By Susan Blumenthal, M.D., Yingna Wang and Nicholas Pruthi
On January 7, 2016, the US Department of Health and Human Services (HHS) and the US Department of Agriculture (USDA) released the 2015-2020 Dietary Guidelines for Americans (8th edition), providing science-based recommendations on nutrition for professionals and policymakers to help all people aged 2 years and older and their families consume a healthy, nutritionally adequate diet. The Guidelines are required under the 1990 National Nutrition Monitoring and Relation Research Act, which states that every 5 years, HHS and USDA must jointly publish a document containing nutritional and dietary information and guidelines for the general public based on current scientific and medical knowledge. The guidelines provide the basis for federal food, nutrition and health policies as well as national nutrition education for the public, thus, influencing the diets of millions of Americans. They also shape federal food assistance programs, such as the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and help determine which foods are chosen for the USDA's National School Lunch Program and School Breakfast Program.
While many of the recommendations have remained consistent with the last set of guidelines released in 2010 (such as advising the consumption of more fruits and vegetables, whole grains, lean meat, and low-fat foods), the 2015 Dietary Guidelines for Americans introduces some new recommendations. For the first time, the USDA guidelines specifically recommend limiting added sugars to 10 percent of one's daily calories. Assuming the average adult American consumes 2,000 calories a day, adult men would be limited to a maximum of 10 teaspoons of sugar per day; but children, women, and those adults who consume fewer calories are advised to consume even less. The guidelines also recommend individuals limit their daily sodium intake to 2,300 milligrams, a significant decrease from 3,400 milligrams, the average amount Americans consume every day. A third recommendation states that individuals should consume less than 10 percent of their daily calories from saturated fats, echoing recommendations from the 2010 edition of the Dietary Guidelines. The new recommendations expand on the concept of "good" fats, such as the omega-3 fatty acids found in some fish. The 2015 guidelines also state that coffee/caffeine consumption appears to be safe in moderate amounts, suggesting that adults can drink up to 3 to 5 cups a day. They also state that a moderate amount of alcohol can be consumed by adults of legal drinking age and women who are not pregnant (up to 1 drink per day for women; 2 drinks per day for men).
Leading up to the release of the Dietary Guidelines, there was some speculation that the document might include recommendations for reductions in meat consumption linked to sustainability and climate change issues, given the large carbon footprint of meat production. While the final edition of the Dietary Guidelines includes lean meat as a part of a healthy diet, the document does not address sustainability issues or the environmental impact of meat production. A notable change to the 2015 edition of the Dietary Guidelines is the inclusion of eggs as part of a healthy diet, against which the government had cautioned for 40 years due to concerns over the potential health damaging effects of high cholesterol intake. Elevated cholesterol levels have been linked to coronary heart disease, type 2 diabetes, high blood pressure, and stroke.
The new guidelines focus on overall shifts in eating patterns to achieve healthier diets and emphasize choosing nutrient-dense foods and beverages without added sugars instead of less healthy choices. This year's guidelines reflect the concept that a healthy eating pattern is not a rigid prescription but rather a flexible framework in which people can enjoy foods that meet their personal, cultural and traditional preferences and align with their budget.
1. Follow a healthy eating pattern across the lifespan. All food and beverage choices matter. Choose a healthy eating pattern at an appropriate calorie level to help achieve and maintain a healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease.
A healthy eating pattern according to the 2015 Dietary Guidelines for Americans includes:
· A variety of vegetables: dark green, red and orange, legumes (beans and peas), starchy and other vegetables
· Fruits, especially whole fruit
· Grains, at least half of which are whole grain
· Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages
· A variety of protein foods including seafood, lean meats and poultry, eggs, legumes such as beans and peas, soy products, and nuts and seeds
· Oils from plants: canola, corn, olive, peanut, safflower, soybean, and sunflower oils, as well as nuts, seeds, seafood, olives, and avocados
· Limiting saturated fats to less than 10 percent of calories per day and trans fats (as low as possible), added sugars (less than 10 percent of calories per day), and sodium (less than 2,300 milligrams per day)
2. Focus on variety, nutrient density, and amount. To meet nutrient needs within calorie limits, choose a variety of nutrient-dense foods across and within all food groups in recommended amounts.
3. Limit calories from added sugars and saturated fats and reduce sodium intake. Consume an eating pattern low in added sugars, saturated fats, and sodium. Cut back on foods and beverages higher in these components to amounts that fit within healthy eating patterns.
Quantitative Key Recommendations are provided for several components of the diet that should be limited, like sugar, sodium and saturated fats:
· Consume less than 10 percent of calories per day from added sugars
· Consume less than 10 percent of calories per day from saturated fats
· Consume less than 2,300 milligrams (mg) per day of sodium
4. Shift to healthier food and beverage choices. Choose nutrient-dense foods and beverages across and within all food groups in place of less healthy choices. Consider cultural and personal preferences to make these shifts easier to accomplish and maintain.
5. Support healthy eating patterns for all. Everyone has a role in helping to create and support healthy eating patterns in multiple settings nationwide, from home to school to work to communities.
Some nutrition experts worry that these new Dietary Guidelines do not go far enough in providing clear, definitive recommendations for what Americans should and should not eat. Dr. Marion Nestle, Professor of Nutrition, Food Studies, and Public Health at New York University, is supportive of the guidelines' emphasis on food patterns, but raises concerns over eliminating restrictions on dietary cholesterol intake. "The dropping of the guideline for cholesterol is worrisome because so much of the research on eggs and cholesterol (eggs are the single greatest source of dietary cholesterol) was sponsored by the egg industry," she emphasized.
Dr. Richard Wender, Chief Cancer Control Officer at the American Cancer Society, has echoed Dr. Nestle's concerns: "By omitting specific dietary recommendations, such as eating less red and processed meat, these guidelines miss a critical and significant opportunity to reduce suffering and death from cancer."
Dr. Walter Willett, Chair of the Department of Nutrition at the Harvard T.H. Chan School of Public Health, and a collaborator on the SNAP to Health project, also expressed concerns about the new guidelines: "This is a loss for the American public and a win for big beef and big soda. The problem isn't just that the public gets misleading, censored information, but that these Guidelines get translated into national food programs, such as the menus for our kids in schools, diets for pregnant women, and programs for low-income Americans. This then gets directly translated into unnecessary premature deaths, diabetes, and suffering ... of course this goes on to mean greater health care costs for all. It is all connected."
Since 1960, the American man, on average, has gained 30 pounds and the American woman, on average, has gained 26 pounds. Today, 69 percent of Americans are overweight. Some speculate that this weight gain could be linked in part to the recommendation about the number of carbohydrate portions included in the guidance of the USDA's Food Pyramid issued in 1992. Going forward, with the adoption of the new 2015 Dietary Guidelines, the weight patterns of Americans must be evaluated longitudinally to determine the effects of this federal guidance on obesity rates in the future.
Another important element of the Dietary Guidelines for Americans is the recommendation that individuals meet the Physical Activity Guidelines for all Americans to reduce the risk of obesity-related chronic illness, such as heart disease and diabetes. Lack of physical activity is an independent risk factor for chronic illness. In the introduction to the 2015 Dietary Guidelines, USDA Secretary Thomas Vilsack and HHS Secretary Sylvia Burwell note: "Today, about half of all American adults--117 million people--have one or more preventable, chronic disease, many of which are related to poor quality eating patterns and physical inactivity."
While the new Dietary Guidelines encourage healthier eating patterns and lifestyles, future editions should clarify the nutritional differences between sources of protein, such as red meat compared to nuts. Specifically, nutrition expert, Dr. Nestle, underscores: "[the term] protein lumps meat together with seafood, poultry, eggs, nuts, seeds, and soy. But grains and dairy also have protein, so using this term makes no nutritional sense and obfuscates the message to eat less meat." According to Dr. Willett: "In fact, the dietary guidelines promote consumption of red meat as long as it is lean, which is not what the science supports. There is strong evidence that red meat consumption increases risk of diabetes, heart attacks, stroke, and some cancers (especially processed meat), and there is not good evidence that this is simply due to the fat content." In the future, the Dietary Guidelines' recommendations could be enhanced by including specific examples of foods to consume less of, instead of advising against nutrients and broad categories of foods. For example, nutritional guidelines from Brazil and Sweden are easily understandable and highlight real food choices, not just the nutrients contained in these products. Dietary Guidelines for Americans in the future should place a greater emphasis on calories and portion sizes as well.
Getting the Guidelines right is important because the document's recommendations are far-reaching in scope, affecting federal food assistance programs and public health initiatives addressing obesity and food insecurity. A recent USDA report estimated that 14 percent of American households experienced food insecurity in 2014, meaning that they had limited access to adequate food at some point during the year, due to lack of money or access. Additionally, obesity and food insecurity co-exist. For example, one third of American children are overweight or obese and 15.3 million of them lived in food insecure households last year.
The federal food assistance program SNAP (Supplemental Nutrition Assistance Program), helps supplement the diets of food insecure households. A recent study found that SNAP beneficiaries are more likely to be obese in comparison to income-eligible and higher-income non-participants (40 percent versus 32 percent versus 30 percent). While the diets of all groups fell far short of the Dietary Guidelines for Americans, the diets of SNAP participants were less healthy than income eligible and higher income nonparticipants of SNAP. This might be in part linked to the higher cost of healthy foods recommended by the Dietary Guidelines, which may not be accessible to low-income Americans and those people living in food deserts. Food deserts are defined as "urban neighborhoods and rural towns without ready access to fresh, healthy, and affordable food. Instead of supermarkets and grocery stores, these communities may not have access to healthy products or are served only by fast food restaurants and convenience stores that offer few healthy, affordable food options."
An important component of the Dietary Guidelines is its Strategies for Action, which recommends increasing the availability and affordability of healthy foods such as vegetables, fruits, and lean protein especially in food deserts. The guidelines also support increasing educational efforts about healthy eating, particularly in Federal nutrition assistance programs. The SNAP to Health project developed a menu of recommendations for improving nutrition and reducing obesity for participants in the Federal Supplemental Nutrition Assistance Program (SNAP), a $76 billion federal food assistance initiative that serves 1 out of 7 Americans, 50 percent of whom are children. Implementing strategies to promote uptake of recommendations included in the Dietary Guidelines has the potential to reduce obesity rates, helping to ensure a healthier start for children enrolled in the program.
While some experts have expressed concerns about specific elements of the Guidelines, most agree they are a step in the right direction by encouraging healthier eating patterns and lifestyles for all Americans. However, there is always room for improvement, and as the impact of the obesity epidemic continues to take a health-damaging toll on people in the United States, and as scientific evidence expands about which foods and beverages are healthy, the next edition of the Dietary Guidelines for Americans in 2020 would benefit from utilizing clearer, more concise language presented in a more visually appealing format with infographics and advice for the general public as well as professionals. Simplified and easier-to-understand information in this document about components of a healthy diet and the significance of physical activity are important ingredients in the recipe for a healthier United States in the years ahead.
Rear Admiral Susan Blumenthal, M.D., M.P.A. (ret.) is the Public Health Editor of The Huffington Post. She is aSenior Fellow in Health Policy at New America and a Clinical Professor at Tufts and Georgetown University Schools of Medicine. Dr. Blumenthal served for more than 20 years in senior health leadership positions in the federal government in the Administrations of four U.S. presidents including as Assistant Surgeon General of the United States, the first Deputy Assistant Secretary of Women's Health, and as Senior Global Health Advisor in the U.S. Department of Health and Human Services. She also served as a White House advisor on health. She provided pioneering leadership in applying information technology to health, establishing one of the first health websites in the government (womenshealth.gov) and the"Missiles to Mammogram" Initiative that transferred CIA, DOD and NASA imaging technology to improve the early detection of breast and other cancers. Prior to these positions, Dr. Blumenthal was Chief of the Behavioral Medicine and Basic Prevention Research Branch, Head of the Suicide Research Unit, and Chair of the Health and Behavior Coordinating Committee at the National Institutes of Health. She has chaired many national and global commissions and conferences and is the author of many scientific publications. Admiral Blumenthal has received numerous awards including honorary doctorates and has been decorated with the highest medals of the U.S. Public Health Service for her pioneering leadership and significant contributions to advancing health in the United States and worldwide. Named by the New York Times, the National Library of Medicine and the Medical Herald as one of the most influential women in medicine, Dr. Blumenthal was named the Health Leader of the Year by the Commissioned Officers Association and as aRock Star of Science by the Geoffrey Beene Foundation. She is the recipient of the Dr. Rosalind Franklin Centennial Life in Discovery Award.
Yingna Wang is a junior at Dartmouth College, majoring in Classical Languages and Literatures with a minor in Global Health. She is a Health Policy Intern at New America in Washington, D.C.
Nicholas Pruthi is a junior at Dartmouth College majoring in Economics. He is serving as a Health Policy Intern at New America in Washington, D.C.