism were 30 to 40 percent more likely to be obese than those with no alcoholism in the family. Women were at particularly high risk: they were almost 50 percent more likely to be obese if there was family alcoholism than if there wasn’t. (Men were 26 percent more likely to be obese.)

Why the change over time? Dr. Grucza says our so-called obesigenic, or obesity-inducing, food environment has changed in the decade between the two surveys. The most likely culprit, he said, “is the nature of the food we eat, and its tendency to appeal to the sorts of reward systems, which are the parts of the brain implicated in addiction.”

Certain foods — loaded with sugar, salt and fat and specially formulated to appeal to consumers — might be cues that trigger overeating in people with the predisposition for addiction, appealing to the primitive reward centers of the brain, and reinforcing the addictive behavior. These types of foods, which the former Food and Drug Administration commissioner Dr. David Kessler has called “hyperpalatable,” may be more reinforcing of overeating than, say, green vegetables, Dr. Grucza said, and they’re more commonly and easily available than they were in the past.

In his book “The End of Overeating,” Dr. Kessler describes how these highly palatable foods — the kind served at fast-food and chain restaurants — change brain chemistry, triggering a neurological response that stimulates people to crave more food, even if they’re not hungry. The sense some people have that they cannot control their intake may in fact be true, he argues, because these rich, sweet and fatty foods stimulate the brain to release dopamine, a neurotransmitter associated with the pleasure center. In the process, they rewire the brain, so that the dopamine pathways light up even at the thought of eating these foods.

Other explanations for the increased obesity among relatives of alcoholics are possible, however. For example, it may be that people from families with alcoholism are more susceptible to stress generally, or to suffer from underlying depression that leads them to drink or overeat.

No single gene is responsible for making someone obese or alcoholic, Dr. Grucza said. But people who eat or drink excessively may share critical characteristics like lack of impulse control and the inability to stop once they get started, a sort of “missing stop signal,” he said. Stress is also implicated in both behaviors.

“The notion of alcoholism being a disease can be oversimplified,” Dr. Grucza said. “At some point, it’s a behavior and a choice. It’s just that some people are more vulnerable to the effect of that choice than others. I think the same is probably true of overeating — some people just don’t have the predisposition to find certain kinds of food that pleasurable, or to eat that much.”

Central Heating May Be Making Us Fat May 26, 2011

Posted by ADAM PARTNERS in Possible causes of Obesity Epidemic in USA.
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Americans like to crank up the heat in the winter — and some scientists think it’s making us fat. Turn down the thermostat, they say, and you might lose a few pounds.

The link between ambient temperature and weight is not completely far-fetched. When we’re exposed to extreme cold, we shiver, an involuntary reaction that makes our skeletal muscles contract to generate heat, burning extra calories in the process.

And even in mildly cold conditions, like in a chilly room with the thermostat turned down to the lower 60s, people generate extra heat without shivering. The process, called non-shivering thermogenesis, may involve a substance called brown fat that adults carry in certain areas, like the upper back and side of the neck. Unlike regular fat, which stores excess energy and calories, brown fat acts like an internal furnace that consumes lots of calories, but it has to be activated first — and cold temperatures do that.

Now, in a provocative new paper, British researchers argue that rising indoor temperatures are contributing to obesity. The research team included scientists from several disciplines, including health psychologists, biologists and those who specialize in the effects of indoor environments.

The hypothesis was initially put forth several years ago in a paper listing 10 “putative contributors” to obesity, including environmental endocrine disruptors, pharmaceuticals that induce weight gain, sleep debt, older mothers having children and epigenetic changes, or environmental factors that influence the expression of our genes.

The newer paper, published this week in the journal Obesity Reviews, looked specifically at indoor temperatures. The researchers found that since central heating became commonplace in the 1960s, room temperatures have increased slowly but steadily in both the United States and Britain. In both countries, obesity has also been on the rise.

The average temperature of living rooms in Britain, around 64.9 degrees Fahrenheit in 1978, had risen to 70.3 degrees by 2008. Bedrooms, kept at 59 degrees in 1978, were up to 65.3 by 1996, the last year figures were available.

In the United States, living rooms have long been heated to just over 70 degrees in the winter, at least when the house is occupied. Bedroom temperatures continue to rise and were up to 68 as of 2005, from 66.7 in 1987.

“What’s particularly noticeable is that people are heating the whole of their house,” said Fiona Johnson, a research fellow at University College London and the paper’s lead author. “In the past they would heat the main living areas, and the bedrooms might be cold at night.” That means people no longer have to adjust to different temperatures as they move through the house.

In addition, most people get around town in heated cars, instead of walking, and children spend less time playing outdoors.

All this time spent in toasty interiors may be affecting the levels of brown fat we carry, Dr. Johnson said. “It’s kind of ‘use it or lose it,’ ” she said. “If you’re not exposed to cold, you’re going to lose your brown fat, and your ability to burn energy will be affected. But you can get it back.”

While we all start out with substantial amounts of brown fat as babies, “it gradually decreases over the life course,” she said. “But if it is needed — if we’re regularly exposed to cold — the body can actually generate more brown fat.”

That is not to say exposure to cold is a major driver of obesity: overeating and lack of exercise are the main causes.

But could lowering the thermostat make a notable difference in people’s weight?

Dr. C. Ronald Kahn, a Harvard Medical School professor who does research on brown fat, says it might actually help with weight control over time, provided people stick with it.

“When we put people in a 60-degree room, they increase their energy expenditure by 100 or 200 calories a day if they’re in light clothing,” like hospital scrubs, he said. “They’re not shivering. They activate their brown fat.”

Over a period of several weeks, they will have burned an extra 3,500 calories, which translates into the loss of one pound. Wearing a sweater will dilute the effect.

The problem, Dr. Kahn said, is that “most people won’t stay at that temperature for very long.”

Less Active at Work, Americans Have Packed on Pounds May 26, 2011

Posted by ADAM PARTNERS in Possible causes of Obesity Epidemic in USA.
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Getty Images/SuperStockA worker operates a press at the New Orleans Times-Picayune, typical of the physical activity that was common in many workplaces in earlier decades.

Looking beyond poor eating habits and a couch-potato lifestyle, a group of researchers has found a new culprit in the obesity epidemic: the American workplace.

A sweeping review of shifts in the labor force since 1960 suggests that a sizable portion of the national weight gain can be explained by decliningphysical activity during the workday. Jobs requiring moderate physical activity, which accounted for 50 percent of the labor market in 1960, have plummeted to just 20 percent.

The remaining 80 percent of jobs, the researchers report, are sedentary or require only light activity. The shift translates to an average decline of about 120 to 140 calories a day in physical activity, closely matching the nation’s steady weight gain over the past five decades, according to the report, published Wednesday in the journal PLoS One.

Today, an estimated one in three Americans are obese. Researchers caution that workplace physical activity most likely accounts for only one piece of the obesity puzzle, and that diet, lifestyle and genetics all play an important role.

But the new emphasis on declining workplace activity also represents a major shift in thinking, and it suggests that health care professionals and others on the front lines against obesity, who for years have focused primarily on eating habits and physical activity at home and during leisure time, have missed a key contributor to America’s weight problem. The findings also put pressure on employers to step up workplace heath initiatives and pay more attention to physical activity at work.

“If we’re going to try to get to the root of what’s causing the obesity epidemic, work-related physical activity needs to be in the discussion,” said Dr. Timothy S. Church, a noted exercise researcher at the Pennington Biomedical Research Center in Baton Rouge, La., and the study’s lead author. “There are a lot of people who say it’s all about food. But the work environment has changed so much we have to rethink how we’re going to attack this problem.”

The report shows that in 1960, one out of two Americans had a job that was physically active. Now it is estimated that only one in five Americans achieves a relatively high level of physical activity at work. Dr. Church notes that because the research doesn’t factor in technological changes, like increasing reliance on the Internet and e-mail, many people in service and desk jobs that have always involved only light activity are now moving less than ever, meaning the findings probably understate how much physical activity has been lost during work hours.

While it has long been known that Americans are more sedentary at work compared with the farming and manufacturing workers of 50 years ago, the new study is believed to be the first in which anyone has estimated how much daily caloric expenditure has been lost in the workplace.

“It’s a light bulb, ‘aha’ moment,” said Barbara E. Ainsworth, the president-elect of the American College of Sports Medicine and an exercise researcher at Arizona State University. “I think occupational activity is part of that missing puzzle that is so difficult to measure, and is probably contributing to the inactivity and creeping obesity that we’re seeing over time.”

For years, the role that physical activity has played in the obesity problem has been uncertain. Numerous studies suggest there has been little change in the average amount of leisure-time physical activity, posing a conundrum for researchers trying to explain the country’s steady weight gain. As a result, much of the focus has been on the rise of fast-food and soft drink consumption.

Other studies have suggested that changing commuting habits, declining reliance on public transportation and even increased time in front of the television have played a role in the fattening of America. But none of those issues can fully explain the complex changes in nationwide weight-gain patterns.

Some earlier research has hinted at the fact that workplace physical activity is associated with weight and health. One seminal set of studies of London bus drivers and conductors showed that the sedentary bus drivers had higher rates of heart disease than the ticket-takers, who moved around during the workday.

Dr. Church said that during a talk on the country’s obesity patterns, he was struck by the fact that Mississippi and Wisconsin both have high rates of obesity, despite having little in common in terms of demographics, education or even weather. It occurred to him that both states have waning agricultural economies, prompting him to begin exploring the link between changes in the labor force and declines in workplace physical activity.

He quickly discovered that a decline in farming jobs alone could not explain increasing obesity around the country, and began exploring job shifts over several decades. Using computer models, Dr. Church and colleagues assigned metabolic equivalent values to various job categories and then calculated changes in caloric expenditure at work from 1960 to 2008.

“You see the manufacturing jobs plummet and realize that’s a lot of physical activity,” said Dr. Church. “It’s very obvious that the jobs that required a lot of physical activity have gone away.”

Ross C. Brownson, an epidemiologist at Washington University in St. Louis, said that both health professionals and the public needed to broaden the traditional definition of physical activity as something that occurs during planned exercise, like running or working out at the gym.

“We need to think about physical activity as a more robust concept than just recreational physical activity,” said Dr. Brownson, whose 2005 report on declining physical activity in the workplace is cited in the PLoS One report. “In many ways we’ve engineered physical activity out of our lives, so we’ve got to find ways to put it back into our lives, like taking walks during breaks or having opportunities for activity that are more routine to our daily lives, not just going to the health club.”

Researchers said it is unlikely that the lost physical activity can ever be fully restored to the workplace, but employers do have the power to increase the physical activity of their employees by offering subsidized gym memberships or incentives to use public transit. Some companies have set up standing workstations, and marketers now offer treadmill-style desks. Employers can also redesign offices to encourage walking, by placing printers away from desks and encouraging face-to-face communication, rather than e-mail.

“The activity we get at work has to be intentional,” said Dr. Ainsworth. “When people think of obesity they always think of food first, and that’s one side of it, but it’s high time to look at the amount of time we spend inactive at work.”

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