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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.
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Railroad tank car transporting high fructose c...

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; = .0032) and high-fructose corn syrup (increase, 1.8 ± 1.4 mmol/L x 24 hours; = .035), but not glucose (decrease, 1.9 ± 0.9 mmol/L x 24 hours; = .14). Similarly, fasting LDL and apoB concentrations were increased during consumption of fructose (LDL increase, 0.29 ± 0.082 mmol/L; = .0023; apoB increase, 0.093 ± 0.022 g/L; = .0005) and high-fructose corn syrup (LDL increase, 0.42 ± 0.11 mmol/L; < .0001; apoB, 0.12 ± 0.031 g/L; < .0001), but not glucose (LDL increase, 0.012 ± 0.071 mmol/L, P= .86; apoB increase, 0.0097 ± 0.019 g/L; = .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.


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

Posted by ADAM PARTNERS in DIETRY GUIDELINES FOR AMERICANS.
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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 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-rdoba 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.

+ nd 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

Ø Ø 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.

 

+

 

nd

 

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.

+ nd 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

+ nd 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

+ nd 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

nd + 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

nd + 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

       
 

ChangClaude 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

 

+

 

Ø

 

↓ 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

 

UK

+ + 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

Posted by ADAM PARTNERS in DIETRY GUIDELINES FOR AMERICANS.
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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.

 

 

 

References

 

 

Bachman JL, Reedy J, Subar AF, Krebs-Smith SM. Sources of food group intakes among the U.S. population, 2001-2002. J Am Diet Assoc.

2008;108(5):804-14.

 

Britten P, Marcoe K, Yamini S, Davis C. Development of food intake patterns for the MyPyramid Food Guidance System. J Nutr Educ Behav. 2006;38(6

Suppl):S78-S92.

Dietary Guidelines Advisory Committee (DGAC). Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2005. Washington DC: U.S. Department of Agriculture, Agricultural Research Service, August 2004.

 

Haven J, Burns A, Britten P, Davis C. Developing the consumer interface for the MyPyramid Food Guidance System. J Nutr Educ Behav. 2006;38(6 Suppl):S124- S135.

 

Marcoe K, Juan W, Yamini S, Carlson A, Britten P. Development of food group composites and nutrient profiles for the MyPyramid Food Guidance System. J Nutr Educ Behav. 2006;38(6 Suppl):S93-S107.

 

National Cancer Institute (NCI). Food Sources of

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.

 

World Cancer Research Fund and American Institute for Cancer Research Report (WCRF/AICR). Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC: AICR,

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

218 years

 

2027

Ages

23 years

 

1471

Ages

48 years

 

1802

Ages

913 years

 

2035

Ages

1418 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

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

Lactoovo

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 Lactoovo  
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

 

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)

 

 

 

Dietary Pattern

Usual U.S.

Intake

Adults 19 year+

DASH with

Reduced Sodium

 

USDA Base

Pattern1

 

 

USDA Plant-based

USDA

Lactoovo

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

 

 

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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.

 

 

 

References

 

 

Aggett PJ, Haschke F, Heine W, Hernell O, Koletzko

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

and exercise in both nonpregnant and pregnant women.

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

 

Christian P. Micronutrients, birth weight, and survival.

Annu Rev Nutr. 2010 Apr 23; Epub ahead of print.

 

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

 

Diabetes Prevention Program Research Group (DPP). The Diabetes Prevention Program (DPP): description of lifestyle intervention. Diabetes Care.

2002;25(12):2165-71.

 

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.

2009;14:374(9702):1677-86.

 

Dietary Guidelines Advisory Committee (DGAC). Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2005. Washington DC: U.S. Department of Agriculture, Agricultural Research Service, August 2004.

 

He W, Sengupta M, Velkoff V, DeBarros K. U.S. Census Bureau. Current Population Reports. P23-209.

65+ in the United States: 2005. Washington, DC: U.S. Government Printing Office, 2005.

 

Institute of Medicine. Subcommittee on Nutrition During Lactation. Committee on Nutritional Status During Pregnancy and Lactation. Food and Nutrition Board. Nutrition During Lactation. Washington, DC: National Academies Press, 1991.

 

Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press, 2002.

 

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.

2002;76(6):1261-71.

 

McGinnis JM, Foege WH. Actual causes of death in the

United States. JAMA. 1993;270(18):2207-12.

 

Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual Causes of Death in the United States, 2000. JAMA 2004; 291(10):1238-45. Correction: JAMA.

2005;293(3):293-4.

 

Picciano MF. Pregnancy and lactation: physiological adjustments, nutritional requirements and the role of dietary supplements. J Nutr. 2003 Jun;133(6):1997S-

2002S.

Saldana TM, Siega-Riz AM, Adair LS. Effect of macronutrient intake on the development of glucose intolerance during pregnancy. Am J Clin Nutr.

2004;79(3):479-86.

 

U.S. Department of Agriculture (USDA). Continuing

Survey of Food Intakes by Individuals 1994-1996,

1998. PB2000-500027. CD-ROM, 2004.

 

U.S. Department of Health and Human Services (HHS). Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. National Center for Disease Prevention and Health Promotion, 1996.

 

Warner MJ, Ozanne SE. Mechanisms involved in the developmental programming of adulthood disease. Biochem J. 2010 Apr 14;427(3):333-47.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10        2010 Dietary Guidelines Advisory Committee

DIETRY GUIDELINES FOR AMERICANS June 7, 2011

Posted by ADAM PARTNERS in DIETRY GUIDELINES FOR AMERICANS.
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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.

 

 

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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.

 

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.

 

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.

•     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.

•     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.

 

 

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•     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

 

 

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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

 

 

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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

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