April 2016 Issue

The 2015–2020 Dietary Guidelines
By David Yeager
Today's Dietitian
Vol. 18 No. 4 P. 34

Experts tell Today's Dietitian what they think about them and how they could impact the health of Americans.

When the 2015–2020 Dietary Guidelines for Americans were released on January 7, there were some notable changes. Out are recommended limits on dietary cholesterol. In are recommended curbs on added sugars and updated guidance on sodium intake. Overall, there's a greater focus on dietary patterns as opposed to specific foods and food groups. In addition to offering guidance to the general public and health care professionals, the guidelines are used by federally funded programs such as the National School Lunch Program and WIC to help determine the types of foods, serving sizes, and menus that will be offered. The guidelines' recommendations also have been incorporated into the newly revised USDA Choose MyPlate program.

Updated every five years as a joint report of the US Department of Health & Human Services (HHS) and the USDA, the stated goal of the guidelines is to "encourage Americans to adopt a series of science-based recommendations to improve how they eat to reduce obesity and prevent chronic diseases like type 2 diabetes, hypertension, and heart disease."1 With obesity affecting more than one-third of American adults—78.6 million people—and obesity-related diseases ranking among the leading causes of death in the United States,2 it stands to reason that the guidelines should continue to focus on disease prevention. Whether they go far enough in advancing this cause has generated a spirited debate among health care experts.

What's New
One change that nearly everyone agrees is beneficial is the recommendation that added sugars be limited to less than 10% of a person's total daily caloric intake.3 This recommendation doesn't include naturally occurring sugars. Although people shouldn't be surprised that they need to cut back on sugar, this is the first time specific limits for added sugars have been included in the guidelines. Because it's a new recommendation, and current food labels don't separate naturally occurring sugars from added sugars, some people may have difficulty discerning the difference between them, says Lisa Jones, MA, RDN, LDN, FAND, a spokesperson for the Pennsylvania Academy of Nutrition and Dietetics.

"I think it's definitely a source of confusion," Jones says, adding that information about added sugars currently isn't on food and beverage labels. "The expectation is that added sugars will be included on food and beverage labels, but no changes [to labels] can be made until the FDA [issues its final ruling]."

Jones says dietitians can help consumers better understand this guideline by putting it in context. She adds that many people are unaware of the amounts of added sugars in common foods. For example, many sodas, coffee-based drinks, and energy drinks can have significant amounts of added sugar. Although these drinks don't specifically list added sugars on their food labels, most of them don't contain ingredients with naturally occurring sugars.3

"In terms of translating the guideline for consumers, if you consider a 2,000 calorie diet, 10% of 2,000 calories equals 200 calories of added sugar. There are approximately 200 calories in 50 g of sugar," Jones says. "If you look at sodas, there are approximately 35 g of sugar in a 12-oz can of soda, and that puts a person close to the recommended daily intake. Even nonsoda beverages can have significant amounts of sugar, so it's still very important to read labels."

Caffeine, although not a nutrient, also was mentioned for the first time in the guidelines. The guidelines don't recommend caffeine consumption, but they note that moderate consumption in healthy adults—400 mg or less per day, between three and five 8-oz cups—isn't associated with an increased risk of major chronic disease, such as cancer, or premature death.3 The guidelines also mention that there isn't much data available on the health effects of energy drinks.3 Sarah Krieger, MPH, RDN, a spokesperson for the Academy of Nutrition and Dietetics, would like to see more specific guidance on caffeine in the 2020 guidelines.

"I work mainly with the under-18 crowd, so for 2020 I would love to see them mention that caffeine is not appropriate for people under 18, and it has affected health care costs," Krieger says. "There have been more emergency room visits because of caffeine, whether it's in supplements or energy drinks. The recommendation is 400 mg or less per day,3 regardless of where you're getting that caffeine from."

Another change was the shift in guidance on sodium intake. The 2010 guidelines recommended 2,300 mg or less per day for adults over 14, but 1,500 mg per day or less for African Americans, people over 51, and those who have hypertension, diabetes, or chronic kidney disease. In other words, the 2010 guidelines recommended that about one-half of the US population consumes 1,500 mg per day or less of sodium.4 The 2015 guidelines recommend 2,300 mg per day or less for people 14 and older and 1,500 mg per day or less for people with hypertension or prehypertension.3

The 2010 sodium guideline recommendations for 1,500 mg of sodium for a targeted group of people "were very specific and extreme and very hard to follow, so they changed the guideline to what it had been [before 2010]; [the 2015 guidelines are] not targeting any specific ethnic or racial or age groups. I think it's moving in the right direction because people took offense to those guidelines," Krieger says. "Following a diet with 1,500 mg or less of sodium is very difficult, and these guidelines are really geared toward healthy people and food programs."

There's also new guidance for cholesterol and fat. The 2010 guidelines recommended 300 mg per day or less of cholesterol, which is equivalent to about two medium-sized eggs.4 The new guidelines don't recommend any limits, but Jones and Krieger agree that people still need to be cognizant of the cholesterol-containing foods they consume.

In addition to removing cholesterol-limiting recommendations, the new guidelines support overall fat consumption according to levels established in the Acceptable Macronutrient Distribution Range, with a shift towards replacing less healthful fats (saturated and trans fats) with more healthful fats (unsaturated fats). And they continue to recommend limiting consumption of saturated fats to less than 10% of total calories.3 For a 2,000 kcal diet, this amounts to 200 kcal per day from saturated fat. All fats contain 9 kcal per gram so the target for a 2,000 kcal diet is approximately 22 g or less of saturated fat per day. Jones and Krieger agree with the new guideline recommendations that people should replace saturated fats, which are more prevalent in red meat and dairy products, with unsaturated fats, which are more prevalent in vegetable oils and nuts, whenever possible.

"We want to focus on consuming less saturated fat," Krieger says. "A lot of those foods happen to have cholesterol anyway, but we don't want to focus on cholesterol; we want to focus on limiting saturated fats." Indeed, the 2015 Dietary Guidelines limit cholesterol intake indirectly by limiting saturated fat intake.

Perhaps the biggest change from previous guidelines is the focus on eating patterns.3 Rather than narrowly prescribing or proscribing specific foods, the new guidelines allow for variation among many different lifestyles. Jones and Krieger see this shift as a positive development that addresses the needs of a widely diverse American public, which in turn can help nutrition professionals counsel clients and patients more effectively. "One size does not fit all," Jones says. "You have to cater to the audience that you're speaking to."

The guidelines suggest the following three types of eating patterns that can support the goal of disease prevention: a healthy US-style, a healthy Mediterranean-style, and a healthy vegetarian-style pattern.3 Each pattern emphasizes fruits, vegetables, legumes, nuts, and whole grains.3 The healthy US-style pattern is similar to the recommended dietary pattern from the 2010 guidelines, with a few changes added to reflect the current recommendations.3 The Mediterranean-style pattern contains more fruit and seafood and less dairy than the US-style pattern, and is geared toward adults because children weren't included in the studies that were used to modify the pattern.3 The vegetarian-style pattern is based on the US-style pattern, including eggs and dairy but without the meat, poultry, and seafood.3 The vegetarian-style pattern also contains higher amounts of soy products, legumes, nuts and seeds, and whole grains.3

Business as Usual?
The guidelines are based on recommendations from the Scientific Report of the 2015 Dietary Guidelines Advisory Committee (DGAC). In February 2015, the DGAC submitted its scientific report to the secretaries of HHS and the USDA to undergo an evidence analysis process that included a public comment period.5 While many in the nutrition profession believe that the 2015 guidelines more accurately reflect the way Americans should eat, some health care experts believe the guidelines don't adequately reflect the scientific findings on which they're based. David Katz, MD, MPH, FACPM, FACP, founding director of Yale University's Yale-Griffin Prevention Research Center, president of the American College of Lifestyle Medicine, and founder of the True Health Initiative, is among those who believe that much of the advisory committee's work was lost in the translation. Specifically, the USDA and HHS removed the DGAC's discussion on sustainability, stating that "because this is a matter of scope, the dietary guidelines aren't the appropriate vehicle for this important policy conversation." Recommendations to require labeling of added sugars and establish a percent DV also weren't included in the final 2015–2020 Dietary Guidelines for Americans, although the FDA proposed adding this information to labels in 2014.

"The scientific [DGAC] part of this process was excellent. The big problem is the political process that diluted the final [Dietary Guidelines for Americans] report," Katz says. "Essentially, what happened, under the influence of lobbying and politics, is that the perfect clarity and all the right messages in the Dietary Guidelines Advisory Committee Report were translated into undecipherable gobbledygook [in the Dietary Guidelines for Americans]. And it's not that they're wrong, it's that they don't say anything."

Of specific concern to Katz is that the Executive Summary of the Dietary Guidelines for Americans states that the report will discuss foods, rather than nutrients. Although the guidelines mention specific foods Americans should eat, they don't mention specific foods to avoid. Katz says this lack of specificity makes it difficult, if not impossible, for people to compare their potential food choices.

"It's overt hypocrisy," Katz says. "[Reading the Dietary Guidelines for Americans is] a sort of window into the world of clever politicians. When the official dietary guidelines talk about what we should eat, they're quite clear. When they talk about what we shouldn't eat, they immediately convert to nutrient-speak. 'Cut down on your saturated fat, but we're not going to tell you what you shouldn't eat, and perish the thought that you should have fewer pepperoni pizzas. Cut down on your sugar intake, but we're not going to say, 'When you're thirsty, drink water instead of soda,' because our friends at Coca-Cola wouldn't like that.'"

The few areas of the guidelines that Katz feels are worthwhile are the parts that were taken directly from the DGAC report. For example, he thinks that removing cholesterol and overall fat limits, in favor of recommending fewer saturated fats, is a good idea. He also believes that ignoring the importance of sustainable food systems, which appeared in the original DGAC report, is a grave disservice to the public because environmental and sustainability issues will affect the nation's ability to produce the food it needs in the coming decades. He notes that an emphasis on sustainability aligns with the opinions of many nutrition and food systems experts in North America and Europe.6

Katz and others feel that another critical omission in the 2015–2020 Dietary Guidelines is a discussion on processed and red meats, which originally appeared in the DGAC report. In October 2015, the International Agency for Research on Cancer, which is the cancer agency of the World Health Organization, published a report in The Lancet Oncology that classifies processed meat as a carcinogen and red meat as a probable carcinogen.7 By avoiding discussion on potentially unhealthful food choices, Katz feels that the Dietary Guidelines for Americans fail to serve the public interest. He feels so strongly about it that he's posted an online petition on Change.org to change the name of the guidelines to something other than Dietary Guidelines for Americans, which he feels is a misleading name.

"Americans should be able to read these guidelines and get the best current thinking on what we should be eating for our health," Katz says. "The best thinking about what's good for the people and the planet should not be for sale to the highest bidder."

Informing the Public
To help provide the most up-to-date scientific information to the public, Katz founded the True Health Initiative, which aims to prevent chronic disease and premature death by building a movement around the fundamentals of healthful living. Rather than deferring to policymakers, he believes nutrition experts and average citizens can use science-based research to improve public health. Although some experts may have different areas of emphasis, he says there's general agreement about the components of a healthful diet,8 and dietitians can play a crucial role in the conversation.

"The confusion that seems to be holding us up is pseudoconfusion, but I think common sense is enough to get us past it. The way to rally people is to focus on areas of broad agreement, rather than the areas of narrow disagreement. Vegans and Paleos don't agree about everything, yet the experts in the vegan diet camp and the experts in the Paleo diet camp advocate diets that are much more alike than different. And they're much more like one another than either is like the typical American diet. I think that's an important message that dietitians could convey to their clients," Katz says. "Translating general guidance into personal behavior requires expert coaching, and dietitians are particularly suited to offer that, but I would encourage them to refer their clients to the DGAC report, rather than the Dietary Guidelines for Americans."

In addition to providing nutrition education and helping people understand the guidelines, dietitians also can make a significant impact by teaching essential skills. Jones says cooking and label reading are two areas where her clients often struggle.

"Some of the clients I talk to don't even look at labels because they find them so confusing," Jones says. "So coming up with ways to help them make that information more actionable, such as focusing on sugar and sodium for clients with diabetes, can make the labels easier to understand and use."

Krieger says many consumers find shopping for healthful foods challenging because of the vast array of food products. She recommends teaching people how to use Choose MyPlate to develop and maintain a healthful eating style. She says Choose MyPlate is a good place to start because it's designed to be the consumer-friendly interpretation of the Dietary Guidelines for Americans, and the website has been updated to be more user friendly. Armed with some useful nutrition information, shopping for healthful foods is much easier.

"When I grocery shop, one-half of my cart is fruits and vegetables, one-quarter of it is lean protein, whether it comes from animals or not, and one-quarter of it is whole grains. Once you start shopping that way, there's a wide variety within those food groups," Krieger says. "Switch it up every time you shop. The combinations are endless. Depending on ethnic cuisines or what's in season, there are so many things to eat that we should never get bored. Eating a wide variety of many different foods is really the foundation of eating an overall healthful diet for your entire life."

— David Yeager is a freelance writer and editor based in southeastern Pennsylvania.

References
1. HHS and USDA release new Dietary Guidelines to encourage healthy eating patterns to prevent chronic diseases. US Department of Health & Human Services website. http://www.hhs.gov/about/news/2016/01/07/hhs-and-usda-release-new-dietary-guidelines-encourage-healthy-eating-patterns-prevent-chronic.html. Updated January 7, 2016. Accessed January 25, 2016.

2. Adult obesity facts. Centers for Disease Control and Prevention website. http://www.cdc.gov/obesity/data/adult.html. Updated September 21, 2015. Accessed January 25, 2016.

3. US Department of Health & Human Services. Dietary Guidelines for Americans 2015–2020: Eighth Edition. http://health.gov/dietaryguidelines/2015/guidelines/. Published January 7, 2016. Accessed January 26, 2016.

4. US Department of Agriculture, US Department of Health & Human Services. Dietary Guidelines for Americans 2010: executive summary. http://www.cnpp.usda.gov/sites/default/files/dietary_guidelines_for_americans/ExecSumm.pdf. Accessed January 26, 2016.

5. US Department of Agriculture, US Department of Health & Human Services. Scientific Report of the 2015 Dietary Guidelines Advisory Committee. http://health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf. Published January 28, 2015. Accessed January 25, 2016.

6. Oldways common ground consensus statement on healthy eating. Oldways Preservation Trust website. http://oldwayspt.org/common-ground-consensus. Accessed February 1, 2016.

7. Bouvard V, Loomis D, Guyton KZ, et al. Carcinogenicity of consumption of red and processed meat. Lancet Oncol. 2015;16(16):1599-1600.