2010 Dietary Guidelines For Americans
2010 Dietary Guidelines For Americans
2010 Dietary Guidelines For Americans
Committee by the
Agricultural Report of the Dietary
Research
Service Guidelines Advisory
United States
Department of
Agriculture Committee on the Dietary
United States
Department of Guidelines for Americans,
Health and
Human Services 2010
May 2010
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May 2010
Contents
It is my privilege to present to you on behalf of the entire 2010 U.S. Dietary Guidelines Advisory
Committee the full Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for
Americans, 2010. In the initial charge to this panel, we were asked to “provide science-based advice for
Americans, in order to promote health and to reduce the risk for major chronic diseases through diet and
physical activity.” More specifically, this involved, among other tasks, that we base our Report upon “the
preponderance of the most current scientific and medical knowledge, and determine what issues for
change need to be addressed,” with a “primary focus on the review of scientific evidence published since
the last DGAC deliberations” and place “primary emphasis on the development of food-based
recommendations.” We attended to each of these objectives and much more during the past 20 months
and we are in consensus and committed to the content and recommendations delineated in the enclosed
Report.
It has been a remarkable journey, filled with extensive investigation and critical evidence-based
review, covering relevant aspects of diet and health. Just under 200 specific questions related to dietary
guidance were initially identified and most were addressed. With assistance from the USDA Nutrition
Evidence Library (NEL), and additional hand searches involving other extensive databases, the
Committee formulated answers to the questions that it believes reflect the most current scientific
evidence. In addition to the expertise represented by our members, we had the outstanding and able
assistance of Dietary Guidelines Management Team staff members from both USDA and HHS, without
whom this task would have been impossible. We also appreciate crucial input from the Federal staff from
both USDA and HHS who each deserve recognition for their invaluable contributions.
The single most sobering aspect of this Report is the recognition that we are addressing an
overweight and obese American population. Across all age, gender and ethnic groups, it is clear that
urgent and systems-wide efforts are needed to address America’s obesity epidemic as top priority.
Everything within this Report is presented through the filter of an obesegenic environment in critical need
of change. This is especially true in regard to American children whose incidence of obesity has tripled in
____________________________________________________________________________________
In this regard, we encourage you to do everything possible to increase funding for greatly needed
research studies on numerous, important and highly strategic nutrition issues raised throughout this
Report. Specifically, in ultimately drafting our conclusion statements, the DGAC was struck by the
number of questions that simply could not be addressed due to the absence of data or limitations due to
inconclusive findings. Likewise, we urge you to further emphasize the importance of keeping current with
the ongoing National Health and Nutrition Examination Survey (NHANES) data. The 2015 DGAC
should be provided with the opportunity to study the impact of the 2010 Report by having access to the
most current, accurate and detailed NHANES nutrient data available at that time. Steps should be taken to
update these data as quickly as possible in order to maintain an accurate and ongoing view of America’s
dietary intake. In addition, the time has come to consider including all Americans, from birth on, as part
of these results since research increasingly points to the importance of diet, even in utero, in shaping
future health. Subsequent reports should include a focus on pregnancy, breastfeeding behavior and early
diet from birth on.
In summary, every member of this Committee has worked diligently, collaboratively and
tirelessly to produce this landmark Report. When differences of interpretation were debated from time to
time, the mutual respect and admiration expressed for each and every member of this group has been
nothing short of inspirational. The Committee looks forward to seeing the final Report become available
online, as well as the subsequent documents, discussion and translational tools that will surely be
generated. Thank you for your steadfast support, enthusiasm and recognition. We remain encouraged and
hopeful that the American public will take these recommendations to heart and benefit extensively from
their implementation.
Sincerely,
____________________________________________________________________________________
Members
Executive Secretaries
Research Librarian
Technical Writer/Editor
The 2010 Dietary Guidelines Advisory Committee The remainder of this Executive Summary provides
(DGAC) was established jointly by the Secretaries of brief synopses of these and all of the other chapters,
U.S. Department of Agriculture (USDA) and the U.S. which review current evidence related to specific topics
Department of Health and Human Services (HHS). The and present the resulting highlights that comprise the
Committee’s task was to advise the Secretaries of fundamental essence of this report.
USDA and HHS on whether revisions to the 2005
Dietary Guidelines were warranted, and if so, to
recommend updates to the Guidelines. The DGAC Major Cross-cutting Findings and
immediately recognized that, on the basis of the vast Recommendations
amount of published research and emerging science on
numerous relevant topics, an updated report was indeed
Total Diet: Combining Nutrients, Consuming
needed.
Foods
The 2010 DGAC Report is distinctly different from
The 2010 DGAC Report concludes that good health and
previous reports in several ways. First, it addresses an
optimal functionality across the lifespan are achievable
American public of whom the majority are overweight
goals but require a lifestyle approach including a total
or obese and yet under-nourished in several key
diet that is energy balanced and nutrient dense. Now, as
nutrients. Second, the Committee used a newly
in the past, a disconnect exists between dietary
developed, state-of-the-art, web-based electronic system
recommendations and what Americans actually
and methodology, known as the Nutrition Evidence
consume. On average, Americans of all ages consume
Library (NEL), to answer the majority of the scientific
too few vegetables, fruits, high-fiber whole grains, low-
questions it posed. The remaining questions were
fat milk and milk products, and seafood and they eat too
answered by data analyses, food pattern modeling
much added sugars, solid fats, refined grains, and
analyses, and consideration of other evidence-based
sodium. SoFAS (added sugars and solid fats) contribute
reviews or existing reports, including the 2008 Physical
approximately 35 percent of calories to the American
Activity Guidelines for Americans. The 2005 Dietary
diet. This is true for children, adolescents, adults, and
Guidelines for Americans were the starting place for
older adults and for both males and females. Reducing
most reviews. If little or no scientific literature had been
the intake of SoFAS can lead to a badly needed
published on a specific topic since the 2005 Report was
reduction in energy intake and inclusion of more
presented, the DGAC indicated this and established the
healthful foods into the total diet.
conclusions accordingly.
The diet recommended in this Report is not a rigid
A third distinctive feature of this Report is the
prescription. Rather, it is a flexible approach that
introduction of two newly developed chapters. The first
incorporates a wide range of individual tastes and food
of these chapters considers the total diet and how to
preferences. Accumulating evidence documents that
integrate all of the Report’s nutrient and energy
certain dietary patterns consumed around the world are
recommendations into practical terms that encourage
associated with beneficial health outcomes. Patterns of
personal choice but result in an eating pattern that is
eating that have been shown to be healthful include the
nutrient dense and calorie balanced. The second chapter
Dietary Approaches to Stop Hypertension (DASH)-style
complements this total diet approach by integrating and
dietary patterns and certain Mediterranean-style dietary
translating the scientific conclusions reached at the
patterns. Similarly, the USDA Food Patterns illustrate
individual level to encompass the broader
that both nutrient adequacy and moderation goals can
environmental and societal aspects that are crucial to
be met in a variety of ways. The daunting public health
full adoption and successful implementation of these
challenge is to accomplish population-wide adoption of
recommendations.
healthful dietary patterns within the context of powerful
influences that currently promote unhealthy consumer
choices, behaviors, and lifestyles.
Individuals also should increase their consumption of The health benefits from consuming a variety of cooked
dietary potassium because increased potassium intake seafood outweigh the risks associated with exposure to
helps to attenuate the effects of sodium on blood methyl mercury and persistent organic pollutants,
pressure. Water is needed to sustain life. However, there provided that the types and sources of seafood to be
is no evidence, except under unusual circumstances, avoided by some consumers are clearly communicated
that water intake among Americans is either excessive to consumers. Overall, consumers can safely eat at least
or insufficient. 12 ounces of a variety of cooked seafood per week
provided they pay attention to local seafood advisories
Alcohol and limit their intake of large, predatory fish. Women
who may become or who are pregnant, nursing mothers,
An average daily intake of one to two alcoholic and children ages 12 and younger can safely consume a
beverages is associated with the lowest all-cause variety of cooked seafood in amounts recommended by
mortality and a low risk of diabetes and coronary heart this Committee while following Federal and local
disease among middle-aged and older adults. Despite advisories.
this overall benefit of moderate alcohol consumption,
the DGAC recommends that if alcohol is consumed, it Conclusion
should be consumed in moderation, and only by adults.
Moderate alcohol consumption is defined as average The 2010 DGAC recognizes the significant challenges
daily consumption of up to one drink per day for involved in implementing the goals outlined in this
women and up to two drinks per day for men, with no Report. The challenges go beyond cost, economic
more than three drinks in any single day for women and interests, technological and societal changes, and
no more than four drinks in any single day for men. One agricultural limitations, but together, stakeholders and
drink is defined as 12 fluid ounces of regular beer, 5 the public can make a difference. We must value
fluid ounces of wine, or 1.5 fluid ounces of distilled preparing and enjoying healthy food and the practices of
spirits. good nutrition, physical activity, and a healthy lifestyle.
The DGAC encourages all stakeholders to take actions
The DGAC found strong evidence that heavy to make every choice available to Americans a healthy
consumption of four or more drinks a day for women choice. To move toward this vision, all segments of
and five or more drinks a day for men has harmful society—from parents to policy makers and everyone
health effects. A number of situations and conditions else in between—must now take responsibility and play
call for the complete avoidance of alcoholic beverages. a leadership role in creating gradual and steady change
to help current and future generations live healthy and
Food Safety and Technology productive lives. A measure of success will be evidence
that meaningful change has occurred when the 2015
Since the release of the 2005 Dietary Guidelines, food DGAC convenes.
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.
Since first published in 1980, the Dietary Guidelines The Role of Diet and Physical Activity in
for Americans have provided science-based advice to Health Promotion: Attenuating Chronic
promote health and reduce risk of major chronic Disease Risks
diseases through optimal diet and regular physical
activity. The Dietary Guidelines have traditionally
A large proportion of deaths each year in the United
targeted the healthy general public older than age 2
States (U.S.) result from a limited number of
years, but as data continue to accumulate regarding the
preventable and modifiable factors. The leading causes
importance of dietary intake during gestation and from
of death for the past two decades have been tobacco use
birth on, it also will become important to consider those
and poor diet and physical inactivity (McGinnis, 1993;
younger than age 2 years in future Guidelines. Because
Mokdad, 2004). The number of deaths related to poor
of their focus on health promotion and risk reduction,
diet and physical inactivity is increasing and may soon
the Dietary Guidelines form the basis of Federal food,
overtake tobacco as the leading cause of death. As
nutrition education, and information programs.
discussed in this Report, poor dietary intake has been
linked to excess body weight and numerous diseases
By law (Public Law 101-445, Title III, 7 U.S.C. 5301 et
and conditions, such as cardiovascular disease (CVD)
seq.), the most recent edition of the Dietary Guidelines
and type 2 diabetes (T2D) and their related risk factors.
is reviewed by a committee of experts, updated if
Even if the overweight/obesity epidemic resolves, the
necessary, and published every 5 years. The legislation
problems of chronic disease would continue to be a
also requires that the Secretaries of the U.S. Department
major health problem because poor-quality diets, even
of Agriculture (USDA) and U.S. Department of Health
in the absence of overweight/obesity, increase the risk
and Human Services (HHS) review all Federal
some of our most common chronic diseases.
publications for the general public containing dietary
guidance information for consistency with the Dietary
The reduction of chronic disease risk merits strong
Guidelines for Americans. This Report presents the
emphasis in our Nation for many reasons, especially
recommendations of the 2010 Dietary Guidelines
because some groups in the population bear a
Advisory Committee (DGAC) to the Secretaries of
disproportionate burden of chronic disease and
USDA and HHS for use in updating the Guidelines.
attendant risk factors. The present Report highlights the
evidence that links diet and different chronic diseases. It
The 2010 DGAC Report is unprecedented in addressing
also summarizes and synthesizes knowledge regarding
an American public, two-thirds of whom are overweight
many individual nutrients and food components into
or obese. Americans are making dietary choices in a
recommendations for an overall total pattern of eating
highly obesogenic environment and at a time of
that can be adopted by the public. Although adherence
burgeoning diet-related chronic diseases affecting
to the Dietary Guidelines is low among the U.S.
people of all ages, ethnic backgrounds, and
population, evidence is accumulating that selecting diets
socioeconomic levels. The DGAC considers the obesity
that comply with the Guidelines reduces the risk of
epidemic to be the single greatest threat to public health
chronic disease and promotes health. Ultimately,
in this century. This Report is therefore focused on
individuals choose the types and amount of food they
evidence-based guidelines and recommendations that
eat and the amount of physical activity they perform,
are considered effective and useful in halting and
but the current environment significantly enhances the
reversing the obesity problem through primary
overconsumption of calories and discourages the
prevention and changes in behavior, the environment,
expenditure of energy. Both sides of this equation are
and the food supply.
discussed in greater detail throughout the Report.
The Report concludes with several Appendices, He W, Sengupta M, Velkoff V, DeBarros K. U.S.
including a compilation of the Committee’s scientific Census Bureau. Current Population Reports. P23-209.
conclusions, a glossary, a brief history of the Dietary 65+ in the United States: 2005. Washington, DC: U.S.
Guidelines for Americans, a listing of the food pattern Government Printing Office, 2005.
analyses conducted for the 2010 DGAC, a summary of
the process used to collect public comments, Institute of Medicine. Subcommittee on Nutrition
biographical sketches of DGAC members, and During Lactation. Committee on Nutritional Status
acknowledgments. During Pregnancy and Lactation. Food and Nutrition
Board. Nutrition During Lactation. Washington, DC:
National Academies Press, 1991.
References
Institute of Medicine. Dietary Reference Intakes for
Energy, Carbohydrate, Fiber, Fat, Fatty Acids,
Aggett PJ, Haschke F, Heine W, Hernell O, Koletzko Cholesterol, Protein, and Amino Acids. Washington,
B, Lafeber H, Ormission A, Rey J, Tormo R. ESPGAN DC: National Academies Press, 2002.
Committee on Nutrition Report: Childhood diet and
prevention of coronary heart disease. J Pediatr Gastr Manton KG, Gu X. Changes in the prevalence of
and Nutr. 1994;19(3):261-9. 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.
The 2010 Dietary Guidelines Advisory Committee Although there is no single “American” or “Western”
(DGAC) supports a total diet approach to achieving diet, average American food patterns currently bear
dietary goals. The purpose of this chapter is to little resemblance to the diet recommended in the 2005
demonstrate how the scientific evidence presented in Dietary Guidelines for Americans. As documented by
each of the topic-specific chapters in Part D: The the latest data from the National Health and Nutrition
Science Base—Energy Balance and Weight Examination Survey (NHANES), Americans eat too
Management; Nutrient Adequacy; Fatty Acids and many calories and too much solid fats, added sugars,
Cholesterol; Protein; Carbohydrates; Sodium, refined grains, and sodium. Americans also eat too little
Potassium, and Water; Alcohol; and Food Safety and dietary fiber, vitamin D, calcium, potassium, and
Technology—can be incorporated into an overall eating unsaturated fatty acids (specifically omega-3s), and
pattern that optimizes health outcomes. other important nutrients that are mostly found in
vegetables, fruits, whole grains, low-fat milk and milk
Until recently, data were insufficient to document the products, and seafood (see Part D. Section 2: Nutrient
impact of whole diets and eating patterns on health Adequacy).
outcomes. The state of the evidence and the
methodologic rigor regarding such questions have Overweight and obesity are highly prevalent in the U.S.
improved tremendously and the data can now be in both adults and children. This is of great public health
incorporated into this Report. concern because excess body fat is associated with a
much higher risk of premature death and many serious
This chapter synthesizes the evidence on dietary disorders, as identified in Part D. Section 1: Energy
components that contribute to excess energy and Balance and Weight Management. Preventing
inadequate nutrient intakes in the United States (U.S.), overweight is highly preferable to initiating weight loss
and the foods that can provide these missing essential treatment after weight gain occurs, because the failure
nutrients and other health benefits. It presents a brief, rate in achieving and maintaining weight loss is very
evidence-based comparison of worldwide eating high. Furthermore, the behaviors required to prevent
patterns, including the Dietary Approaches to Stop overweight are less daunting than the behaviors necessary
Hypertension (DASH), Mediterranean, and other to lose and sustain weight loss. Currently, the average
patterns, along with a description of the U.S. American gains about a pound a year between the ages of
Department of Agriculture (USDA) Food Patterns with 20 to 60 years. Some persons gain much more.
vegetarian variations. Remaining conscious of one’s body weight throughout
life and adopting a lifestyle early on that will achieve and
A nutrient-dense total diet has multiple health benefits sustain weight control across the lifespan are paramount
and can be implemented in various ways. The U.S. is to maintaining good health and quality of life.
comprised of individuals of all ages who come from
many cultures and have a variety of food and taste A Special Focus on Children and Adolescents
preferences. All of these factors were considered in The single most significant adverse health trend among
developing a recommended total diet that is flexible U.S. children in the past 40 years has been the dramatic
while meeting nutrient needs without exceeding energy increase in overweight and obesity (see Part D. Section
requirements. 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
Children (ages 2 to 18 years) consume an average of • Solid fats (percent of solid fat intake)
400 calories per day as beverages. The major beverages — Grain-based desserts, including cakes, cookies,
for children and calories from each are somewhat pies, doughnuts, and granola bars (10.9%)
different: — Regular cheese (7.7%)
— Sausage, franks, bacon, and ribs (7.1%)
• Fluid milk (160 calories per day) — Pizza (5.9%)
• Soda (118 calories per day) — 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%) Maximum limits on SoFAS are meant to be estimates
• Added sugars (percent of added sugars intake) and not necessarily daily targets (see limits from USDA
— Soda (36.6%) Food Patterns, Table B2.3, end of this chapter). These
— Grain-based desserts (11.7%) foods should constitute a very small proportion of total
— Fruit drinks (11.5%) energy intake in the total diet. Figure B2.1 contrasts the
— Dairy-based desserts (6.4%) current disproportionately high intake of SoFAS with
— Candy (6.2%) 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)
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 milk and milk products, without exceeding overall
calories from SoFAS. This is too high. They should calorie needs.
reduce intake of calories from SoFAS by 20 to 30
percent. This means that no more than 5 to 15 percent Consume Nutrient-dense Foods (But Not Too
of total calories should be derived from SoFAS. For Much of Them)
example, the USDA Food Patterns limit SoFAS to
about 120 calories in the 1600-calorie pattern, 160 Currently, Americans consume less than 20 percent of
calories in the 1800-calorie pattern, and 260 calories in the recommended intakes for whole grains, less than 60
the 2000-calorie pattern (Table B2.3, at the end of the percent for vegetables, less than 50 percent for fruits,
chapter, lists SoFAS limits for all calorie levels). and less than 60 percent for milk and milk products
Reduction of calories from SoFAS to these amounts (Figure B2.2). Inadequate intakes of nutrient-dense
allows for increased intakes of nutrient-dense foods foods from these basic food groups place individuals at
such as vegetables (including cooked dry beans and risk for lower than recommended levels of specific
peas), fruits, whole grains, and fat-free and low-fat fluid nutrients, namely vitamin D, calcium, potassium, and
dietary fiber.
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 recommendation that half of grains consumed be whole
combination of the macronutrients carbohydrates, fats, grains, also assisting in meeting dietary fiber
and protein in varying proportions. These are the major recommendations (see Part D. Section 5:
sources of energy in any food or diet. Understanding Carbohydrates).
their role in the diet will help Americans make
appropriate food choices. Dietary fats (both solid fats and oils) are high in calories
(9 kcal/g). Unsaturated fats, including omega-3 from
Carbohydrates (4 kcal/g) are the primary source of seafood sources, should be increased and saturated fat
energy intake, and higher intakes of carbohydrates, and trans fatty acid intake should be minimized. Given
especially complex sources, are recommended for active typical patterns of consumption in the U.S., dietary
people. Sedentary individuals, and thus most saturated fat intake is highly correlated with total fat
Americans, should lower their intakes of refined intake. Consuming the recommended intake of saturated
carbohydrates, greatly reducing intakes of sugar and fat (less than 10% of calories immediately as an interim
sugar-sweetened beverages and refined grains that are step toward an eventual goal of less than 7% of calories)
high in calories, but relatively low in certain nutrients. is more likely achievable when total fat intake is less
Whole-grain versions of many grain products (such as than 30 percent of total calories. It is recommended that
plain white bread, rolls, bagels, muffins, pasta, total fat should be in the range of 20 to 35 percent of
breakfast cereals) should be substituted to meet the total calories but derived mostly from oils within a
References
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
1
Based 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.
Table B2.2. Top five sources of energy among U.S. children, adolescents, and adults by age, NHANES 2005-061
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
2010 Dietary Guidelines Advisory Committee Report
Energy Level of
Pattern2 1000 1200 1400 1600 1800 2000 2200 2400 2600 2800 3000 3200
Fruits 1c 1c 1½ c 1½ c 1½ c 2c 2c 2c 2c 2½ c 2½ c 2½ c
Vegetables 1c 1½ c 1½ c 2c 2½ c 2½ c 3c 3c 3½ c 3½ c 4c 4c
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 2c 2c 2c 3c 3c 3c 3c 3c 3c 3c 3c 3c
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%)
1
Food 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.
2
Food 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.
3
SoFAS are calories from solid fats and added sugars.
23
24
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)
Qualitative
Description
Emphasizes Potassium-rich Vegetables, fruits, Plant foods - Plant foods - Plant foods -
vegetables, fruits, and whole grains, vegetables, fruits, vegetables, fruits, vegetables, fruits,
and low-fat milk low-fat milk products whole grains, whole grains, whole grains,
products legumes, low-fat legumes, nuts, seeds, legumes, nuts, seeds,
milk products soy foods, milk soy foods
products
Includes Whole grains, Enriched grains, lean Lean meat, eggs, Eggs, oils Non-dairy milk
poultry, fish, and meat, fish, and oils fish, and oils alternatives
nuts
2010 Dietary Guidelines Advisory Committee Report
Limits (small Red meats, sweets, Solid fats Solid fats No meat, poultry, No animal products
amount) and sugar-containing Added sugars Added sugars fish Added sugars
beverages Added sugars
Nutrients
Calories (kcal) 2000 2000 2000 2000 2000 2000
Carbohydrates 48.4% 58% 56.7% 55.8% 56.7% 56.8%
(% total kcal)
Protein 15.2% 18% 15.2% 16.3% 15.2% 13.3%
(% total kcal)
Total Fat 33.5% 27% 32% 31% 31% 33%
(% total kcal)
Saturated Fat 10.9% 6% 8.4% 7.8% 7.8% 6.8%
(% total kcal)
Monounsaturated 12.5% 10% 12.0% 11.4% 11.8% 12.4%
(% total kcal)
Polyunsaturated 6.8% 8% 9.0% 9.3% 9.4% 12.0%
(% total kcal)
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,
2010 Dietary Guidelines Advisory Committee Report
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
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 - -
25
26
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)
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
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.
3
Non-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 2. Appendix: Dietary
Patterns and Health Outcomes
As originally developed, the DASH diet was designed In many observational studies, vegetarian diets and
to provide a nutrient profile that might lower blood lifestyle have been associated with improved health
pressure. As such, it is a derived dietary pattern. outcomes. The types of vegetarian diets consumed in
Nonetheless, it is based on foods that are routinely the U.S. vary considerably. Strict vegetarians (i.e.,
available in U.S. and was studied using foods purchased vegans), do not consume any animal products, while
at local stores. At present, few adults, even those with other types of vegetarians, such as lacto-ovo
hypertension, eat a diet that is consistent with the vegetarians, consume milk and eggs. Although not strict
DASH dietary pattern (Mellen, 2008). vegetarians, many individuals consume small or
minimal amounts of animal products. On average,
vegetarians consume fewer calories from fat than non-
Mediterranean-style Dietary Patterns vegetarians, particularly saturated fat, and have a higher
consumption of carbohydrates than non-vegetarians. In
In view of the large number of cultures and agricultural addition, vegetarians tend to consume fewer overall
patterns of countries that border the Mediterranean Sea, calories and have a lower body mass index than non-
the “Mediterranean” diet is not a single dietary pattern. vegetarians. These characteristics, in addition to the
Countries included those of southern-most Europe, the dietary pattern per se, may contribute to the improved
Middle East, and northern-most Africa. Interest in health outcomes of vegetarians.
traditional Mediterranean-style diets is substantial
because such diets have been associated with Although no or minimal consumption of animal
considerable health benefits. Because of the multiplicity products is a hallmark of vegetarian diets, these diets
of dietary patterns termed “Mediterranean,” it has been have a clear potential for confounding, particularly from
challenging to characterize these diets. Although a other dietary and non-dietary factors. Hence, the
traditional Mediterranean diet has no well-accepted set improved health experience of vegetarians may not only
of criteria, it can be described as one that emphasizes result from reduced consumption of saturated fats but
breads and other cereal foods usually made from wheat, also from greater consumption of vegetables, fruit, nuts,
vegetables, fruits, nuts, unrefined cereals, and olive oil; and grains or from other health attributes, such as not
includes fish and wine with meals (in non-Islamic smoking cigarettes.
countries); and is reduced in saturated fat, meat, and
full-fat dairy products (Kris-Etherton, 2001;
Trichopoulou, 2003; WCRF/AICR, 2007). Table B2.5 Other Dietary Patterns
displays the nutrient profile and food group composition
of Mediterranean-style diets, as reported in three cohort In view of the increasing diversity of the U.S.
studies (one from Greece, one from Spain, and one from population, interest in the health effects of non-Western
the U.S.) (Fung, 2009; Karanja, 1999; Lin, 2003; diets is substantial. One group of diets with potential
Nunez-Cordoba, 2008; Trichopoulou, 2003; Wilcox, health benefits are those consumed in Asia. It is well-
2007). documented that in Southeast Asia, coronary heart
disease rates have been among the lowest in the world.
Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Fung TT, Chiuve SE, McCullough ML, Rexrode KM,
Azizi F. Beneficial effects of a Dietary Approaches to Logroscino G, Hu FB. Adherence to a DASH-style diet
Stop Hypertension eating plan on features of the and risk of coronary heart disease and stroke in women.
metabolic syndrome. Diabetes Care. 2005 Arch Intern Med. 2008 Apr 14;168(7):713-20. Erratum
Dec;28(12):2823-31. in: Arch Intern Med. 2008 Jun 23;168(12):1276.
Brunner EJ, Mosdøl A, Witte DR, Martikainen P, Fung TT, Rexrode KM, Mantzoros CS, Manson JE,
Stafford M, Shipley MJ, Marmot MG. Dietary patterns Willett WC, Hu FB. Mediterranean diet and incidence
and 15-y risks of major coronary events, diabetes, and of and mortality from coronary heart disease and stroke
mortality. Am J Clin Nutr. 2008 May;87(5):1414-21. in women. Circulation. 2009 Mar 3;119(8):1093-100.
Cai H, Shu XO, Gao YT, Li H, Yang G, Zheng W. A Fung TT, Willett WC, Stampfer MJ, Manson JE, Hu
prospective study of dietary patterns and mortality in FB. Dietary patterns and the risk of coronary heart
Chinese women. Epidemiology. 2007 May;18(3):393- disease in women. Arch Intern Med. 2001 Aug 13-
401. 27;161(15):1857-62.
Núñez-Córdoba JM, Valencia-Serrano F, Toledo E, Sciarrone SE, Strahan MT, Beilin LJ, Burke V, Rogers
Alonso A, Martínez-González MA. The Mediterranean P, Rouse IR. Ambulatory blood pressure and heart rate
diet and incidence of hypertension: the Seguimiento responses to vegetarian meals. J Hypertens. 1993
Universidad de Navarra (SUN) Study. Am J Epidemiol. Mar;11(3):277-85.
2009 Feb 1;169(3):339-46.
Shimazu T, Kuriyama S, Hozawa A, Ohmori K, Sato Y,
Osler M, Heitmann BL, Gerdes LU, Jørgensen LM, Nakaya N, Nishino Y, Tsubono Y, Tsuji I. Dietary
Schroll M. Dietary patterns and mortality in Danish patterns and cardiovascular disease mortality in Japan: a
men and women: a prospective observational study. Br prospective cohort study. Int J Epidemiol. 2007
J Nutr. 2001 Feb;85(2):219-25. Jun;36(3):600-9.
Panagiotakos D, Pitsavos C, Chrysohoou C, Palliou K, Singman HS, Berman SN, Cowell C, Maslansky E,
Lentzas I, Skoumas I, Stefanadis C. Dietary patterns Archer M. The Anti-Coronary Club: 1957 to 1972. Am
and 5-year incidence of cardiovascular disease: a J Clin Nutr. 1980 Jun;33(6):1183-91.
multivariate analysis of the ATTICA study. Nutr Metab
Cardiovasc Dis. 2009 May;19(4):253-63. Sofi F, Cesari F, Abbate R, Gensini GF, Casini A.
Adherence to Mediterranean diet and health status:
Panagiotakos DB, Pitsavos C, Matalas AL, Chrysohoou meta-analysis. BMJ. 2008 Sep 11;337:a1344.
C, Stefanadis C. Geographical influences on the
association between adherence to the Mediterran nean Swain JF, McCarron PB, Hamilton EF, Sacks FM,
diet and the prevalence of acute coronary syndromes, in Appel LJ.Characteristics of the diet patterns tested in
Greece: the CARDIO2000 study. Int J Cardiol. 2005 the optimal macronutrient intake trial to prevent heart
Apr 8;100(1):135-42. disease (OmniHeart): options for a heart-healthy diet. J
Am Diet Assoc. 2008 Feb;108(2):257-65.
Parikh A, Lipsitz SR, Natarajan S. Association between
a DASH-like diet and mortality in adults with Takahashi Y, Sasaki S, Okubo S, Hayashi M, Tsugane
hypertension: findings from a population-based follow- S. Blood pressure change in a free-living population-
up study. Am J Hypertens. 2009 Apr;22(4):409-16. based dietary modification study in Japan. J Hypertens.
2006 Mar;24(3):451-8.
Rouse IL, Beilin LJ, Armstrong BK, Vandongen R.
Blood-pressure-lowering effect of a vegetarian diet: Trichopoulou A, Bamia C, Trichopoulos D. Anatomy of
controlled trial in normotensive subjects. Lancet. 1983 health effects of Mediterranean diet: Greek EPIC
Jan 1;1(8314-5):5-10. prospective cohort study. BMJ. 2009 Jun 23;338:b2337.
Table B2.5. Selected dietary patterns with documented cardiovascular health benefits (adjusted to 2000 calories)
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)
35
36
Table B2.5 (continued). Selected dietary patterns with documented cardiovascular health benefits (adjusted to 2000 calories)
Mediterranean
DASH with Mediterranean Mediterranean Diet
Dietary Pattern Reduced Sodium Diet (Greece) Diet (Spain) (U.S.) Japanese Okinawan
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
2010 Dietary Guidelines Advisory Committee Report
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)
Table B2.5 (continued). Selected dietary patterns with documented cardiovascular health benefits (adjusted to 2000 calories)
Mediterranean
DASH with Mediterranean Mediterranean Diet
Dietary Pattern Reduced Sodium Diet (Greece) Diet (Spain) (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
Plant Proteins:
- 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 <1g <0.1
(oz)
- Soy products nd nd nd See legumes. See legumes.
(oz)
DASH N = 12 12 12 + 10 +
(9 RCT, 3 Positive 1Ø
prospective 2 Neutral 1 n/d
cohort)
Appel LJ et al., 2005 RCT Positive N = 164 adult with + + Overall Between Diet Differences -
(OmniHeart) prehypertension or SBP:
stage 1 hypertension Pro vs.Cho diet: P =0.002; Unsat Fat vs.
Cho: P = 0.005
U.S. 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; + + SBP: P< 0.001
225 females DBP: Males P <0.001; Females P = 0.003
Normo and
hypertensive subjects
2010 Dietary Guidelines Advisory Committee Report
U.S.
Appel LJ et al., 2003 RCT Positive N = 810 free living + + SBP and DBP:
adults P <0.001
Normo and
Hypertensive
U.S.
Azadbakht L et al., RCT Neutral N =116 subjects with + + For both men and women P<0.001
2005 metabolic syndrome
BP > 130/85
Iran
Dauchet L et al., 2007 Longitudinal Positive N= 6,119 (2596 men, + + SBP: P <0.05
and cross- 3523 women); free DBP: P < 0.01
sectional living Longitudinal results: DASH score: SBP:
analysis P<0.002; DBP: P<0.02
France
2010 Dietary Guidelines Advisory Committee Report
Forman JP et al., 2009 Prospective Positive N = 83,882 females; + + Outcome in multivariate HR (95%
cohort study Nurse’s Health Study CI) for incident HTN
II
Normotensive
U.S.
Miller ER et al., 2002 RCT Positive N = 43 + + SBP, DBP: P <0.001
U.S.
Nowson CA et al., 2009 RCT Positive N = 111 females + Ø SBP: P = 0.38, 0.21**
(menopausal) + ** +** DBP: P = 0.61, 0.27**
** With HTN meds
Australia
DASH N = 12 12 12 + 10 +
(9 RCT, 3 Positive 1Ø
prospective 2 1 n/d
cohort) Neutral
Nowson CA et al., 2004 RCT Positive N = 94 males and + + SBP: P = 0.001
females DBP: P = 0.05
Australia
Sacks FM et al., 2001 RCT (cross- Positive N = 390 (males, + n/d SBP: P < 0.001
over) females; black and
white)
U.S.
Schulze MB et al., 2003 Prospective Positive N = 8,552 females + + HR (95% CI) for incident HTN
cohort study Normotensive
Germany
39
40
Spain
VEGETARIAN N = 4 RCT 3Positive 4+ 3+
1 Neutral 1Ø
Hakala P and Karvetti RL, RCT Positive N = 110 adults + + SBP: P = 0.05
1989 DBP: P = 0.01
Finland
Margetts BM et al., 1986 RCT (cross- Neutral N = 58; 42 males, 16 + Ø SBP: P , 0.05
over) females
Untreated mild
hypertensives
2010 Dietary Guidelines Advisory Committee Report
Australia
Rouse IL et al., 1983 RCT (cross- Positive N = 59 males and + + SBP, DBP: P <0.01
over) females
Australia
Sciarrone SE et al., 1993 RCT Positive N = 21 males + + Ovo-lacto vegetarian
Australia
JAPANESE/OKINAWAN N = 1 RCT 1 Positive 1+ 1Ø
Table B2.7. Dietary patterns, cardiovascular disease (CVD), and mortality in adults
Fung et al., 2001 N = 69,017, 38 – + nd Higher Prudent-pattern score assoc w/ lower risk 12 y follow-up: 1984-1996
63 yrs at baseline total CHD (RR Q5 vs Q1=0.61, 95% CI: 0.49-0.76,
P for trend <0.001); after adjustment for BMI, Baseline=1984
Prospective Cohort Nurses’ Health smoking, caloric intake, supplemental use, hormone All FQQs using 1984 format
Study Study replacement therapy, and other coronary risk factors (116 item)
(RR=0.76, 95% CI: 0.60-0.98, P for trend = 0.03).
Positive U.S. 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).
41
42
Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults
Fung et al., 2008 N = 88,517, 34 - + + RR of CHD across quintiles of DASH score = 1.0, 24y follow-up: 1980-2004
59 yrs at baseline 0.99, 0.86, 0.87 and 0.76 (95% CI: 0.67 - 0.85, P for
trend <0.001) Baseline=1980
Prospective Cohort Nurses’ Health and Included data from older 1980
Study Study Stroke Magnitude of risk difference was similar for nonfatal FFQ (61 item) and 1984 FFQ
MI and fatal CHD
Positive U.S.
DASH score assoc w/ ↓ risk of stroke
Heidemann et al., N = 72,113 + + Prudent pattern assoc w/ 28% lower risk of 18 y follow-up: 1984-2002
2008 cardiovascular mortality and 17% lower risk of all-
Nurses’ Health cause mortality, Baseline=1984
Prospective Cohort Study All FQQs using 1984 format
Study Western pattern assoc w/ 22% higher risk of (116 item)
U.S. cardiovascular mortality, 16% higher risk of cancer,
Positive and 21% higher risk of all-cause mortality.
DASH and DASH N=10
Variations 1 RCT
2010 Dietary Guidelines Advisory Committee Report
9 Cohort
Hu et al., 2000 N=44,875 men, + + Two patterns explaining < 20% of the variance 8 y follow-up from 1986
40-75 y at identified by factor analysis: Prudent and Western
Prospective Cohort baseline Authors conclude dietary
Study Higher Prudent score assoc w/ monotonic lower patterns derived from their
Health risk of CHD (RR across quintiles: 1.0, 0.84, 0.76, FFQ predict CHD risk
Positive Professionals 0.71, 0.66 (95% CI: 0.54-0.80, P for trend < 0.0001 independent of other lifestyle
Follow-up Study For fatal CHD after adjustment for age, smoking, factors.
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
Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults
Levitan et al., 2009 36,019 women, + + Top quartile of DASH score had 37% lower rate of 7 y follow-up; dietary intake
48-83 y at heart failure (HF); rate ratios across quartiles = 1 only measured at baseline
Prospective Cohort baseline (ref), 0.85 (95% CI: 0.66-1.11), 0.69 (95% CI: 0.54-
Study 0.88), and 0.63 (95% CI: 0.48-0.81), P for trend Hypertension was based on
Swedish <0.001. self-report.
Neutral Mammography
Cohort Both HF-assoc hospitalization and death were
determined
Osler et al., 2001 N= 5,872 (2,994 + + Prudent pattern inversely assoc w/ all-cause (hazard
men, 2,878 ratios =0.63 in women =0.75 in men) and
Prospective Cohort women) cardiovascular mortality
Study Random equal-
sized samples Western pattern not associated w/ mortality
Neutral 30,40,50, 60-y at
baseline
Danish World
Health
Organization
MONICA survey
Parikh et al., 2009 N=5532 adults w/ + + DASH-like group had lower unadjusted mortality 8.2 person-years follow-up
hypertension rates per 1,000 person-yrs for all-cause mortality
Prospective Cohort NHANES III and (P=0.02), stroke mortality (P<0.001), and cancer Secondary outcomes included
Study (1988-1994) Stroke mortality (P=0.05). specific causes of mortality
U.S. CVD, ischemic heart disease,
Neutral DASH-like group, after adjusting for multiple stroke, and cancer
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).
Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults
Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults
Fung et al., 2009 N = 76,522 , 38 - + + Top aMed quintile ↓risk CHD and stroke: RR CHD 20 y follow-up: 1984-2004
63 yrs at baseline = 0.71, 95% CI: 0.62-0.82, P for trend < 0.0001, RR
Prospective Cohort stroke = 0.87, 95% CI: 0.73-1.02, P for trend = 0.03 Baseline=1984
Study Nurses’ Health and All FQQs using 1984 format
Study Stroke CVD mortality ↓: top quintile RR=0.61, 95%
Neutral CI:0.49-0.76, P for trend <0.0001
U.S.
Harriss et al., 2007 N= 40,653 + + Mediterranean dietary factor inversely assoc w/ CVD Mean follow-up = 10.4 y
(16,673 men, and IHD mortality
Prospective Cohort 23,908 women) Involved migrants to Australia
Study IHD, HR (highest compared w/ lowest quartile) = from Mediterranean countries
Melbourne 0.59 (95% CI: 0.39-0.89, P for trend=0.03) (24% of subjects were
Neutral Collaborative Mediterranean born)
Study Excluding subjects w/ prior CVD (HR=0.51, 95%
CI: 0.30-0.88, P for trend = 0.03)
MEDITERRANEAN N=13
1 Index
1 Systematic Rev
1 Meta Analysis
9 Cohort
1 Case Control
Knoops et al., 2004 N= 40,653 (1,507 + + Mediterranean diet (HR = 0.77, 95% CI: 0.68 - 0.88) 10 y mortality from all causes
men, 832 assoc w/ ↓ risk all-cause mortality (CVD, CHD, and Cancer)
Prospective Cohort women)
Study Similar results were observed for mortality from
HALE cohort coronary heart disease, cardiovascular diseases, and
Neutral cancer
Netherlands
45
46
Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults
Mente et al., 2009 146 prospective + nd Among the dietary exposures with strong evidence of Used Bradford Hill guidelines
cohort studies causation from cohort studies, only the to derive causation score based
Systematic Review/ + 43 RCTs Mediterranean dietary pattern is related to CHD in on 4 criteria (strength,
Meta-analysis (pub1950-2007) RCTs consistency, temporality, and
coherence) for each dietary
Positive Europe, Asia, exposure in cohort studies and
U.S. examined for consistency with
the findings of RCTs.
Mitrou et al, 2007 N= 352,497 + + Men: multivariate HR all-cause mortality = 0.79 5 y follow-up
(196,158 men, (95% CI: 0.76 - 0.83), CVD mortality = 0.78 (95%
Prospective Cohort 156,339 women) CI: 0.69 - 0.87), cancer mortality = 0.83 (95% CI: Used 9-point score to assess
Study median age = 62 0.76 - 0.91). conformity with
Mediterranean dietary pattern
Positive NIH-AARP Diet Women: ↓ risks = 12% cancer mortality (P for trend (components included
and Health Study = 0.04); = 20% all-cause mortality (P for trend < vegetables, legumes, fruits,
0.001). nuts, whole grains, fish,
2010 Dietary Guidelines Advisory Committee Report
CARDIO2000
Study
Greece
2010 Dietary Guidelines Advisory Committee Report
Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults
Panagiotakos et al., N = 2,101 + nd Pattern characterized by cereals, small fish, and olive 5 y follow-up
2009 oil assoc w/ ↓ CVD risk (HR = 0.72, 95% CI: 0.52 -
ATTICA Study 1.00) Exclusion of CVD done by
Prospective Cohort detailed clinical evaluation
Study Greece Pattern characterized by fruit and vegetables using
olive oil in cooking (HR = 0.80, 95% CI: 0.66 -
Neutral 0.97)
Neutral
Waijers et al., 2006 N = 5,427 women nd + Principal component analysis identified 3 diet 8.2 y follow-up
(aged >60 years) patterns: Mediterranean, Traditional Dutch, and
Prospective Cohort Healthy Dutch
Study EPIC Study Healthy trad Dutch pattern assoc w/ ↓ mortality rate;
women in highest tertile 30% ↓mortality risk
Neutral Netherlands
47
48
Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults
VEGETARIAN N=5
4 Cohort
1 Time series
Chang-Claude et al., N = 1,904 ; 858 + Ø ↓ risk ischemic heart disease (RR = 0.70, 95% CI: A cohort study of vegetarians
2005 males, 1,046 0.41 – 1.18) and health-conscious persons
females in Germany was followed-up
Prospective Cohort No effect on mortality (RR = 1.10, 95% CI: 0.89 – prospectively for 21 years,
Study 1,165 lacto-ovo, 1.36) including 1,225 vegetarians
679 non-veg, 60 and 679 health-conscious
Neutral vegans. nonvegetarians
Germany
Fraser et al., 2005 (N=30,292 males, + + Rate ratio (RR) (Adventist/Stanford study) Two concurrent California
N=50,562 1st event fatal CHD = 0.59 (95% CI, 0.43-0.80) men observational studies, one with
2010 Dietary Guidelines Advisory Committee Report
Time series females) and 0.49 (0.32-0.76) women. unusual dietary habits, are
California Vegetarian Adventists, RR = 0.45 (0.24-0.84) and compared. Similar diagnostic
Neutral Seventh Day 0.20 (0.06-0.63) men and women, respectively. criteria were used in both the
Adventists 1st event MI RR = 0.60 (0.47-0.78) and 0.46 (0.33- Adventist Health Study and
(N=297,126 male, 0.65). the Stanford Five-City Project.
344,401 female) Vegetarian Adventists RR = 0.37 (0.20-0.66) and
Stanford Five- 0.62 (0.35-1.09) men and women, respectively.
City Project
U.S.
VEGETARIAN N=5
4 Cohort
1 Time series
2010 Dietary Guidelines Advisory Committee Report
Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults
Key et al., 1996 N = 10,771; + + Daily consumption of fresh fruit assoc w/ ↓ Mortality ratios measured for
4,336 males, mortality ischemic heart disease (rate ratio = 0.76, vegetarianism and for daily
Prospective Cohort 6,435 females 95% CI: 0.60 – 0.97), cerebrovascular disease (rate versus less than daily
Study ratio = 0.68, 95% CI: 0.47 – 0.98), and all causes consumption of wholemeal
UK (rate ratio = 0.79, 95% CI: 0.70 – 0.90) bread, bran cereals, nuts or
Neutral 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 N = 76,172 men + + Compared to non-vegetarians, vegetarians had 24% ↓ Vegetarians were those who
and women IHD mortality (rate ratio = 0.76, 95% CI:0.62-0.94) did not eat any meat or fish (n
Meta-analysis: 5 = 27,808). Non-vegetarians
Prospective Cohort U.S. Reduction in mortality among vegetarians varied were from a similar
Studies significantly with age at death. background to the vegetarians
within each study.
Neutral 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).
Mann et al., 1997 N = 10,802; + + An increase in mortality for IHD was observed with 13.3 y follow-up
4,102 males, increasing intakes of total and saturated animal fat
Prospective Cohort 6,700 females and dietary cholesterol-death rate ratios in the third Prospective observation of
Study tertile compared with the first tertile: 329, 95% vegetarians, semi-vegetarians,
Health conscious, confidence interval (CI) 150 to 721; 277, 95% CI and meat eaters
Neutral mean age=33-34 125 to 613; 353, 95% CI 157 to 796, respectively.
Table B2.7 (continued). Dietary patterns, cardiovascular disease (CVD), and mortality in adults
JAPANESE/
N=1 Cohort
OKINAWAN
Shimazu et al., 2007 N=40,547, 40-79 + + 3 patterns identified by principal components 7 y follow-up
yrs at baseline analysis: i) a Japanese dietary pattern highly
Prospective Cohort Japan correlated with soybean products, fish, seaweeds,
Study vegetables, fruits and green tea, (ii) an ‘animal food’
dietary pattern and (iii) a high-dairy, high-fruit-and-
Neutral vegetable, low-alcohol (DFA) dietary pattern.
ND = Not determined.
2010 Dietary Guidelines Advisory Committee Report
Part B. Section 3: Translating and
Integrating the Evidence: A Call to Action
The data clearly document that America is experiencing of vegetables and fruits among ethnic groups, but also
a public health crisis involving overweight and obesity. have a higher prevalence of hypertension and related
Particularly alarming is the further evidence that the diseases, such as stroke. Although the reasons for these
obesity epidemic involves American children and differences are complex and multifactorial, this Report
youth, as nearly one in three are classified as overweight addresses research indicating that certain dietary
or obese. Childhood obesity and overweight is a serious changes can provide a means to reduce health
health concern in the United States (U.S.) because of disparities. If we are successful in changing dietary
immediate health consequences, as well as because it intake patterns of all Americans through a systematic
places a child at increased risk of obesity in adulthood, approach, we will go a long way in narrowing the gap in
with all its attendant health problems such as health disparities.
cardiovascular diseases (CVD) and type 2 diabetes
(T2D). All adults—parents, educators, caregivers, Although obesity is related to many chronic health
teachers, policy makers, health care providers, and all conditions, it is not the only diet-related public health
other adults who work with and care about children and problem confronting the Nation. Nutritionally
families—serve as role models in some capacity and suboptimal diets with or without obesity are
share responsibility for helping the next generation etiologically related to many of the most common,
prevent obesity by promoting healthy lifestyles at all costly, and yet preventable health problems in the U.S.,
ages. Primary prevention of obesity, starting in particularly CVD (atherosclerosis, stroke) and related
pregnancy and early childhood, is the single best risk factors (T2D, hypertension, and hyperlipidemia),
strategy for combating and reversing America’s obesity some cancers, and osteoporosis. Improved nutrition and
epidemic for current and future generations. While there appropriate eating behaviors have tremendous potential
is also an urgent need to improve the health and well- to enhance public health, prevent or reduce morbidity
being of children and adults who are already overweight and mortality, and decrease health care costs.
and obese, primary prevention offers the strongest
universal benefits. Solving the obesity problem will take The science is not perfect; evidence is strong in some
a coordinated system-wide, multi-sectoral approach that areas and limited or inconsistent in other areas.
engages parents as well as those in education, Nevertheless, this Report is an urgent call to action to
government, healthcare, agriculture, business, address a major public health crisis by focusing on
advocacy, and the community. This approach must helping all Americans achieve energy balance through
promote primary prevention among those who are not adoption and adherence to current nutrition and
yet overweight and address weight loss and fitness physical activity guidelines.
among those who are overweight.
After reviewing its entire Report, the Dietary Guidelines
Disparities in health among racial and ethnic minorities Advisory Committee (DGAC) recognized a need to not
and among different socioeconomic groups have been only document the evidence, but to translate and
recognized as a significant concern for decades. Several integrate major findings that have cross-cutting public
subgroups of the population (Native Americans, Blacks, health impact and provide guidance on how to
Hispanics, and segments of the population with low implement the changes necessary to enhance the health
income) have a strikingly high prevalence of overweight and well being of the population. Below are the four
and obesity. Dietary patterns vary among different major cross-cutting findings from the 2010 DGAC
ethnic and socioeconomic groups. Individuals of lower Report, followed by suggestions for implementation.
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
Nominations were sought from the public through a The Dietary Guidelines for Americans provide science-
Federal Register notice published on April 10, 2008. based advice for Americans, ages 2 years and older, in
Prospective members of the DGAC were expected to be order to promote health and to reduce the risk of major
knowledgeable about current scientific research in chronic diseases through diet and physical activity.
human nutrition and chronic disease, and be respected
and published experts in their fields. They would be The Dietary Guidelines form the basis of Federal
familiar with the purpose, communication, and nutrition policy, nutrition standards, nutrition programs,
application of the Dietary Guidelines and have and nutrition education for the general public and are
demonstrated interest in the public’s health and well- published jointly by USDA and HHS every 5 years.
being through their research and educational endeavors.
Expertise was sought in specific specialty areas, The charge to the Dietary Guidelines Advisory
including, but not limited to, the prevention of chronic Committee, whose duties were time-limited and solely
diseases (e.g., cancer, cardiovascular disease, type 2 advisory in nature, was as follows:
diabetes, obesity, and osteoporosis), energy balance
(including physical activity), epidemiology, food safety • Inform the Secretaries of both Departments if no
and technology, general medicine, gerontology, nutrient changes to the Dietary Guidelines for Americans,
bioavailability, nutrition biochemistry and physiology, 2005 are warranted. This action will disband the
nutrition education, pediatrics, public health, and DGAC.
evidence review methodology. • Inform the Secretaries of both Departments if
changes are warranted, based on the preponderance
The Secretaries of USDA and HHS jointly selected of the most current scientific and medical
individuals for membership to the 2010 DGAC. The knowledge, and determine what issues for change
chosen individuals are highly respected by their peers need to be addressed.
for the depth and breadth of their scientific knowledge
Developing and grading each Conclusion was a For some research questions, the DGAC’s systematic
deliberative and time-consuming process that benefited review generated recommendations for future research.
Table C1. 2010 DGAC Conclusion Grading Chart used to grade the strength of the body of evidence supporting
conclusion statements
Expert Grade Not
Elements Strong Moderate Limited Opinion Only Assignable
Quantity One large study with Several studies by Limited number of Unsubstantiated Relevant
Number of studiesa diverse population independent studies by published studies have
Number of study or several good investigators research studies not been
participants quality studies Low number of done
Large number of Doubts about subjects studied
subjects studied adequacy of and/or inadequate
Studies with sample size to sample size within
negative results have avoid Type I and studies
sufficiently large Type II error
sample size for
adequate statistical
power
Impact Studied outcome Some doubt about Studied outcome is Objective data Indicates
Importance of relates directly to the the statistical or an intermediate unavailable area for
studied outcomes question clinical outcome or future
Magnitude of significance of the surrogate for the research
effect Size of effect is effect true outcome of
clinically interest
meaningful OR size of effect is
small or lacks
Significant statistical and/or
(statistical) clinical significance
difference is large
Generalizability Studied population, Minor doubts Serious doubts Generalizability NA
intervention, and about about limited to scope
Generalizability to outcomes are free generalizability generalizability due of experience
population of from serious doubts to
interest about narrow or different
generalizability study population,
intervention or
outcomes studied
Use of the USDA Food Patterns for Special recommended intakes for five major food groups and
Analyses for subgroups within several of the groups. They also
recommend an allowance for intake of oils and limits on
intake of calories from solid fats and added sugars. The
The 2010 DGAC identified specific questions that they
calories and nutrients that would be expected from
felt could best be addressed through a food pattern
consuming a specified amount from each component of
modeling approach, using the USDA Food Patterns and
the patterns are determined by calculating nutrient
the modeling process developed to address similar
profiles. A nutrient profile is the consumption-weighted
requests by the 2005 DGAC.
average nutrient content for nutrient-dense forms of
foods within each group. These nutrient profiles can be
Briefly, the USDA Food Patterns describe types and
modified based on the assumptions for each food
amounts of food to consume that will provide a
pattern modeling analysis. Additional details on the
nutritionally satisfactory diet. They include
USDA Food Patterns can be found in the report for the
2010 Dietary Guidelines Advisory Committee Report 63
food pattern modeling analysis, Adequacy of the USDA subcommittees requested analyses to obtain information
Food Patterns, which is available at on the potential impact of consumers selecting only
www.dietaryguidelines.gov. lacto-ovo vegetarian choices, eliminating legumes, or
choosing varying levels of fat as a percent of calories
The USDA Food Patterns were originally developed in (DGAC, 2004). The use of food pattern modeling
the 1980s (Cronin, 1987; Welsh, 1993), and were analyses for the 2005 DGAC has been documented
substantially revised and updated in 2005, concurrent (Britten, 2006b; Nicklas, 2005; Weaver, 2005).
with the development of the 2005 Dietary Guidelines
(Britten, 2006a). The 2005 updates included use of Five 2010 DGAC subcommittees identified a total of 18
nutrient goals from the Institute of Medicine (IOM) questions that they felt could be addressed through food
Dietary Reference Intakes reports that were released pattern modeling. Several questions were merged or
from 1997 to 2004 (IOM, 1997, 1998, 2000, 2001, dropped, resulting in 12 modeling analyses that were
2002, 2004). The developmental process and the food completed and provided as reports to the relevant
patterns resulting from the 2005 update have been subcommittees. For each question, a specific approach
documented in detail (Britten, 2006a; Marcoe, 2006). was drafted by USDA staff and provided to the
subcommittee for comment. After the approach was
A food pattern modeling process was developed for and discussed and accepted, USDA staff completed the
used by the 2005 DGAC to determine the hypothetical analytical work and drafted a full report for the
impact on nutrients in and adequacy of the food patterns subcommittee’s consideration. Each report was
when specific changes are made. The structure of the discussed by the relevant subcommittee, and the
USDA Food Patterns allows for modifications that test analysis and report were revised as needed. The food
the overall impact on diet quality of various dietary pattern modeling analyses conducted for the DGAC are
recommendation scenarios. Most analyses involved listed in Table C2. Full reports for each analysis are
identifying the impact of specific changes in amounts or available online at www.dietaryguidelines.gov;
types of foods that might be recommended by the summary discussions are provided in relevant chapters
Committee or selected by consumers. For example, of the DGAC Report, as shown in the Table.
Table C2. Food pattern modeling analyses conducted for the 2010 DGAC
E3.1: Adequacy of the USDA Food Patterns Part B.2: The Total Diet:
How well do the USDA Food Patterns, using updated food intake and nutrient Combining Nutrients,
data, meet IOM and potential DG 2010 nutrient recommendations? Consuming Foods
E3.2: Realigning Vegetable Subgroups Part B.2: The Total Diet:
What revisions to the vegetable subgroups may help to highlight vegetables of Combining Nutrients,
importance and allow recommendations for intake levels that are achievable, Consuming Foods
without compromising the nutrient adequacy of the patterns?
E3.3: Vegetarian Food Patterns Part B.2: The Total Diet:
How well do plant-based or vegetarian food patterns, adapted from the USDA Combining Nutrients,
Food Patterns, meet IOM and potential DG 2010 nutrient recommendations? Consuming Foods
E3.4: Starchy Vegetables Part B.2: The Total Diet:
How do the nutrients provided by the starchy vegetable subgroup compare with Combining Nutrients,
those provided by grains and those provided by other vegetable subgroups? Consuming Foods
How would nutrient adequacy of the patterns be affected by considering starchy
vegetables as a replacement for some grains rather than as a vegetable
subgroup?
E3.5: “Typical Choices” Food Patterns Part B.2: The Total Diet:
What is the impact on caloric and nutrient intake if the USDA Food Patterns Combining Nutrients,
are followed but typical rather than nutrient-dense food choices are made? Consuming Foods
The Committee used conclusions from the NEL American Dietetic Association, Scientific Affairs and
systematic review as the primary means to answer their Research. ADA Evidence Analysis Manual. Adapted for
research questions. These Conclusion statements were the USDA Evidence Analysis Library. American
integrated with results from food modeling analyses, Dietetic Association: Chicago, IL, 2008.
reviews of reports from expert groups, dietary intake
analyses, presentations by expert consultants, Britten P, Lyon J, Weaver C, Nicklas T, Kris-Etherton
established nutrition science knowledge, and/or expert P, Weber J, Marcoe K, Davis C. MyPyramid food
opinion of the DGAC and the broader scientific intake pattern modeling for the Dietary Guidelines
community to inform the development of the Advisory Committee. J Nutr Ed Behav. 2006b;38(6
Committee’s Implications statements. The Implications Supple):S143-S52.
statements are an extension of the NEL Conclusion
statements that lay out the overarching conclusion that
the Committee has drawn about the question.
Cronin F, Shaw A, Krebs-Smith S, Marsland P, Light Lohr, K. Rating the strength of scientific evidence:
L. Developing a food guidance system to implement the relevance for quality improvement programs. Int J Qual
Dietary Guidelines. J Nut Educ. 1987;19:281-302. Health Care. 2004;16:9-18.
Dietary Guidelines Advisory Committee. Report of the Institute of Medicine. Dietary reference intakes for
Dietary Guidelines Advisory Committee on the Dietary water, potassium, sodium, chloride, and sulfate.
Guidelines for Americans, 2005. Washington DC: U.S. Washington DC: National Academies Press, 2004.
Department of Agriculture, Agricultural Research
Service, August 2004. Marcoe K, Juan WY, Yamini E, Carlson A, Britten P.
Development of food group composites and nutrient
Institute of Medicine. Dietary reference intakes for profiles for MyPyramid Food Guidance System. J Nutr
calcium, phosphorus, magnesium, vitamin D, and Ed Behav. 2006;38(6 Suppl):S93-S107.
fluoride. Washington DC: National Academies Press,
1997. Nicklas TA, Weaver C, Britten P, Stitzel KF. The 2005
Dietary Guidelines Advisory Committee: Developing a
Institute of Medicine. Dietary reference intakes for key message. J Am Diet Assoc. 2005;105(9):1418-24.
thiamin, riboflavin, niacin, vitamin b6, folate, vitamin
B12, pantothenic acid, biotin, and choline. Washington Weaver C, Nicklas T, Britten P. The 2005 Dietary
DC: National Academies Press, 1998. Guidelines Advisory Committee Report: Achieving
nutritional recommendations through food-based
Institute of Medicine. Dietary reference intakes for guidance. Nutr Today. 2005; 40(3):102-7.
vitamin C, vitamin E, selenium, and carotenoids.
Washington DC: National Academies Press, 2000. Welsh S, Davis C, Shaw A. USDA’s Food Guide:
Background and Development. Washington DC: U.S.
Institute of Medicine. Dietary reference intakes for Department of Agriculture, Human Nutrition
vitamin A, vitamin K, arsenic, boron, chromium, Information Service Misc. Publication 1514, 1993.
copper, iodine, iron, manganese, molybdenum, nickel,
silicon, vanadium, and zinc. Washington DC: National
Academies Press, 2001.
Figure D1.1. Mean total energy intake in comparison to recommended ranges for age and sex groups
3200
3000
2800
2600
2400
2200
2000
Calories
1800
1600
1400
1200
1000
800
600
400
200
Note: Vertical lines represent recommended ranges of calorie intake based on sex and age, with the triangle
denoting mean energy intake for each group.
Source: What We Eat in America, National Health and Nutrition Examination Survey (WWEIA, NHANES), 2005-
2006, individuals 2 years and older (excluding breast-fed children), Day 1 dietary intake data, weighted. Available
at: www.ars.usda.gov/ba/bhnrc/fsrg. (USDA, 2008).
Table D1.1. Mean intake of energy and mean contribution (kcal) of various U.S. foods among U.S. population, by
age, NHANES 2005–2006
All Age Age Age Age Age Age Age Age Age Age
Age Group Persons 2-18 2-3 4-8 9-13 14-18 19+ 19-30 31-50 51-70 71+
Sample Size 8549 3778 497 899 1047 1335 4771 1310 1537 1224 700
Mean Intake of Energy (kcal) 2157 2027 1471 1802 2035 2427 2199 2407 2354 2020 1691
a b,c
Rank Food Group
1 Grain-based desserts 138 138 68 136 145 157 138 128 145 134 141
2 Yeast breads 129 114 65 98 109 151 134 120 128 149 141
Chicken and chicken mixed
3 121 113 59 92 122 143 123 154 141 97 67
dishes
4 Soda/energy/sports drinks 114 118 23 50 105 226 112 186 121 73 33
5 Pizza 98 136 47 95 128 213 86 129 108 48 21
6 Alcoholic beverages 82 6 - - - 18 106 120 135 82 40
7 Pasta and pasta dishes 81 91 86 97 101 78 78 92 81 75 50
8 Mexican mixed dishes 80 63 26 40 76 86 85 146 99 48 9
9 Beef and beef mixed dishes 64 43 19 23 42 70 71 81 78 58 55
10 Dairy desserts 62 76 40 93 86 64 58 48 58 59 78
11 Potato/corn/other chips 56 70 37 60 72 88 51 62 61 41 23
12 Burgers 53 55 14 27 49 99 53 71 60 40 25
13 Reduced fat milk 51 86 91 95 92 69 39 43 39 35 48
All Age Age Age Age Age Age Age Age Age Age
Age Group Persons 2-18 2-3 4-8 9-13 14-18 19+ 19-30 31-50 51-70 71+
Sample Size 8549 3778 497 899 1047 1335 4771 1310 1537 1224 700
Mean Intake of Energy (kcal) 2157 2027 1471 1802 2035 2427 2199 2407 2354 2020 1691
a b,c
Rank Food Group
14 Regular cheese 49 43 32 31 41 60 51 64 52 45 37
15 Ready-to-eat cereals 49 65 58 77 60 61 44 50 39 41 57
Sausage, franks, bacon, and
16 49 47 43 44 53 46 49 47 53 51 39
ribs
17 Fried white potatoes 48 52 35 43 49 68 46 64 52 36 16
18 Candy 47 56 41 50 59 66 44 42 50 42 26
Nuts/seeds and nut/seed
19 42 27 22 26 30 26 47 28 50 60 43
mixed dishes
20 Eggs and egg mixed dishes 39 30 20 25 31 36 42 38 44 44 39
21 Rice and rice mixed dishes 36 24 19 20 28 24 41 49 49 30 20
22 Fruit drinks 36 55 46 51 51 65 29 45 33 18 13
23 Whole milk 33 60 104 76 42 45 25 30 28 17 22
24 Quick breads 32 19 17 13 17 28 36 34 34 42 33
26 Soups 26 20 18 23 19 18 28 25 22 37 36
28 Other white potatoes 25 14 11 11 16 18 29 24 25 33 38
Other fish and fish mixed
29 25 10 9 10 11 11 30 22 29 34 35
dishes
30 Crackers 24 27 38 34 24 21 23 25 23 21 25
a
Rank for all persons only. Columns for other age groups are ordered by this ranking. The top five food groups for
each age group are bolded.
b
Specific foods contributing at least 2 percent of energy for all persons in descending order are listed. Specific
foods contributing at least 2 percent of energy for any given subgroup are then also listed in italics.
c
Specific foods contributing at least 1 percent of energy for all persons in descending order: eggs and egg mixed
dishes, rice and rice mixed dishes, fruit drinks, whole milk, quick breads, cold cuts, soups, salad dressing, other
white potatoes, other fish and fish mixed dishes, crackers, and 100 percent orange/grapefruit juice.
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.
The result of the continued energy imbalance has the figures are 72.3 percent of women and 64.1 percent
resulted in a very high prevalence of overweight and of men. The prevalence is higher in Hispanic and Black
obesity in the U.S. in both adults (Flegal, 2010) and women. In children, 9.5 percent of infants and toddlers
children (Ogden, 2010). In adults, the age-adjusted are at or above the 95th percentile of the weight-for-
figures are 35.5 percent of women and 32.2 percent of recumbent-length growth charts. Among children and
men are obese. Combining overweight and obese adults, adolescents ages 2 through 19 years, 11.9 percent are at
Source: Centers of Disease Control and Prevention. Division of Nutrition, Physical Activity, and Obesity. State
Nutrition, Physical Activity and Obesity (NPAO) Program: Technical Assistance Manual. January 2008. Accessed
April 21, 2010. http://www.cdc.gov/obesity/downloads/TA_Manual_1_31_08.pdf - pg 36 of the document.
Examining shifts in the food environment over the past The amount and type of beverages available have
40 years is helpful in understanding why Americans changed over time. Total beverage milk declined 33
have difficulty meeting the U.S. Dietary Guidelines. percent from 1970 to 2008 with a decrease in whole
Tables D1.2 through D1.4 and Figures D1.3 and D1.4 milk and increase in other beverage milk products. Fruit
provide an overview of shifts in our food environment juice availability increased 25 percent from 1970 to
and consumer behaviors from 1970 to 2008. Food 2008, while vegetable juice availability has remained
available for consumption has increased in all major constant since the data became available in 1999. In
food categories (Figure D1.3) and is not in alignment 2008, almost two times more fruit drinks, cocktails, and
with recommendations as outlined in the U.S. Dietary ades (12.9 gallons per person) were available than fruit
Guidelines (Figure D1.4). Average daily per capita juice (6.9 gallons). Among carbonated soft drinks, total
calories, adjusted for spoilage and other waste, availability increased from 39 gallons per person per
increased from 2057 in 1970 to 2674 in 2008. Added year in 1984 to 47 gallons in 2008, a 20 percent
fats and oils (not including naturally occurring fats from increase. During this time, availability of diet soft
meats and dairy) availability per person increased 56 drinks increased 58 percent from 9 to 15 gallons per
percent, from 56 pounds in 1970 to 87 pounds in 2008. person per year, and availability of regular soft drinks
Availability of added sugars and sweeteners per person increased 9 percent from 30 to 32 gallons per person per
increased 15 percent, from 119 pounds per person in year. In 2008, more than two times the amount of
1970 to 136 pounds in 2008. carbonated soft drink (46.9 gallons per person) was
available than total beverage milk (20.8 gallons)
(USDA, 2010). As indicated in Table D1.9 (see end of
Figure D1.3. Average daily per capita calories from the U.S. food availability in 1970, 1990, and 2008, adjusted
for spoilage and other waste
Figure D1.4. Loss-adjusted per capita food availability was out of balance with dietary recommendations in 2008
Table D1.2. Changes over time in selected measures of the U.S. food retail and food service environment
Table D1.4. Changes over time in the average portion size of selected food items sold in the U.S. marketplace
Food Item Portion Size (year) Portion Size (year) Percent Change
It appears that the food environment is not supporting vegetables and fruits is associated with lower body mass
Americans in consuming a healthy eating pattern. The index (BMI), while lack of supermarkets and long
solution will likely reside not only in consumer distances to supermarkets are associated with higher
education and behavior but also in a change in our BMI. Increased density of fast food restaurants and
overall food system (Story, 2009). convenience stores is related to increased BMI. More
evidence is available regarding the relationship between
Evidence on the Relationship Between the the environment and vegetable and fruit intake than for
Food Environment and Body Weight and body weight.
Vegetable and Fruit Intake
This conclusion is based on the review of 10 systematic
Evidence is growing that the food environment is reviews that investigated the relationship between the
associated with dietary intake, body weight, and the environment and body weight, energy intake, and
consumption of vegetables and fruits. Availability of vegetable and fruit intake (Black, 2008; Casagrande,
healthy food, including vegetables and fruits, is 2009; Dunton, 2009; Ford, 2008; Giskes, 2007;
associated with improved dietary intake and weight Holsten, 2009; Jago, 2007; Kamphuis, 2006; Papas,
status, especially in economically disadvantaged areas. 2007; van der Horst, 2007). All 10 studies suggested
The presence of supermarkets and other sources of associations between the environment and body weight
Breakfast Eating Behavior—Modest evidence Evidence for Adults. The literature review identified
suggests that children who do not eat breakfast are at six prospective cohort studies (Crossman, 2006;
increased risk of overweight and obesity. The Merten, 2009; Niemeier, 2006; Nooyens, 2005;
evidence is stronger for adolescents. There is Purslow, 2008; van der Heijden, 2007). The studies
inconsistent evidence that adults who skip breakfast were conducted in the U.S., the United Kingdom, and
are at increased risk for overweight and obesity. the Netherlands. Studies ranged in sample size from
228 (Nooyens, 2005) to 20,064 (van der Heijden,
Evidence for Children. The literature review 2007), and three studies included only men (Nooyens,
identified 15 studies: one randomized controlled trial 2005; Purslow, 2008; van der Heijden, 2007). Three
(Rosado , 2008), one non-randomized controlled trial studies found an inverse relationship between
(Ask, 2006), and 13 prospective cohort studies breakfast consumption and body weight in adults
(Affenito, 2005; Albertson, 2007, 2009; Barton, 2005; (Merten, 2009; Niemeier, 2006; Purslow, 2008). One
78 2010 Dietary Guidelines Advisory Committee Report
study initially found an inverse relationship, but after Evidence for Children. The literature review
adjusting for potential confounders the relationship identified one prospective cohort study (Franko,
was no longer significant (Nooyens, 2005). One study 2008). The study was conducted in the U.S. and had a
found an inverse relationship between breakfast intake sample of 2,379 girls. This study found that increased
and body weight in men, and no relationship in meal frequency, measured by number of days with
women (Crossman, 2006). We did not review the more than three meals, was inversely associated with
literature on the use of breakfast consumption as a tool BMI in adolescent girls.
for adults actively losing weight.
Evidence for Adults. The literature review identified
Snacking Behavior—Evidence suggesting that one prospective cohort study (van der Heijden, 2007).
snacking is associated with increased body weight is The study investigated the association between food
inconsistent. patterns and long-term weight gain in U.S. men over
10 years. An increased number of eating occasions in
Evidence for Children. The literature review addition to three standard meals was associated with a
identified six studies: five cohort studies (Bisset, higher risk of 5-kilogram weight gain over time. The
2007; Black, 2006; Field, 2004; Francis, 2003; Committee did not review the literature on the use of
Phillips, 2004) and one case-control study (Novaes, eating frequency as a tool for adults actively losing
2008). The studies were conducted in the U.S., weight.
Canada, and Brazil. Studies ranged in sample size
from 100 (Novaes, 2008) to 14,977 (Field, 2004), and Self-monitoring Behavior—Strong evidence shows
three studies included only girls (Black, 2006; Francis, that for adults who need or desire to lose weight, or
2003; Phillips, 2004). Two studies found a positive who are maintaining body weight following weight
relationship between snacking and body weight in loss, self-monitoring of food intake improves
children (Bisset, 2007; Novaes, 2008). Two studies outcomes.
found no relationship between snacking and body
weight in children (Black, 2006; Phillips, 2004). One The literature review identified seven studies: six
study initially found a negative relationship between randomized controlled trials (Adachi, 2007; Carels,
snacking and adiposity in girls, but after adjusting for 2008; Helsel, 2007; Lowe, 2008; Tate, 2001; Wylie-
potential confounders, the relationship was no longer Rosett, 2001) and one non-randomized controlled trial
significant (Field, 2004). One study only found that (Yon, 2007). In the majority of studies, diet self-
snacking in front of the television was associated with monitoring included keeping a daily record of food
development of overweight in children (Francis, consumed, with a focus on monitoring calorie intake.
2003). One of the reasons for the inconsistency of The studies were conducted in the U.S. and Japan.
findings is likely due to the variability in the design of Studies ranged in sample size from 42 (Helsel, 2007)
studies and definitions for snacking. to 588 (Wylie-Rosett, 2001), and all seven studies
included both men and women. Six studies found a
Evidence for Adults. The literature review identified positive relationship between diet self-monitoring and
two prospective cohort studies (Halkjaer, 2009; Woo, weight loss in adults (Adachi, 2007; Carels, 2008;
2008). The studies were conducted in Sweden and Helsel, 2007; Tate, 2001; Wylie-Rosett, 2001; Yon,
Hong Kong. Studies ranged in sample size from 1,010 2007) only one study found no relationship between
(Woo, 2008) to 22,570 (Halkjaer, 2009). In the study diet self-monitoring and weight loss in adults (Lowe,
of Halkjaer et al. (2009) diets high in snack food were 2008).
associated with increased waist circumference over the
5-year follow-up period. Increased variety of snack
food was associated with increased weight gain over a
5- to 9-year follow-up period in the study of Woo et
al. (2008). The DGAC did not review the literature on
the use of snacking as a tool for adults actively losing
weight.
Underweight 0.51 1
12.5-18 28-40
(< 18.5 kg/m2) (0.44-0.58) (1-1.3)
Normal weight 0.42 1
2 11.5-16 25-35
(18.5-24.9 kg/m ) (0.35-0.50) (0.8-1)
Overweight 0.28 0.6
7-11.5 15-25
(25.0-29.9 kg/m2) (0.23-0.33) (0.5-0.7)
Obese 0.22 0.5
5-9 11-20
(≥ 30.0 kg/m2) (0.17-0.27) (0.4-0.6)
1
Calculations assume a 0.5-2 kg (1.1-4.4 lbs) weight gain in the first trimester (based on Siega-Riz et al., 1994;
Abrams et al., 1995; Carmichael et al., 1997).
Except for the prepregnancy obese category, the IOM’s • During prenatal care, provide women with sound
recommended GWG ranges are the same as those dietary and physical activity counseling to help
issued in 1990. With regard to obese women, the new them attain GWG within their recommended
guidelines provide an upper limit to their recommended ranges. Dietary guidance needs to emphasize that
GWG range, based on evidence mostly derived from energy intake requirements during pregnancy
class I obese women (BMI: 30-34.9). Another increase to a lower extent than other nutrient
difference between the 1990 and 2009 IOM guidelines requirements. Thus, the DGAC recommends that
is that the cut-off points for the prepregnancy BMI women be advised to consume nutrient-dense diets
categories are now based on the World Health to ensure an optimal nutrient supply for themselves
Organization (WHO) instead of the Metropolitan Life and their offspring without exceeding their energy
Insurance Tables cut-off points. The 1990 IOM intake needs.
prepregnancy BMI categories (based on Metropolitan • Provide proper guidance to women between
Life Insurance tables) were: underweight (<19.8); pregnancies to help them avoid retaining excessive
normal (19.8-26.0); overweight (26.1-29.0); obese postpartum weight.
(>29). The 2009 IOM prepregnancy BMI categories • Effectively disseminate the new GWG guidelines
(based on WHO tables) were: underweight (<18.5); through relevant clinical and community contact
normal (18.5-24.9); overweight (25.0-29.9); obese points, including the Special Supplemental
(≥30). Nutrition Program for Women, Infants, and
Children (WIC) program. Because women
The IOM’s Recommendations for Implementing belonging to racial/ethnic minority groups are
the Guidelines disproportionately affected by overweight or
The IOM recommends a comprehensive approach for obesity, it is essential for dissemination efforts to be
carrying out its GWG guidelines and the DGAC conducted with cultural competency. They also
concurs with these recommendations: need to take into account the structural barriers that
prevent low-income women from accessing healthy
• Given the major influence that prepregnancy BMI foods and being physically active in their living and
has on GWG and key maternal and child health working environments.
indicators, develop improved approaches to prevent
the onset of obesity among girls so that they have a
healthy weight by the time they become pregnant
for the first time.
Table D1.6. Mean intake of energy and mean contribution (kcal) of various foods among U.S. male children and
adolescents, by age, NHANES 2005-2006
Males,
All Males, Males, Males, Males, 14-18
Age/Sex 2-18 years 2-3 years 4-8 years 9-13 years years
Sample Size n=1857 n=250 n=431 n=522 n=654
Mean Intake of Energy (kcal) 2249 1519 1923 2158 2865
1 2,3
Rank Food Group
1 Pizza 173 55 119 158 274
2 Grain-based desserts 149 82 157 144 171
3 Soda/energy/sports drinks 146 22 45 119 299
4 Chicken and chicken mixed dishes 135 63 101 145 181
5 Yeast breads 126 67 114 105 178
6 Reduced fat milk 94 84 110 96 81
7 Dairy desserts 87 38 98 100 83
8 Pasta and pasta dishes 84 77 91 91 74
9 Ready-to-eat cereals 76 58 92 69 77
10 Burgers 73 10 31 62 140
11 Potato/corn/other chips 72 36 74 68 87
12 Whole milk 69 120 83 46 61
13 Mexican mixed dishes 65 30 40 79 86
14 Fruit drinks 61 46 53 62 71
15 Candy 59 38 58 64 62
16 Fried white potatoes 56 41 42 48 81
17 Sausage, franks, bacon, and ribs 56 57 48 62 57
18 Beef and beef mixed dishes 48 25 15 42 91
Table D1.7. Mean intake of energy and mean contribution (kcal) of various foods among U.S. female children and
adolescents, by age, NHANES 2005-2006
Females,
All Females, Females, Females, Females, 14-18
Age/Sex 2-18 years 2-3 years 4-8 years 9-13 years years
Sample Size n=1921 n=247 n=468 n=525 n=681
Mean Intake of Energy (kcal) 1796 1419 1691 1903 1937
1 2,3
Rank Food Group
1 Grain-based desserts 126 53 117 147 141
2 Yeast breads 101 64 83 114 120
3 Pasta and pasta dishes 98 97 103 111 82
4 Pizza 97 38 73 96 144
5 Chicken and chicken mixed dishes 89 54 84 96 101
6 Soda/energy/sports drinks 88 23 54 90 144
7 Reduced fat milk 77 100 81 87 56
8 Potato/corn/other chips 67 38 46 77 88
9 Dairy desserts 65 42 88 71 43
10 Mexican mixed dishes 62 21 41 74 85
11 Candy 54 43 42 53 71
12 Ready-to-eat cereals 54 58 63 52 45
13 Whole milk 50 87 70 38 27
14 Fruit drinks 49 47 49 39 59
15 Fried white potatoes 47 29 44 50 53
16 Regular cheese 39 26 35 35 53
Methodological Challenges percent of children (20%) with BMI between the 85th
The methodological challenges associated with and 94th percentile had elevated body fatness.
accurately measuring energy intake and energy
expenditure in children are significant. Young children, The greatest challenge, however, with respect to
for example, are unable to report for themselves what accurately assessing dietary intake in children, is due to
they have consumed, thus parents or other caregivers the inevitable bias that results from implausible reports
must provide proxy diet intake for the child. Older of energy intake, which in several studies has been
children vary with respect to the age at which they can shown to affect one-third to one-half of children’s
provide reasonable accurate dietary intake information, dietary reports (Gibson and Neate, 2007; Huang, 2004;
and this is difficult to assess (Newby, 2007). Even Johnson, 2008a, 2009; Savage, 2008a; Timpson, 2008).
relatively small increases in daily energy intake can In a review of 10 validation studies, underreporting of
result in significant excess weight gain over time, energy intake was much more common among
however, dietary assessment methods generally lack the overweight children, and also varied by age, such that
sensitivity to detect small differences in energy intake. older and heavier children were more likely to
underreport energy intake compared with younger,
Accurate assessment of adiposity also poses a normal weight children (Livingstone, 2000). In a study
methodological challenge. The majority of studies by Savage et al. (2008a), nearly two-thirds of
assessing the relationship between dietary intake and implausible energy intake reporters were overweight
adiposity in children have relied on BMI as a surrogate (BMI>85th percentile), compared with only 27 percent
measure of adiposity, even though it provides a poor of the plausible energy intake reporters. Recent reports
estimate of body fat. In a report by Freedman et al. in the pediatric scientific literature have stressed the
(2009) only 77 percent of children with BMI ≥ 95th importance of assessing and adjusting for implausible
percentile had elevated percent body fat as measured by energy intake in order to more precisely assess
dual energy x-ray absorptiometry, and an even smaller associations between dietary intake and adiposity in
children. In these studies, rather than simply eliminating
It is noteworthy that the four longitudinal studies Dietary Fat and Adiposity in Children
described above that found positive associations of Background—The relationship of dietary fat to
dietary energy density with adiposity, calculated energy adiposity in children has been studied more extensively
density by methods that excluded all or most beverages than for other macronutrients, primarily because of its
(Johnson, 2008a, 2008b, 2009; McCaffrey, 2008). This high energy density and palatability, both qualities
method was chosen because the high water content of likely to promote passive overconsumption of energy if
beverages can disproportionately contribute to the not regulated (Parsons, 1999). In addition, studies
overall energy density values and have been shown to suggest that fat intake induces less potent satiety signals
dilute associations with health outcomes (Kant, 2005; and less compensation with respect to subsequent
Cox, 2000; Ledikwe, 2005). In addition, they measured energy intake, compared with dietary protein or
adiposity (fat mass) objectively by dual energy x-ray carbohydrate (Doucet, 1997; Bray, 2004), and that fat
absorptiometry (Johnson, 2008a, 2008b, 2009), or by oxidation is not as highly regulated as carbohydrate
doubly-labeled water technique (McCaffrey, 2008). utilization (see Part D.5 Section: Carbohydrates for a
discussion of the varying influences of fat,
One longitudinal study found no association between carbohydrate, and protein on satiety). In metabolic
dietary energy density and adiposity among children studies of children, meal induced thermogenesis
who were followed annually from age 2 to 18 years increased more after a high-carbohydrate meal than
(Alexy, 2005). Participants in this cohort were classified after a high-fat meal; and although fat oxidation
by dietary pattern into clusters based on percent energy increased after the high fat meal, postprandial fat
from fat, with dietary energy density lowest at 3.7 (0.4) storage was greater after the high fat meal compared
in the low fat cluster; 4.0 (0.4) in the medium fat intake; with the high carbohydrate meal (Maffeis, 2001).
and highest at 4.1 (0.4) in the high fat cluster. Mean
BMI during the study period differed significantly, with Evidence Summary—Increased intake of dietary fat is
the highest BMI in the low-fat, low dietary energy associated with greater adiposity in children. The
density cluster, a result the investigators suggest may DGAC conducted a full NEL search to evaluate the
have reflected underreporting of energy intake among association between dietary fat intake and adiposity in
overweight participants, difficulty in detecting minor children. Results of this review were supplemented by
overconsumption of energy, and lack of power due to the findings of prospective studies included in an earlier
small sample size. In addition, dietary energy density in evidence review conducted by the ADA. This
this study was calculated by including all beverages conclusion was based on 28 peer-reviewed articles
which may have diluted associations with health which addressed the research question, 21 studies from
outcomes; and BMI was used as a surrogate measure of the earlier ADA review; and seven studies from the
adiposity which may have limited precision and subsequent NEL review. This included four RCTs
specificity. In a report by Freedman et al. (2009) only (Caballero, 2003; Hakanen, 2006; Lauer, 1995;
77 percent of children with BMI at or greater than the Niinikoski, 2007); and 24 longitudinal studies (21 from
95th percentile had elevated percent body fat as the ADA review and 3 from the NEL review) (Alexy,
measured by dual energy x-ray absorptiometry, and an 2004, 1999; Johnson, 2008b; Karaolis-Danckert, 2007;
even smaller percent of children (20%) with BMI Berkey, 2000; Bogaert, 2003; Boulton, 1995; Carruth,
between the 85th and 94th percentile had elevated body 2001; Davison, 2001; Eck, 1992; Francis, 2003;
fatness. Gazzaniga, 1993; Klesges, 1995; Lee, 2001; Maffeis,
1998; Magarey, 2001; Newby, 2003; Robertson, 1999;
In summary, evidence from a limited number of Rolland-Cachera, 1995; Scaglioni, 2000; Shea, 1993;
methodologically strong, longitudinal cohort studies of Skinner, 2003, 2004; Wang, 2003). Fourteen of the
children and adolescents suggests that there is a positive studies were conducted in the U.S.
association between dietary energy density and
increased adiposity in children. This is based on reports Of the 24 longitudinal studies, 15 found a positive
that used objective measures of adiposity (dual energy association between total fat intake or intake of high-fat
x-ray absorptiometry or doubly labeled water foods and adiposity in all or a subsample of the
technique), carefully assessed and adjusted for under population studied (Carruth, 2001; Davison, 2001; Eck,
2010 Dietary Guidelines Advisory Committee Report 91
1992; Francis, 2003; Gazzaniga, 1993; Johnson, 2008a; show that lipids could be improved without a
Karaolis-Dankert, 2007; Klesges, 1995; Lee, 2001; deleterious effect on growth.
Magarey, 2001; Newby, 2003; Robertson, 1999;
Skinner, 2003, 2004; Wang, 2003). The varied results In summary, the combination of evidence from
between studies were a product of using multiple methodologically strong studies in the NEL and ADA
measures of adiposity within the same study, reviews supports a conclusion that dietary fat and
conducting analyses stratified by different variables adiposity in children are positively associated.
(e.g., sex, weight status), and/or dietary fat measured in Methodological differences between studies, however,
both absolute terms (total grams) as well as a percent of were significant, especially with respect to dietary
energy intake. Nine other longitudinal studies found no assessment procedures, identification of implausible
association between total fat intake and adiposity in energy intake reports, choice of anthropometrics, and
children (Alexy, 1999, 2004; Berkey, 2000; Bogaert, statistical approaches. Despite these methodological
2003; Boulton, 1995; Maffeis, 1998; Rolland-Cachera, differences and limitations, collectively the studies
1995; Scaglioni, 2000; Shea, 1993). A greater tended to find either a positive association or no
proportion of the studies that found a positive significant association between dietary fat and adiposity
association between dietary fat and adiposity, however, with the weight of evidence leaning towards a positive
used multiple measures of adiposity, such as skinfold association. Additional prospective studies that assess
measures, and body composition by dual energy x-ray both the amount and type of fat in relation to changes in
absorptiometry, rather than only BMI, which provides a childhood adiposity are warranted, however. Part D.
poor estimate of actual body fat (Freedman, 2009). Section 3: Fatty Acids and Cholesterol provides
additional information about dietary fat.
Three of the four RCTs found no association between
percent energy from dietary fat and adiposity. The Intake of Fruits and Vegetables and Adiposity
STRIP clinical trial, which tested the effects of a fat- in Children
modified diet from 7 months of age (Hakanen, 2006), Background—Fruits and vegetables are excellent
reported less obesity among intervention girls compared sources of complex carbohydrates, dietary fiber, and
with control girls at age 10 years, but no differences for several vitamins and minerals that are important for
boys; while at age 14 years, Niinikoski et al. (2007) normal growth and development in childhood. In
found no difference in obesity between treatment addition, fruits and vegetables are a good source of
groups, for either males or females. Caballero et al. shortfall nutrients, such as dietary fiber and potassium,
(2003) reported no change in percent body fat in a 3- which are currently consumed by children in amounts
year school-based nutrition and physical activity that are less than adequate for optimal health benefits.
intervention among 1,704 Native American children, Among adults, diets that are high in fruits and
who were age 7 years at baseline. Results showed that vegetables are associated with decreased risk of
percent body fat and BMI did not differ by treatment hypertension, T2D, CVD, and certain cancers. Evidence
group at study end. However, children in the from epidemiologic studies also suggests that childhood
intervention group reported lower total energy intake eating patterns are associated with risk of some diet-
(1892 vs. 2157 kcal/d) and percent energy from total fat related cancers (Steinmetz, 1991; Krebs-Smith, 1996;
(31.1% vs. 33.6%) compared with the control group, Maynard, 2003). Although fewer studies have been
and percent energy from fat was lower in the conducted in children, associations have been found
intervention school lunches compared to the control between increased intake of fruits and vegetables and
schools (28.2% vs. 32.0%). Finally for the Dietary lower blood pressure (Couch, 2008; Lazarou, 2009;
Intervention in Children (DISC) trial (Lauer, 1995), McNaughton, 2008; Moore, 2005) and reduced
which tested the safety and efficacy of lowering dietary prevalence of metabolic syndrome (Pan, 2008). Because
intake of fat and cholesterol in children with elevated evidence that dietary intake of foods and nutrients tends
low-density lipoprotein (LDL)-cholesterol, analyses of to track over time through childhood and adolescence,
growth patterns showed no difference in BMI, height, as well as to adulthood (Bertheke, 2001; Kelder, 1994;
or weight between the lower fat, lower saturated fat Lake, 2006; Mikkila, 2005; Nicklas, 1991; Resnicow,
intervention groups versus controls. It should be noted, 1998; Singer, 1995; Stein, 1991), the public health
however, that in this trial, great effort was taken to benefits of achieving optimal intake of fruits and
ensure that energy intake would not decrease and vegetables in childhood are significant.
growth would be maintained, because the goal was to
2. Conduct well-controlled and powered research 8. Conduct studies to refine gestational weight gain
studies testing interventions that are likely to recommendations among obese women according
improve energy balance in children at increased risk to their level of prepregnancy obesity.
of childhood obesity, including dietary approaches
that reduce energy density, total energy, dietary fat, Rationale: The recommended gestational weight
and sugar-sweetened beverages, and promote gain range for obese women was based mostly on
greater consumption of fruits and vegetables. evidence from class I obese women (BMI: 30-34.9).
This represents an important gap in knowledge at a
Rationale: Very few solid data are available on time when the prevalence of class II (BMI: 35-39.9)
interventions in children. and class III obese (BMI ≥ 40) women continues to
rise in the U.S., with 14.2 percent of women
3. Conduct research to clarify both the positive and (25.5% of non-Hispanic Black women) falling in
negative environmental influences that affect body these two categories (IOM, 2009).
weight.
9. Substantially improve prepregnancy BMI and
Rationale: How changing the environment affects gestational weight gain monitoring and surveillance
dietary intake and energy balance needs in the U.S.
documentation.
Rationale: No nationally representative data are
4. Conduct research on the effect of local and national available to describe pre-gravid BMI and
food systems on dietary intake. gestational weight gain patterns in the U.S.
population.
Rationale: It is necessary to clarify the relative
contributions of the different sectors on dietary 10. Conduct longitudinal studies with adequate designs
intake. to further examine the association between
breastfeeding and maternal postpartum weight
5. Conduct considerable new research on other changes, as well as impact on offspring.
behaviors that might influence eating practices.
Rationale: Studies need to have a sample size large
Rationale: We need to know more about child enough to take into account the small effect size
feeding practices, family influences, peer thus far detected and the large inter-subject
influences, etc., and what can improve them. variability in maternal postpartum weight loss.
(Ohlin and Rossner [1990] found that maternal
6. Conduct research on the influence of snacking weight loss ranged from -12.3 kg to +26.5 kg
behavior and meal frequency on body weight and during the first year following the delivery of the
obesity. Develop better definitions for snacking as child). Studies need to have adequate comparison
the research moves forward. groups that are clearly and consistently defined
according to their breastfeeding intensity/duration
Rationale: These are two issues that may alter food patterns. Women who practice different infant
intake and body weight but of which we know little. feeding methods have different background
characteristics. Thus, it is essential that future
7. Invest in well-designed randomized controlled trials observational studies control statistically for key
with long-term follow-up periods to assess the confounders including prepregnancy BMI,
influence of different dietary intake and physical gestational weight gain, socio-economic and
demographic characteristics, and intentional weight
2010 Dietary Guidelines Advisory Committee Report 105
loss. Studies need to measure maternal weight at Aeberli I, Kaspar M, Zimmermann MB. Dietary intake
different time points to be able to validate the use of and physical activity of normal weight and overweight 6
either self-reported weights or weights recorded in to 14 year old Swiss children. Swiss Med Wkly.
clinical charts. 2007;137(29-30):424-30.
11. Determine whether and how isocaloric solid foods Affenito SG, Thompson DR, Barton BA, Franko DL,
and liquids differ in their influence on satiety (De Daniels SR, Obarzanek E, Schreiber GB, Striegel-
Graaf, 2006; Rolls, 2009). Moore RH. Breakfast consumption by African-
American and white adolescent girls correlates
Rationale: The great majority of studies reviewed positively with calcium and fiber intake and negatively
estimated dietary energy density based on foods with body mass index. J Am Diet Assoc.
only, excluding all beverages (Bes-Rastrollo, 2008; 2005;105(6):938-45.
Ello Martin, 2007; Greene, 2006; Ledikwe, 2007;
Rolls, 2005; Savage, 2008b; Saquib, 2008). The Albertson AM, Affenito SG, Bauserman R, Holschuh
decision to include only foods in dietary energy NM, Eldridge AL, Barton BA. The relationship of
density estimations has been largely justified on ready-to-eat cereal consumption to nutrient intake,
statistical and not physiological grounds (Ledikwe, blood lipids, and body mass index of children as they
2005). Studies that have incorporated all beverages age through adolescence. J Am Diet Assoc.
in the dietary energy density estimations, including 2009;109(9):1557-65.
water (Iqbal, 2006) have yielded null results. Few
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different energy density definitions, these studies Holschuh N, Affenito SG, Bauserman R, Striegel-
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2009;1-9.
Children and • Children and adolescents should do 60 minutes (1 hour) or more of physical activity daily.
Adolescents — Aerobic: Most of the 60 or more minutes a day should be either moderate- or vigorous-
intensity aerobic physical activity, and should include vigorous-intensity physical activity
at least 3 days a week.
— Muscle-strengthening: As part of their 60 or more minutes of daily physical activity,
children and adolescents should include muscle-strengthening physical activity on at
least 3 days of the week.
— Bone-strengthening: As part of their 60 or more minutes of daily physical activity, children
and adolescents should include bone-strengthening physical activity on at least 3 days of the
week.
• It is important to encourage young people to participate in physical activities that are
appropriate for their age, that are enjoyable, and that offer variety.
Adults • All adults should avoid inactivity. Some physical activity is better than none, and adults who
participate in any amount of physical activity gain some health benefits.
• For substantial health benefits, adults should do at least 150 minutes (2 hours and 30
minutes) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) a week of
vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and
vigorous-intensity aerobic activity. Aerobic activity should be performed in episodes of at
least 10 minutes, and preferably, it should be spread throughout the week.
• For additional and more extensive health benefits, adults should increase their aerobic
physical activity to 300 minutes (5 hours) a week of moderate-intensity, or 150 minutes a
week of vigorous-intensity aerobic physical activity, or an equivalent combination of
moderate- and vigorous-intensity activity. Additional health benefits are gained by engaging
in physical activity beyond this amount.
• Adults should also include muscle-strengthening activities that are moderate or high intensity
and involve all major muscle groups on 2 or more days a week, as these activities provide
bone-strengthening and other additional health benefits.
Older Adults • Older adults should follow the adult guidelines. When older adults cannot meet the adult
guidelines, they should be as physically active as their abilities and conditions will allow.
• When older adults cannot do 150 minutes of moderate-intensity aerobic activity a week
because of chronic conditions, they should be as physically active as their abilities and
conditions allow.
• Older adults should do exercises that maintain or improve balance if they are at risk of
falling.
• Older adults should determine their level of effort for physical activity relative to their level
of fitness.
• Older adults with chronic conditions should understand whether and how their conditions
affect their ability to do regular physical activity safely.
Note: The PAGAC report applies to children age 6 years and older. There was not enough evidence to review to
determine the relationship between dose of physical activity and health outcomes in children younger than age 6. There is
every reason to believe that these guidelines promote healthy growth and development for children under age 6.
Source: HHS, 2008. http://www.health.gov/paguidelines/committeereport.aspx.
Alcoholic Beverages
Beer
Regular beer 12 fl oz 153
Light beer 12 fl oz 103
Wine
Table wines, all 5 fl oz 123
Sake 1 fl oz 39
Distilled spirits/mixed drinks
Distilled spirits (gin, rum, vodka, whiskey), 80 Proof 1.5 fl oz 97
Crème de menthe, 72 Proof 1.5 fl oz 186
Cosmopolitan
(vodka, orange liqueur, cranberry juice, lime juice) 2.75 fl oz 146
Gin & tonic
(gin, tonic water) 6.5 fl oz 147
Margarita
(tequila, orange liqueur, lime juice) 4 fl oz 168
Martini
(gin, dry vermouth) 2.25 fl oz 124
Mojito
(white rum, lime juice, club soda, mint, sugar) 6 fl oz 143
Pina colada
(light rum, coconut cream, pineapple juice) 9 fl oz 495
Rum & cola
(dark rum, cola) 6.5 fl oz 152
Screwdriver
(vodka, orange juice) 6.5 fl oz 172
Whiskey sour
(whiskey, sour mix) 3.5 fl oz 162
Milk
Whole milk 8 fl oz 149
Reduced fat (2%) milk 8 fl oz 122
Low-fat (1%) milk 8 fl oz 102
Fat-free milk 8 fl oz 83
Coffee and Tea
Black tea 8 fl oz 0
Green tea 8 fl oz 0
Tea sweetened with 2 sugar packets 8 fl oz 22
Regular coffee 8 fl oz 0
Decaffeinated coffee 8 fl oz 0
Coffee sweetened with 2 sugar packets 8 fl oz 22
100% Juice
Apple juice 8 fl oz 114
Carrot juice 8 fl oz 94
Cranberry juice 8 fl oz 137
Grape juice 8 fl oz 152
Orange juice 8 fl oz 117
Pineapple juice 8 fl oz 133
Pomegranate juice 8 fl oz 136
Tomato juice 6 fl oz 31
Sugar Sweetened Beverages
Cola 12 fl oz 136
Energy drink 8 fl oz 115
Fruit punch drink 8 fl oz 117
Hot cocoa 8 fl oz 192
Lemonade drink 8 fl oz 99
Orange Juice drink 8 fl oz 134
Sports drink 8 fl oz 50
Diet beverages
Diet Fruit and Vegetable Drinks 8 fl oz 10
Diet cola 12 fl oz 0
Low calorie cola 12 fl oz 7
Low calorie sports drink 8 fl oz 26
Nutrient enriched water beverage 8 fl oz 0
Sugar free energy drink 8 fl oz 10
Source: U.S. Department of Agriculture, Agricultural Research Service, USDA Nutrient Data Laboratory. 2009.
USDA National Nutrient Database for Standard Reference, Release 22. http://www.ars.usda.gov/nutrientdata.
The USDA Food Patterns include vitamin D from For this review of calcium and health, the DGAC
fortified fluid milk, fortified ready-to-eat cereals, primarily relied upon three sources of information: (1)
fortified butter and margarine, and the naturally calcium intake data from the NHANES (Bailey, 2010a);
occurring vitamin D in meat, poultry, fish, and eggs. (2) an AHRQ evidence report, Vitamin D and Calcium:
The food patterns that contain 3 cup equivalents from A Systematic Review of Health Outcomes (Chung,
the fluid milk and milk products food group provide 2009); and (3) the 1997 IOM report on Dietary
sufficient vitamin D to meet the current AI for all Reference Intakes for Calcium, Phosphorus,
children and adults, aged 19 to 50 years (i.e., 5 µg/d). Magnesium, Vitamin D and Fluoride (FNB, 1997). The
However, the patterns do not provide sufficient vitamin results of the Committee’s review are presented below.
D for adults over 50 years (i.e., 10 µg/d). The Food
Patterns at 1000 to 1400 calories that contain only 2 cup Calcium and Health: Adequate calcium status is
equivalents from the fluid milk and milk products group important for optimal health of the skeleton, in addition
do not provide adequate vitamin D to meet the AI of 5 to having vital roles in nerve transmission,
µg per day for children, aged 2 to 8 years. Additional vasoconstriction, vasodilation, and muscle contraction
vitamin D could be obtained by selecting more natural (FNB, 1997). Emerging evidence suggests a role for
food sources of vitamin D, such as certain fish, and calcium intake in cardiovascular health and lowering
fortified sources of vitamin D, such as fortified orange risk for breast cancer (Chung, 2009). Evidence on other
juice. In addition, choosing fortified fluid milk or yogurt health-related outcomes, such as growth in infants and
2010 Dietary Guidelines Advisory Committee Report 141
children, body weight (see Part D. Section 1: Energy because: (1) many Americans fall short of the
Balance and Weight Management and Part D. Section recommended intake levels for fluid milk and milk
4: Protein), colorectal (CRC), prostate and pancreatic products (see Question 2 on Food Groups and Selected
cancer, preeclampsia, pregnancy-induced hypertension, Dietary Components Underconsumed); (2) relative
and preterm birth, is too insufficient or inconsistent to proportions of fluid milk and cheese consumption have
permit strong conclusions (Chung, 2009). changed over time and they differ in some important
ways in nutrient content (Figure D2.18); and (3) some
Calcium Intake: NHANES data from 2003-2006 individuals desire non-dairy calcium sources for a
indicate that the majority of the population does not variety of physiological, psychosocial, and personal
meet the AI for calcium, except for boys and girls, aged reasons (see Appendix E3.6 at
1 to 3 years, due to fluid milk consumption (Bailey, www.dietaryguidelines.gov for the full report). When
2010a). With diet alone, 96 percent and 94 percent of fluid milk and milk products are removed from the
girls and boys, aged 1 to 3 years, respectively, and 67 USDA Food Patterns, calcium drops substantially
percent and 80 percent of girls and boys, aged 4 to 8 below the AI across all energy levels. In addition,
years, respectively, meet the AI (500 mg/d and 800 vitamins D and A, and choline, magnesium,
mg/d for 1- to 3-year-olds and 4- to 8-year-olds, phosphorus, and potassium also fall below 100 percent
respectively). However, only 15 percent and 22 percent of DRI levels in some or all patterns. When fat-free
of girls and boys, aged 9 to 13 years, respectively, are fluid milk is substituted for some or all of the low-fat
above the AI of 1300 milligrams per day for calcium, cheese in the USDA Food Patterns: (1) energy, protein,
and only 10 percent and 42 percent of adolescent girls and calcium levels remain similar; (2) vitamin A, and
and boys, respectively, aged 14 to 18 years, are above choline, magnesium, and potassium increase slightly;
the AI of 1300 milligrams per day for calcium. Between (3) sodium, cholesterol, and saturated fatty acids
70 percent to 75 percent of women and 37 percent to 44 decrease slightly; and (4) vitamin D content is
percent of men, aged 19 to 50 years, fail to meet the AI substantially improved across energy levels. Of the non-
for calcium (1000 mg/d) (Figure D2.17). Less than 10 dairy alternatives evaluated as a substitute for fluid
percent of women and less than 22 percent of men older milk, yogurt, and cheese in the USDA Food Patterns,
than 51 years meet the AI for calcium (1200 mg/d). soymilk fortified with calcium and vitamins A and D is
Forty-three percent of the population consumes the alternative with the most similar nutrient profile to
supplements that contain calcium. When supplements fluid milk (compared to calcium-fortified rice drink or
are added to dietary intake, the percentage of children orange juice; tofu prepared with calcium sulfate; green
and adults up to age 30 years who meet their AIs vegetables; green soybeans; white beans; almonds; and
improve very little. However, total calcium intakes canned sardines and salmon with bone).
increase substantially in women and men, aged 31 to 50
years, 51 to 70 years, and those older than 71 years Both calcium content and bioavailability should be
when calcium supplements are used (Bailey, 2010a). considered when selecting dietary sources of calcium.
Less than 2 percent of the population exceeds the UL The fluid milk and milk products food group provides
for calcium (Bailey, 2010a). These calcium intakes are more than 70 percent of the calcium consumed by
compared against the 1997 AI for calcium. Should the Americans. Some plant foods contribute calcium that is
IOM determine new AIs for calcium, comparisons of well absorbed, but the large quantity of these plant
intakes to AI standards should be adjusted accordingly. foods that would be needed to provide the equivalent
amount of calcium found in 8 ounces of fluid milk may
Sources of Calcium: Fluid milk and milk products are be unachievable for many. Individuals who perceive
the most bioavailable sources of calcium (Table D2.12) that they are lactose intolerant or allergic to dairy
and are also the major sources of calcium in typical products should be evaluated for such before
American diets (Table D2.13). The USDA Food unnecessarily limiting or eliminating dairy-based foods
Patterns specify 2 (for those 8 years and under) or 3 (for from their dietary patterns (NIH, 2010). Lactose-
those 9 years and older) cup equivalents per day from reduced or low-lactose dairy-based products may assist
the fluid milk and milk products food group and meets in obtaining nutrients provided by the fluid milk and
the goals for calcium intake. milk products food group for those who are lactose
intolerant.
The DGAC conducted a food pattern modeling analysis
to assess nutrient adequacy with various changes in Potassium—Conclusions and implications of
intake from the fluid milk and milk products group inadequate dietary intakes of potassium related to health
142 2010 Dietary Guidelines Advisory Committee Report
outcomes are presented in Part D. Section 6: Sodium, (older than age 50 years) (ARS, 2008). For all
Potassium, and Water. Based on 2001-2002 NHANES Americans, older than 1 year, mean intakes of dietary
data, usual intakes for less than 3 percent of Americans, fiber fall short of the AIs, with less than 3 percent
older than 1 year, meet the AI for potassium (Moshfegh, meeting recommended intake levels (ARS, 2010c).
2005). Approximately 6 percent and less than 3 percent Inadequate intake of dietary fiber is widespread.
of adult men and women, respectively, consume
potassium at intake levels that reach the AI. For boys Dietary sources of fiber are found in vegetables and
and girls, aged 9 to 13 years and 14 to 18 years, and for fruits, whole grains, cooked dry beans and peas, and
children, aged 4 to 8 years, less than 3 percent of these nutsall foods that are lacking in the typical American
age-sex groups meet AIs for potassium intakes. diet (see Question 2 on Food Groups and Selected
Approximately 6 percent of children, aged 1 to 3 years, Dietary Components Underconsumed). Table D2.16
reach the AI for potassium intake. Analysis of 2005- lists the best food sources of dietary fiber per standard
2006 NHANES data also indicates that potassium amount, from the ARS nutrient database, along with the
intakes fall short of the AIs for all age-sex groups, with number of calories for each standard amount. Table
approximately 97 percent of Americans not meeting D2.17 lists the major sources of dietary fiber from
recommended intake levels (Figure D2.19) (ARS, American food consumption data. Refined breads, rolls,
2008). buns, and pizza crust are not among the best sources of
dietary fiber, but contribute substantially to what little
Dietary sources of potassium are found in all food dietary fiber is consumed because they are so ubiquitous
groups, notably in vegetables and fruits (see Question 2 in current dietary patterns of Americans. Refined grains
on Food Groups and Selected Dietary Components are overconsumed in the American diet (see Question 1
Underconsumed). Table D2.14 lists the best food on Nutrients and Dietary Components Overconsumed)
sources of potassium per standard amount, from the and provide less dietary fiber per portion than
ARS nutrient database, along with the number of vegetables, fruits, whole grains, cooked dry beans and
calories for each standard amount. Table D2.15 lists the peas, and nuts. Americans should replace such foods
major sources of potassium from American food with foods that are higher in dietary fiber while not
consumption data. Americans typically consume increasing total energy intakes.
potassium-rich foods in relatively low amounts.
Americans should select foods from all food groups that
are higher in potassium content to better meet NUTRIENT ISSUES FOR SELECTED
recommendations for intake. POPULATION SUBGROUPS
Dietary Fiber—Conclusions and implications
The 2010 DGAC agrees with the 2005 DGAC Report,
regarding inadequate intakes of dietary fiber related to
noting that special nutrient recommendations are
health outcomes are presented in Part D. Section 5:
warranted for the following subgroups and nutrients:
Carbohydrates. Based on 2003-2006 NHANES data,
less than 3 percent of Americans, older than 1 year,
• Adolescent females and women of reproductive
have a usual intake of dietary fiber that exceeds the AI
(ARS, 2010c). Less than 3 percent of adult men and capacityfolic acid
approximately 6 percent and of adult women consume • Adolescent females and women of reproductive
dietary fiber at intake levels that reach the AI. For boys capacity—iron
and girls, aged 9 to 13 years and 14 to 18 years, and • Persons over age 50 yearsvitamin B12
children, aged 1 to 3 years and 4 to 8 years, less than 3
percent of these age-sex groups meet their AIs for
dietary fiber intakes (Figure D2.20).
The base USDA Food Patterns that include foods from A full systematic review was not conducted, because
all of the basic food groups provide adequate amounts although the DGAC believes that the issue is still
of folate and other enrichment nutrients for all age-sex pertinent, little new data have been published since
According to 2005-2006 NHANES data, the estimated For the general, healthy population, there is no evidence
mean daily vitamin B12 intakes from foods ranged from to support a recommendation for the use of
3.96 (girls, aged 12 to 19 years) to 7.91 µg (men, aged multivitamin/mineral supplements in the primary
40 to 49 years) (ARS, 2008). For men and women,
148 2010 Dietary Guidelines Advisory Committee Report
prevention of chronic disease. Limited evidence published papers. NIH conference panelists used this
suggests that supplements containing combinations of AHRQ report (Huang, 2006) as a foundational piece of
certain nutrients are beneficial in reversing chronic evidence for their independent review, along with
disease when used by special populations; in contrast, further scientific evidence provided by scientific experts
certain nutrient supplements appear to be harmful in who addressed six key questions posed by the NIH
other subgroups. panel. The DGAC used the three key sources of
evidence, as previously indicated, along with three
Implications meta-analyses, three systematic reviews, and 11
randomized controlled nutrient supplementation trials
Although intake of a variety of multivitamin/mineral that were published after the 2006 AHRQ report and
supplements increase blood levels of many nutrients, 2006 NIH conference to group and summarize overall
notably in individuals with suboptimal nutrient status evidence by outcome or body system.
before supplementation (Maraini, 2009), long-term
effects on primary prevention of several chronic Cancer
diseases has not been demonstrated. In this context, In healthy adults, no effects of beta-carotene
obtaining essential micronutrients from foods when supplementation or a combined vitamin A plus zinc
possible is the optimal approach and reliance on supplement or vitamin A plus beta-carotene supplement
multivitamin/mineral supplements is discouraged. At on cancer prevention were reported. There was an
present, Americans are encouraged to meet overall observed beneficial effect of a combined beta-carotene,
nutrient requirements within energy levels that balance vitamin E, and selenium supplement on lowering gastric
daily energy intake with expenditure. This can be cancer incidence and gastric and overall cancer
accomplished through a variety of food intake patterns mortality in inadequately nourished men and women in
that include nutrient-dense forms of foods. China. A reduced overall cancer risk in men, but not
women, in France, was noted with a beta-carotene,
Review of the Evidence vitamins E and C, selenium, and zinc combination.
Lowering of prostate cancer incidence and mortality in
The DGAC evaluated three primary sources of evidence men and CRC in adult smokers with vitamin E
to reach this conclusion: (1) an AHRQ-commissioned supplementation was reported. An observed adverse
systematic review on nutrient supplements and chronic effect of beta-carotene supplementation or a combined
disease prevention (Huang, 2006); (2) the 2006 NIH beta-carotene plus vitamin A supplement on lung cancer
“State-of-the-Science Conference on and mortality in adult smokers and in individuals
Multivitamin/Mineral Supplements for Chronic Disease exposed to asbestos was noted. Data presented by
Prevention” (Coates, 2007a); and (3) the American program participants of the NIH conference (NIH,
Journal of Clinical Nutrition supplement, “n-3 Fatty 2006) were congruent with the AHRQ report (Huang,
Acids: Recommendations for Therapeutics and 2006) regarding beneficial effects of a combined beta-
Prevention” (Akabas, 2006a). This review was limited carotene, vitamin E, and selenium supplement on
to vitamins, minerals, and EPA and DHA. Other dietary lowering gastric cancer in nutritionally deficient adults
supplements—such as botanicals, hormones, peptides, in China (Greenwald, 2007) and harmful effects of
and amino acids—were not evaluated. beta-carotene supplementation or a combined beta-
carotene plus vitamin A supplement on increasing lung
Huang et al. (2006) established four key questions to cancer in adult smokers and individuals exposed to
guide the examination of published literature regarding asbestos (Greenwald, 2007).
health outcomes of multivitamin/mineral supplements
in the primary prevention of 10 chronic disease A meta-analysis (Tanvetyanon 2008) confirmed that
categories, including cancer, vascular, endocrine, lung cancer incidence increased with beta-carotene
neurological, sensory, liver, renal, musculoskeletal, supplementation in former smokers and individuals
infectious, and pulmonary diseases. These investigators exposed to asbestos. Conversely, lung cancer incidence
also evaluated published data on the effects of 14 was not significantly increased in the overall population
single-nutrient supplements and four functionally of male physicians (Hennekens, 1996) or women in
related paired-nutrient supplements on these chronic health professions who were not former smokers (Lee,
diseases as well as the safety of eight single-nutrient 1999) and who consumed beta-carotene supplements on
supplements on health-related outcomes. Their alternate days. Among all current smokers, the risk of
conclusions were based on findings reported in 63 lung cancer incidence significantly increased by 24
2010 Dietary Guidelines Advisory Committee Report 149
percent in individuals receiving any beta-carotene 2002) (see Part D. Section 3: Fatty Acids and
supplement. A more recent study by Liu et al. (2009) Cholesterol for a discussion on fish intake).
examined a panel of cancer markers in stored lung
tissue from participants of the Physician’s Health Study Sensory Disease
who developed lung cancer. Neither smoking status nor In adults, no effects of beta-carotene supplementation
beta-carotene supplementation status was significantly on sensory diseases were reported. Lessening of age-
different for the 39 men from whom samples of lung related macular degeneration and total mortality, only in
tissue were provided. Significant differences in selected adults with intermediate or advanced disease, with
markers of lung cancer were not found between adult supplementation of zinc or zinc plus antioxidant
men supplemented with beta-carotene versus placebo, nutrients was noted. However, no effect of
suggesting that factors other than the beta-carotene multivitamin/mineral supplements on preventing
supplement lead to lung cancer development. cataracts in healthy Americans was found (Huang,
2006; NIH, 2006).
Among healthy postmenopausal women living in rural
Nebraska, combined calcium plus vitamin D A combined zinc plus antioxidant nutrients supplement
supplementation lowered all-cancer risk over a 4-year that also included copper reversed age-related macular
intervention compared to placebo or calcium alone degeneration in individuals with diagnosed disease
(Lappe, 2007). Recent findings from the Selenium and (Seddon, 2007). A common over-the-counter
Vitamin E Cancer Prevention Trial (SELECT) multivitamin/mineral supplement reduced total (by
demonstrated that supplementation of selenium alone, 18%) and nuclear (by 34%) lens events but doubled the
vitamin E alone, or combined selenium plus vitamin E number of posterior subcapsular cataracts in men and
had no effect on prostate cancer compared to placebo in women, aged 55 to 75 years (Clinical Trial of
adult men in the U.S., Puerto Rico, and Canada Nutritional Supplements and Age-Related Cataract,
(Lippman, 2009). CTNS, 2008). Findings from the Women’s Health
Study demonstrated that vitamin E supplementation on
Cardiovascular Disease alternate days, versus placebo, had no effect on overall
In adults, no effect of beta-carotene supplementation on cataract incidence or nuclear, cortical or posterior
CVD was noted, and no effect of a combined beta- subcapsular cataract incidence, even when controlling
carotene, vitamins E and C, selenium, and zinc for cataract progression risk factors (Christen, 2008).
supplement on ischemic CVD incidence was reported. Fish intake, but not EPA or DHA supplements, was
Among adults, a combined vitamin A plus zinc related to lower risk of macular degeneration (Johnson,
supplement or vitamin A plus beta-carotene supplement 2006).
had no impact on cerebrovascular disease or CVD
(Huang, 2006; NIH, 2006). The effect of vitamin E Some evidence supports DHA supplementation by
supplementation on CVD prevention, particularly pregnant women and lactating mothers at 200 to 300
among older women, had incomplete evidence on milligrams per day to promote cognitive development
which to base a positive recommendation for and possibly visual acuity in their offspring (Eilander,
supplementation (Traber, 2007). Additional vitamin K, 2007; Koletzko, 2008). Consumption of 6 to 10 ounce
beyond that consumed in a multivitamin supplement, equivalents of seafood per week would achieve the
reduced the progression of coronary artery calcification DHA intake goal (Brenna, 2009) for this population
in individuals with greater than or equal to 85 percent (see Part D. Section 3: Fatty Acids and Cholesterol).
supplementation compliance and in individuals with
preexisting coronary artery calcification (Shea, 2009). Musculoskeletal Disease
Retention of bone mineral density in postmenopausal
EPA and DHA supplementation as a treatment strategy women is well-documented with calcium
lowered blood concentration of triacylglycerol as a supplementation and a reduction in hip and non-
marker of CVD, lowered overall mortality in persons vertebral fractures and falls with combined calcium and
with CVD, and lowered arrhythmias and sudden death vitamin D supplements in older women, particularly
(Akabas, 2006b). The American Heart Association those with low levels of these nutrients before
recommends a total of 1 gram per day of EPA plus supplementation (Huang, 2006; NIH, 2006). Modest
DHA from a combination of higher omega-3 fatty acid- positive effects of a combined calcium plus vitamin D
containing fish and supplements, if needed, in supplement on bone health and fall prevention in older
individuals with coronary heart disease (Kris-Etherton, individuals has been confirmed in recent studies
150 2010 Dietary Guidelines Advisory Committee Report
(Heaney, 2007). Vitamin K supplementation does not infectious, and pulmonary diseases have not been
appear to provide significant benefit to bone mineral documented (NIH, 2006).
density in older adults (Booth, 2008), although vitamin
K is an important nutrient for bone health. Other Factors
An increased risk of kidney stone formation with
Neurological and Central Nervous System calcium supplementation and discoloration of the skin
Disease with beta-carotene supplement use was noted (Huang,
A study in community-living older adults in Scotland 2006). However, few, if any, randomized placebo-
found that daily supplementation with combined controlled clinical trials have tested the safety of
vitamins A, C, D, E, B6 and B12, thiamin, riboflavin, nutrient supplements used as single or combinations of
niacin, folic acid, pantothenic acid, iron, zinc, copper, nutrients by the healthy population of Americans. A
manganese, and iodine did not prevent cognitive meta-analysis that examined effects of beta-carotene,
decline, although supplementation was associated with vitamins A, C, and E, and selenium as single nutrients
positive changes in verbal fluency among participants or as combinations of antioxidants on various outcome
older than age 75 years and in those at risk of nutritional measures reported increased risk of death across a
deficiency (McNeill, 2007). Pitkin (2007) noted that variety of low-bias clinical trials with beta-carotene and
supplementation of women of reproductive capacity vitamins A and E supplementation (Bjelakovic, 2007).
with folic acid, along with adequate intake of folic acid-
fortified foods and usual intakes of dietary folate, was Relevant Contextual Issues
beneficial in preventing NTDs in offspring (see One distinct limitation to studies on the effects of
Question 4 within Nutrient Issues for Selected multivitamin/mineral supplement use on chronic disease
Population Subgroups). An additional topic addressed endpoints is insufficient standardization of preparation
by the NIH panel included the effect of vitamin B6 and compositions and characteristics (Yetley, 2007). Some
of folic acid, with or without vitamin B12, discrepancies exist between the actual content of
supplementation on cognitive decline; no effects were nutrients in supplements and the amounts reported on
reported in older adults (NIH, 2006) (see Question 6 product labels, along with differences in chemical
within Nutrient Issues for Selected Population formulations and dosing regimens that affect
Subgroups). bioavailability, bioequivalency, and, ultimately,
biological effects. Although randomized placebo-
DHA may lower risk of cognitive decline and controlled trials reduce confounding effects on primary
Alzheimer’s disease (Akabas, 2006b), although a more outcomes of interest in rigorous studies, the fact that 53
recent 2-year randomized controlled trial of EPA plus percent of adults in the U.S. use multivitamin/mineral
DHA supplementation in older individuals showed no supplements on a somewhat regular basis (Bailey,
change in cognitive function compared to an olive oil 2010a), with supplements contributing substantially to
control (Dangour, 2010). DHA supplementation overall adequacy of nutrient intakes among adults
modulated functional brain activity in healthy boys, (Murphy, 2007), limits the generalizability of nutrient
aged 8 to 10 years (McNamara, 2010), although this supplement effects within a healthy and adequately
evidence was exploratory and requires further nourished population. Nutritional status at baseline may
investigation. EPA plus DHA supplementation did not modify long-term health effects of nutritional
impact self-rated depression in a group of non- supplements as may the age at which nutritional
depressed older individuals compared to a placebo supplements are initiated and the duration of their use
group (van de Rest, 2008). One meta-analysis (Fairfield, 2007). Moreover, typical users of
concluded that EPA plus DHA supplementation multivitamin/mineral supplements are older, non-
improved mood only in individuals already diagnosed Hispanic white women and individuals with higher
with mood disorders (Appleton, 2010). education and physical activity levels, lower BMI, and
greater nutrient adequacy from dietary intake (Rock,
Other Systems 2007). These demographic and physical characteristics
In adults, no effects of beta-carotene supplementation are also positively correlated to an overall healthy
on endocrine diseases were reported (Huang, 2006). lifestyle, including health care screening and self-
EPA and DHA may improve insulin sensitivity efficacy in primary prevention of chronic disease.
(Akabas, 2006b). Effects of a daily Distinguishing the contribution of a single-nutrient or
multivitamin/mineral supplement on liver, renal, combined-nutrient supplement to long-term health
Vitamin D
Needs for Future Research
4. Conduct high-quality, long-term dose-response
Recommendations for further studies include: studies with relevant health outcomes including
bone as well as functional outcomes related to the
Nutrients and Dietary Components immune system, autoimmune disorders, and chronic
Overconsumed diseases such as coronary heart disease,
hypertension, cancer, and diabetes.
1. Develop and test behavior-based interventions
designed to lower dietary intakes of nutrients and Rationale: There is a need for additional research
dietary components overconsumed, focusing on on the relation between threshold values of
SoFAS. 25(OH)D and relevant functional outcomes at each
life stage and in understudied populations.
Rationale: SoFAS contribute a substantial number
of calories to the typical American diet without 5. Investigate the metabolic partitioning, fate, and
adding important micronutrients. Interventions that mobilization of key vitamin D metabolites at
are proven successful in lowering dietary recommended and greater than recommended
levels.
2010 Dietary Guidelines Advisory Committee Report 153
Rationale: Studies that assess the availability of and risk assessments, of nutrient supplements in a
stored vitamin D, relative contributions of diverse range of healthy population groups.
endogenously produced and dietary vitamin D, and
impact of important confounders such as body Rationale: Research on the efficacy and safety of
weight and body fat on vitamin status are warranted nutrient supplements is vital to the guidance of
(Brannon, 2008b). public policy recommendations, given that the
majority of Americans use nutrient supplements at
Folate any point in time.
6. Conduct studies on the long-term health impact of Nutrient Adequacy and Eating Behaviors
fortification on NTDs, CRC, stroke, cognitive
function, and other health outcomes, such as 10. Convene a consensus panel to define breakfast,
emerging evidence suggesting that high folic acid breakfast consumers, and breakfast skipping;
intakes in some pregnant women may lead to snacking; and eating frequency that can be
asthma in their offspring (Whitrow, 2009), to fully consistently applied to studies.
understand the impact of this ecological
experiment. Rationale: Identifying healthful eating behaviors is
important to primary prevention of chronic disease
Rationale: A substantial amount of time has in Americans. Common definitions of specific
elapsed since the U.S. and Canada mandated folic eating behaviors are vital to testing and
acid fortification. Since 1998, many research understanding the role of these behaviors in health
studies have evaluated the benefits and risks of and wellness.
fortification. Much of the research demonstrated
benefit, while some of the research has shown 11. Conduct longitudinal studies on the cumulative
increased health risk. Further research is warranted. nutritional risks of breakfast skipping and/or health
benefits of breakfast consumption. Identify critical
Vitamin, Mineral, and Nutrient Supplements components of breakfast and snacks, such as
vegetables, fruits, whole grains, and/or fluid milk
7. Conduct studies on the precision in self-reported and milk products, and their related health benefits.
intakes of multivitamin/mineral supplements.
Rationale: Breakfast intake is associated with
Rationale: More than one-half of the population positive outcomes such as improved school
reports the use of nutrient supplements; however, performance among children. Further
the frequency and consistency of this use is understanding of other nutrition-related health
sporadic for many. Greater accuracy in self-reported benefits is needed.
use of nutrient supplements is important to
understanding short- and long-term health effects.
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TABLE D2.1 Nutritional goals for age/sex groups, based on Dietary Reference Intakes and Dietary
Guidelines recommendations, and USDA Food Patterns using these goals as targets
TABLE D2.2 Vitamin A: Selected food sources ranked by amounts of vitamin A and energy per standard
food portion and per 100 grams of foods
TABLE D2.3 Vitamin C: Selected food sources ranked by amounts of vitamin C and energy per standard
food portion and per 100 grams of foods
TABLE D2.4 Vitamin K: Selected food sources ranked by amounts of vitamin K and energy per standard
food portion and per 100 grams of foods
TABLE D2.5 Vitamin E: Selected food sources ranked by amounts of vitamin E and energy per standard
food portion and per 100 grams of foods
TABLE D2.6 Choline: Selected food sources ranked by amounts of choline and energy per standard food
portion and per 100 grams of foods
TABLE D2.7 Magnesium: Selected food sources ranked by amounts of magnesium and energy per
standard food portion and per 100 grams of foods
TABLE D2.8 Phosphorus: Selected food sources ranked by amounts of phosphorus and energy per
standard food portion and per 100 grams of foods
TABLE D2.9 Functions of the nutrients of concernvitamin D, calcium, potassium, dietary fiber
TABLE D2.10 Vitamin D: Selected food sources ranked by amounts of vitamin D and energy per standard
food portion and per 100 grams of foods
TABLE D2.11 Food sources of vitamin D listed in descending order by percentage of their contribution to
intake among the U.S. population ages 2+, WWEIA, NHANES 2005-2006
TABLE D2.12 Calcium: Selected food sources ranked by amounts of calcium and energy per standard
food portion and per 100 grams of foods
TABLE D2.13 Food sources of calcium listed in descending order by percentages of their contribution to
intake among the U.S. population ages 2+, WWEIA, NHANES 2005-2006
TABLE D2.14 Potassium: Selected food sources ranked by amounts of potassium and energy per standard
food portion and per 100 grams of foods
TABLE D2.15 Food sources of potassium listed in descending order by percentages of their contribution
to intake among the U.S. population ages 2+, WWEIA, NHANES 2005-2006
TABLE D2.16 Dietary fiber: Selected food sources ranked by amounts of dietary fiber and energy per
standard food portion and per 100 grams of foods
TABLE D2.17 Food sources of dietary fiber listed in descending order by percentages of their contribution
to intake among the U.S. population ages 2+, WWEIA< NHANES 2005-2006
TABLE D2.18 Folate: Selected food sources ranked by amounts of folate and energy per standard food
portion and per 100 grams of foods
TABLE D2.19 Iron: Selected food sources ranked by amounts of iron and energy per standard food
portion and per 100 grams of foods
TABLE D2.20 Vitamin B12: Selected food sources ranked by amounts of vitamin B12 and energy per
standard food portion and per 100 grams of foods
Table D2.1. Nutritional goals for age/sex groups, based on Dietary Reference Intakes and Dietary Guidelines recommendations, and USDA food patterns
using these goals as targets1
Source of Child Female Male Female Male Female Male Female Male Female Male Female Male
Nutrient (units) Goal 1-3 4-8 4-8 9-13 9-13 14-18 14-18 19-30 19-30 31-50 31-50 51+ 51+
Macronutrients
Protein (g) RDA2 13 19 19 34 34 46 52 46 56 46 56 46 56
(% of calories) AMDR3 5-20 10-30 10-30 10-30 10-30 10-30 10-30 10-35 10-35 10-35 10-35 10-35 10-35
Carbohydrate (g) RDA 130 130 130 130 130 130 130 130 130 130 130 130 130
(% of calories) AMDR 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65
Total fiber (g) 14g/1000 kcal4 14 17 20 22 25 25 31 28 34 25 31 22 28
Total fat (% kcal) AMDR 30-40 25-35 25-35 25-35 25-35 25-35 25-35 20-35 20-35 20-35 20-35 20-35 20-35
Saturated fat (% kcal) DG5 <10% <10% <10% <10% <10% <10% <10% <10% <10% <10% <10% <10% <10%
Linoleic acid (g) AI 7 10 10 10 12 11 16 12 17 12 17 11 14
(% kcal) AMDR 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10 5-10
α-Linolenic acid (g) AI 0.7 0.9 0.9 1.0 1.2 1.1 1.6 1.1 1.6 1.1 1.6 1.1 1.6
(% kcal) AMDR 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2 0.6-1.2
2010 Dietary Guidelines Advisory Committee Report
Cholesterol (mg) DG <300 <300 <300 <300 <300 <300 <300 <300 <300 <300 <300 <300 <300
Minerals
Calcium (mg) AI6 500 800 800 1300 1300 1300 1300 1000 1000 1000 1000 1200 1200
Iron (mg) RDA 7 10 10 8 8 15 11 18 8 18 8 8 8
Magnesium (mg) RDA 80 130 130 240 240 360 410 310 400 320 420 320 420
Phosphorus (mg) RDA 460 500 500 1250 1250 1250 1250 700 700 700 700 700 700
Potassium (mg) AI 3000 3800 3800 4500 4500 4700 4700 4700 4700 4700 4700 4700 4700
Sodium (mg) UL7 <1500 <1900 <1900 <2200 <2200 <2300 <2300 <2300 <2300 <2300 <2300 <2300 <2300
Zinc (mg) RDA 3 5 5 8 8 9 11 8 11 8 11 8 11
Copper (µg) RDA 340 440 440 700 700 890 890 900 900 900 900 900 900
Selenium (µg) RDA 20 30 30 40 40 55 55 55 55 55 55 55 55
2010 Dietary Guidelines Advisory Committee Report
Table D2.1 (continued). Nutritional goals for age/sex groups, based on Dietary Reference Intakes and Dietary Guidelines recommendations, and USDA
food patterns using these goals as targets1
Source of Child Female Male Female Male Female Male Female Male Female Male Female Male
Nutrient (units) Goal 1-3 4-8 4-8 9-13 9-13 14-18 14-18 19-30 19-30 31-50 31-50 51+ 51+
Vitamins
Vitamin A (µg RDA 300 400 400 600 600 700 900 700 900 700 900 700 900
RAE)
Vitamin D (µg) AI 5 5 5 5 5 5 5 5 5 5 5 10 10
Vitamin E (mg AT) RDA 6 7 7 11 11 15 15 15 15 15 15 15 15
Vitamin C (mg) RDA 15 25 25 45 45 65 75 75 90 75 90 75 90
Thiamin (mg) RDA 0.5 0.6 0.6 0.9 0.9 1 1.2 1.1 1.2 1.1 1.2 1.1 1.2
Riboflavin (mg) RDA 0.5 0.6 0.6 0.9 0.9 1 1.3 1.1 1.3 1.1 1.3 1.1 1.3
Niacin (mg) RDA 6 8 8 12 12 14 16 14 16 14 16 14 16
Vitamin B6 (mg) RDA 0.5 0.6 0.6 1 1 1.2 1.3 1.3 1.3 1.3 1.3 1.5 1.7
Vitamin B12 (µg) RDA 0.9 1.2 1.2 1.8 1.8 2.4 2.4 2.4 2.4 2.4 2.4 2.4 2.4
Choline (mg) AI 200 250 250 375 375 400 550 425 550 425 550 425 550
Vitamin K (µg) AI 30 55 55 60 60 75 75 90 120 90 120 90 120
Folate (µg DFE) RDA 150 200 200 300 300 400 400 400 400 400 400 400 400
USDA Food Pattern
using goals as 1000 1200 1400 1600 1800 1800 2200 2000 2400 1800 2200 1600 2000
targets
1
USDA Food intake patterns at 2600, 2800, 3000, and 3200 calories were designed to meet the needs of males 14 to 18 and 19 to 30. Their nutritional goals
are the same as for the patterns at 2200 and 2400 calories.
2
Recommended Dietary Allowance, IOM.
3
Acceptable Macronutrient Distribution Range, IOM.
4
14 grams per 1000 calories, IOM.
5
Dietary Guidelines recommendation.
6
Adequate Intake, IOM.
7
Upper Limit, IOM.
Sources: IOM 2006, Britten et al., 2006.
165
Table D2.2. Vitamin A: Food sources ranked by amounts of vitamin A and energy per standard food portions and
per 100 grams of foods (Amounts of vitamin A present in standard food portions are ≥ 20% of RDA for adult men,
which is 900 µg RAE 1)
Vitamin A in Vitamin A
Calories in Standard Calories per 100
Standard Standard Portion per 100 grams
Food Portion Size Portion2 (µg RAE)2 grams2 (µg RAE) 2
Vitamin C Vitamin C
Calories in in Standard Calories per 100
Standard Standard Portion per 100 grams
Food Portion Size Portion1 (mg)1 grams1 (mg) 1
Vitamin C Vitamin C
Calories in in Standard Calories per 100
Standard Standard Portion per 100 grams
Food Portion Size Portion1 (mg)1 grams1 (mg) 1
Kale, cooked from fresh or frozen ½ cup 18-20 531-573 28-30 817-882
Collards, cooked from fresh or frozen ½ cup 25-31 418-530 26-36 440-623
Spinach, cooked from fresh, frozen, or
canned ½ cup 21-32 444-514 23-34 462-541
Turnip greens, cooked from fresh or frozen ½ cup 14-24 265-426 20-29 368-519
Beet greens, cooked from fresh ½ cup 19 349 27 484
Dandelion greens, cooked from fresh ½ cup 17 290 33 551
Mustard greens, cooked from fresh ½ cup 10 210 15 300
Spinach egg noodles, cooked 1 cup 211 162 132 101
Brussels sprouts, cooked from fresh or
frozen ½ cup 28-33 109-150 36-42 140-194
Spinach, raw 1 cup 7 145 23 483
Broccoli, cooked from fresh or frozen ½ cup 26-27 81-110 28-35 88-141
Cabbage, cooked from fresh ½ cup 17 82 23 109
Asparagus, cooked from frozen ½ cup 16 72 18 80
Green leaf lettuce 1 cup 5 63 15 174
Cabbage, raw 1 cup 18 53 25 76
Romaine lettuce 1 cup 8 48 17 103
Savoy cabbage 1 cup 19 48 27 69
Broccoli, raw ½ cup 15 46 34 102
Okra, cooked from fresh or frozen ½ cup 18-26 32-44 22-28 40-48
Tuna, canned in oil, drained 3 ounces 168 37 198 44
Dried plums (prunes), stewed ½ cup 133 32 107 26
Green peas, canned ½ cup 60 32 69 37
Cowpeas, cooked from frozen ½ cup 112 31 132 37
Green snap beans, canned ½ cup 18 30 23 39
Chinese cabbage, cooked from fresh ½ cup 10 29 12 34
Celery, cooked ½ cup 14 28 18 38
Kiwifruit 1 medium 42 28 61 40
Dried plums (prunes) ¼ cup 104 26 240 60
Rhubarb, cooked from frozen, sweetened ½ cup 139 25 116 21
Peas, edible-podded, cooked from frozen ½ cup 42 24 52 30
1
Source: U.S. Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory. 2009. USDA
National Nutrient Database for Standard Reference, Release 22. Available at:
http://www.ars.usda.gov/ba/bhnrc/ndl.
Nutrient Function
Calcium Calcium is the key nutrient in the development and maintenance of bones; additionally
calcium aids in blood clotting and muscle and nerve functioning.
Vitamin D Vitamin D aids in the intestinal absorption of calcium and phosphorus, so it helps to
maintain serum levels of these minerals in the body at normal levels. Vitamin D also plays
roles in cellular metabolism, which involve antiproliferation and prodifferentiation actions.
Potassium Potassium assists in muscle contraction, maintaining fluid and electrolyte balance in cells,
transmitting nerve impulses, and releasing energy during metabolism. Diets rich in
potassium lower blood pressure, blunt the adverse effects of salt on blood pressure, may
reduce the risk of developing kidney stones, and may decrease bone loss.
Dietary Fiber Fiber helps maintain the health of the digestive tract and promotes proper bowel
functioning.
Source: Adapted from Dietary Reference Intakes: The Essential Guide to Nutrient Requirements, (IOM, 2006).
Contribution to Cumulative
Food Category Intake, % Contribution, %
¾ - 1 cup
Fortified ready-to-eat cereals (various) (~1 ounce) 100-210 250-1000 309-373 1818-3333
Orange juice, calcium fortified 1 cup 117 500 47 201
Plain yogurt, nonfat 8 ounces 127 452 56 199
Romano cheese 1.5 ounces 165 452 387 1064
Pasteurized process Swiss cheese 2 ounces 189 438 334 772
Evaporated milk, nonfat ½ cup 100 371 78 290
Tofu, raw, regular, prepared with
calcium sulfate ½ cup 94 434 76 350
Plain yogurt, low-fat 8 ounces 143 415 63 183
Fruit yogurt, low-fat 8 ounces 232 345 102 152
Ricotta cheese, part skim ½ cup 171 337 138 272
Swiss cheese 1.5 ounces 162 336 380 791
Sardines, canned in oil, drained 3 ounces 177 325 208 382
Pasteurized process American cheese
food 2 ounces 187 323 330 570
Provolone cheese 1.5 ounces 149 321 351 756
Mozzarella cheese, part-skim 1.5 ounces 128 311 302 731
Cheddar cheese 1.5 ounces 171 307 403 721
Muenster cheese 1.5 ounces 156 305 368 717
Low-fat milk (1%) 1 cup 102 305 42 125
Soymilk, original and vanilla, with
added calcium 1 cup 104 299 43 123
Skim milk (nonfat) 1 cup 83 299 34 122
Reduced fat milk (2%) 1 cup 122 293 50 120
Low-fat chocolate milk (1%) 1 cup 158 290 63 116
Low-fat buttermilk (1%) 1 cup 98 284 40 116
Rice milk, with added calcium 1 cup 113 283 47 118
Whole chocolate milk 1 cup 208 280 83 112
Whole milk 1 cup 149 276 61 113
Plain yogurt, whole milk 8 ounces 138 275 61 121
Reduced fat chocolate milk (2%) 1 cup 190 272 76 109
Ricotta cheese, whole milk ½ cup 216 257 174 207
Tofu, firm, prepared with calcium
sulfate and magnesium chloride ½ cup 88 253 70 201
1
Data source: U.S. Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory. 2009.
USDA National Nutrient Database for Standard Reference, Release 22. Available at:
http://www.ars.usda.gov/ba/bhnrc/ndl.
Potato, baked, flesh and skin 1 sm. potato 128 738 93 535
Prune juice, canned 1 cup 182 707 71 276
Carrot juice, canned 1 cup 94 689 40 292
Tomato paste ¼ cup 54 664 82 1014
Beet greens, cooked from fresh ½ cup 19 654 27 909
White beans, canned ½ cup 149 595 114 454
Tomato juice, canned 1 cup 41 556 17 229
Plain yogurt, nonfat 8 ounces 127 579 56 255
Tomato puree ½ cup 48 549 38 439
Sweet potato, baked in skin 1 medium 103 542 90 475
Clams, canned 3 ounces 126 534 148 628
Plain yogurt, low-fat 8 ounces 143 531 63 234
Orange juice, fresh 1 cup 112 496 45 200
Halibut, cooked 3 ounces 119 490 140 576
Soybeans, green, cooked ½ cup 127 485 141 539
Tuna, yellowfin, cooked 3 ounces 118 484 139 569
Lima beans, cooked ½ cup 108 478 115 508
Soybeans, mature, cooked ½ cup 149 443 173 515
Rockfish, Pacific, cooked 3 ounces 103 442 121 520
Cod, Pacific, cooked 3 ounces 89 439 105 517
Evaporated milk, nonfat ½ cup 100 425 78 332
Low-fat chocolate milk (1%) 1 cup 158 425 63 170
Reduced fat chocolate milk (2%) 1 cup 190 422 76 169
Bananas 1 medium 105 422 89 358
Spinach, cooked from fresh or canned ½ cup 21-25 370-419 23 346-466
Tomato sauce ½ cup 29 405 24 331
Peaches, dried, uncooked ¼ cup 96 398 239 996
Prunes, stewed ½ cup 133 398 107 321
Skim milk (nonfat) 1 cup 83 382 34 156
Rainbow trout, cooked 3 ounces 128 381 150 448
Apricots, dried, uncooked ¼ cup 78 378 241 1162
Pinto beans, cooked ½ cup 122 373 143 436
Pork loin, center rib, lean, roasted 3 ounces 190 371 223 437
Low-fat buttermilk (1%) 1 cup 98 370 40 151
Low-fat milk (1%) 1 cup 102 366 42 150
Lentils, cooked ½ cup 115 365 116 369
Plantains, cooked ½ cup 89 358 116 465
Kidney beans, cooked ½ cup 112 358 127 405
1
Source: U.S. Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory. 2009. USDA
National Nutrient Database for Standard Reference, Release 22. Available at:
http://www.ars.usda.gov/ba/bhnrc/ndl.
Contribution to Cumulative
Food Category Intake, % Contribution, %
Contribution to Cumulative
Food Category Intake, % Contribution, %
Folate in
Calories in Standard Calories Folate per
Standard Standard Portion per 100 100 grams
Food Portion Size Portion1 (µg DFE) 1 grams1 (µg DFE) 1
Folate in
Calories in Standard Calories Folate per
Standard Standard Portion per 100 100 grams
Food Portion Size Portion1 (µg DFE) 1 grams1 (µg DFE) 1
FIGURE D2.1 Distribution of usual intakes of sofas (solid fats and added sugars) as percent of total calories,
by age/sex group
FIGURE D2.2 Comparison of mean usual daily intake of calories from solid fats and from added sugars, by
age/sex group
FIGURE D2.3 Distribution of usual daily intakes of sofas (solid fats and added sugars) in calories, in
comparison to maximum limits, by age/sex group
FIGURE D2.4 Distribution of usual daily intakes of sodium, in milligrams, in comparison to adequate
intake(AI) levels and upper limits, by age/sex group
FIGURE D2.5 Distribution of usual daily intakes of saturated fatty acids as a percent of total calories, in
comparison to maximum limit, by age/sex group
FIGURE D2.6 Distribution of usual daily intakes of cholesterol, in milligrams, in comparison to maximum
limit, by age/sex group
FIGURE D2.7 Distribution of usual daily intakes of refined grains, in ounce equivalents, in comparison to
maximum limits, by age/sex group
FIGURE D2.8 Distribution of usual daily intakes of vegetables, in cup equivalents, in comparison to
recommended intake levels, by age/sex group
FIGURE D2.9 Distribution of usual daily intakes of fruits, in cup equivalents, in comparison to
recommended intake levels, by age/sex group
FIGURE D2.10 Distribution of usual daily intakes of whole grains, in ounce equivalents, in comparison to
recommended intake levels, by age/sex group
FIGURE D2.11 Distribution of usual daily intakes of milk and milk products, in cup equivalents, in
comparison to recommended intake levels, by age/sex group
FIGURE D2.12 Distribution of usual daily intakes of meat, poultry, fish, eggs, soy products, nuts, and seeds,
in ounce equivalents, in comparison to recommended intake levels, by age/sex group
FIGURE D2.13 Distribution of usual daily intake of oils, in grams, in comparison to recommended intake
levels, by age/sex group
FIGURE D2.14 Level of adequacy expressed as estimated percentages of Americans with nutrient intakes
from food above their requirements (EARs)
FIGURE D2.15 Level of adequacy expressed as estimated percentages of Americans with nutrient intakes
from food above the adequate intake (AI) level
FIGURE D2.16 Distribution of usual daily intakes of vitamin D, in micrograms, in comparison to adequate
intake (AI) levels, by age/sex group
FIGURE D2.17 Distribution of usual daily intakes of calcium, in milligrams, in comparison to adequate intake
(ai) levels, by age/sex group
FIGURE D2.18 Relative proportions of fluid milk and cheese available for consumption over time
FIGURE D2.19 Distribution of usual daily intakes of potassium, in milligrams, in comparison to adequate
intake (AI) levels, by age/sex group
FIGURE D2.20 Distribution of usual daily intakes of dietary fiber, in grams, in comparison to adequate intake
(AI) levels, by age/sex group
Figure D2.1. Distribution of usual intakes of SoFAS (solid fats and added sugars) as percent of total Calories, by age/sex group
Bars show, from left to right, percent of Calories from SoFAS at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles.
2010 Dietary Guidelines Advisory Committee Report
Source: Selected Intakes as Ratios of Energy Intake, U.S. Population, 2001-04. Risk Factor Monitoring and Methods Branch Web site. Applied Research
Program. National Cancer Institute. http://riskfactor.cancer.gov/diet/usualintakes/energy/. Updated April 13, 2010. Accessed April 22, 2010.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.2. Comparison of mean usual daily intake of calories from solid fats and from added sugars, by age/sex group
Source: Usual Dietary Intakes: Food Intakes, U.S. Population, 2001-04. Risk Factor Monitoring and Methods Branch Web site. Applied Research Program.
National Cancer Institute. http://riskfactor.cancer.gov/diet/usualintakes/pop/. Updated April 13, 2010. Accessed April 22, 2010.
191
192
Figure D2.3. Distribution of usual daily intakes of SoFAS (solid fats and added sugars) in Calories, in comparison to maximum limits, by age/sex group
Bars show, from left to right, Calories from SoFAS at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows maximum recommended
limit for each age/sex group.
2010 Dietary Guidelines Advisory Committee Report
Source: Usual Dietary Intakes: Food Intakes, U.S. Population, 2001-04. Risk Factor Monitoring and Methods Branch Web site. Applied Research Program.
National Cancer Institute. http://riskfactor.cancer.gov/diet/usualintakes/pop/. Updated April 13, 2010. Accessed April 22, 2010.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.4. Distribution of usual daily intakes of sodium, in milligrams, in comparison to Adequate Intake (AI) levels and Tolerable Upper Intake Limits
(UL), by age/sex group
Bars show, from left to right, usual sodium intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Solid horizontal line shows AI and dotted
horizontal line shows UL for each age/sex group.
Source: Sodium (mg): Usual Intakes from Food and Water, 2003-2006, Compared to Adequate Intakes and Tolerable Upper Intake Levels. Food Surveys
Research Group, Agricultural Research Service, USDA. What We Eat in America, NHANES 2003-2006. Web site:
http://www.ars.usda.gov/Services/docs.htm?docid=18349 Updated April 1, 2010, Accessed April 22, 2010.
193
194
Figure D2.5. Distribution of usual daily intakes of saturated fatty acids as a percent of total Calories in comparison to maximum limit, by age/sex group
Bars show, from left to right, percent of Calories from saturated fatty acids at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows
maximum recommended limit.
2010 Dietary Guidelines Advisory Committee Report
Source: Usual Energy Intake from Saturated Fat. Risk Factor Monitoring and Methods Branch Web site. Applied Research Program. National Cancer
Institute. http://riskfactor.cancer.gov/diet/usualintakes/energy/t4.html. Updated April 13, 2010. Accessed April 22, 2010.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.6. Distribution of usual daily intakes of cholesterol, in milligrams, in comparison to maximum limit, by age/sex group
Bars show, from left to right, usual cholesterol intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows maximum
recommended limit.
Source: Cholesterol (mg): Usual Intakes from Food and Water, 2003-2006, Compared to the Recommendation of Below 300 mg. Food Surveys Research
Group, Agricultural Research Service, USDA. What We Eat in America, NHANES 2003-2006. Website:
http://www.ars.usda.gov/Services/docs.htm?docid=18349 Updated April 1, 2010, Accessed April 22, 2010.
195
196
Figure D2.7. Distribution of usual daily intakes of refined grains, in ounce equivalents, in comparison to maximum limits, by age/sex group
Bars show, from left to right, usual refined grains intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows maximum
recommended limit for each age/sex group.
2010 Dietary Guidelines Advisory Committee Report
Source: Usual Intake of Non-whole Grains. Risk Factor Monitoring and Methods Branch Web site. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/usualintakes/pop/t16.html. Updated April 13, 2010. Accessed April 22, 2010.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.8. Distribution of usual daily intakes of vegetables, in cup equivalents, in comparison to recommended intake levels, by age/sex group
Bars show, from left to right, usual vegetable intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows recommended intake
level for each age/sex group.
Source: Usual Intake of Total Vegetables, Including Cooked Dry Beans & Peas. Risk Factor Monitoring and Methods Branch Web site. Applied Research
Program. National Cancer Institute. http://riskfactor.cancer.gov/diet/usualintakes/pop/t14.html. Updated April 13, 2010. Accessed April 22, 2010.
197
198
Figure D2.9. Distribution of usual daily intakes of fruits, in cup equivalents, in comparison to recommended intake levels, by age/sex group
Bars show, from left to right, usual fruit intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows recommended intake level for
each age/sex group.
2010 Dietary Guidelines Advisory Committee Report
Source: Usual Intake of Total Fruit. Risk Factor Monitoring and Methods Branch Web site. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/usualintakes/pop/t3.html. Updated April 13, 2010. Accessed April 22, 2010.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.10. Distribution of usual daily intakes of whole grains, in ounce equivalents, in comparison to recommended intake levels, by age/sex group
Bars show, from left to right, usual whole grains intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows recommended intake
level for each age/sex group.
Source: Usual Intake of Whole Grains. Risk Factor Monitoring and Methods Branch Web site. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/usualintakes/pop/t15.html. Updated April 13, 2010. Accessed April 22, 2010.
199
200
Figure D2.11. Distribution of usual daily intakes of milk and milk products, in cup equivalents, in comparison to recommended intake levels, by age/sex
group
Bars show, from left to right, usual milk and milk product intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows
recommended intake level for each age/sex group.
2010 Dietary Guidelines Advisory Committee Report
Source: Usual Intake of Total Milk, Yogurt, & Cheese. Risk Factor Monitoring and Methods Branch Web site. Applied Research Program. National Cancer
Institute. http://riskfactor.cancer.gov/diet/usualintakes/pop/t32.html. Updated April 13, 2010. Accessed April 22, 2010.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.12. Distribution of usual daily intakes of meat, poultry, fish, eggs, soy products, nuts, and seeds, in ounce equivalents, in comparison to
recommended intake levels, by age/sex group
Bars show, from left to right, usual meat, poultry, fish, eggs, soy products, nuts, and seeds intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles.
Horizontal line shows recommended intake level for each age/sex group.
Source: Usual Intake of Total Meat, Fish, Poultry, Eggs, Soy Products, Nuts, & Seeds. Risk Factor Monitoring and Methods Branch Web site. Applied
Research Program. National Cancer Institute. http://riskfactor.cancer.gov/diet/usualintakes/pop/t28.html. Updated April 13, 2010. Accessed April 22, 2010.
201
202
Figure D2.13. Distribution of usual daily intakes of oils, in grams, in comparison to recommended intake levels, by age/sex group
Bars show, from left to right, usual oils intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows recommended intake level for
each age/sex group.
2010 Dietary Guidelines Advisory Committee Report
Source: Usual Intake of Oils. Risk Factor Monitoring and Methods Branch Web site. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/usualintakes/pop/t33.html. Updated April 13, 2010. Accessed April 22, 2010.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.14. Level of adequacy expressed as estimated percentages of Americans with nutrient intakes from food above their requirements (EARs)
Source: Moshfegh, Alanna; Goldman, Joseph; and Cleveland, Linda. 2005. What We Eat in America, NHANES 2001-2002: Usual Nutrient Intakes from
Food Compared to Dietary Reference Intakes. U.S. Department of Agriculture, Agricultural Research Service.
203
204
Figure D2.15. Level of adequacy expressed as estimated percentages of Americans with nutrient intakes from food above the Adequate Intake (AI) level.
2010 Dietary Guidelines Advisory Committee Report
Sources: Moshfegh, Alanna; Goldman, Joseph; and Cleveland, Linda. 2005. What We Eat in America, NHANES 2001-2002: Usual Nutrient Intakes from
Food Compared to Dietary Reference Intakes. U.S. Department of Agriculture, Agricultural Research Service.
Moshfegh, Alanna; Goldman, Joseph; Ahuja, Jaspreet; Rhodes, Donna; and LaComb, Randy. 2009. What We Eat in America, NHANES 2005-2006: Usual
Nutrient Intakes from Food and Water Compared to 1997 Dietary Reference Intakes for Vitamin D, Calcium, Phosphorus, and Magnesium. U.S.
Department of Agriculture, Agricultural Research Service.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.16. Distribution of usual daily intakes of vitamin D, in micrograms, in comparison to Adequate Intake (AI) levels, by age/sex group
Bars show, from left to right, usual vitamin D intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows the AI level for each
age/sex group.
Source: Moshfegh, Alanna; Goldman, Joseph; Ahuja, Jaspreet; Rhodes, Donna; and LaComb, Randy. 2009. What We Eat in America, NHANES 2005-
2006: Usual Nutrient Intakes from Food and Water Compared to 1997 Dietary Reference Intakes for Vitamin D,Calcium, Phosphorus, and Magnesium.
U.S. Department of Agriculture, Agricultural Research Service.
205
206
Figure D2.17. Distribution of usual daily intakes of calcium, in milligrams, in comparison to Adequate Intake (AI) levels, by age/sex group
Bars show, from left to right, usual calcium intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows AI level for each age/sex
group.
2010 Dietary Guidelines Advisory Committee Report
Source: Moshfegh, Alanna; Goldman, Joseph; Ahuja, Jaspreet; Rhodes, Donna; and LaComb, Randy. 2009. What We Eat in America, NHANES 2005-
2006: Usual Nutrient Intakes from Food and Water Compared to 1997 Dietary Reference Intakes for Vitamin D, Calcium, Phosphorus, and Magnesium.
U.S. Department of Agriculture, Agricultural Research Service.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.18. Relative proportions of fluid milk and cheese available for consumption over time
Graph shows loss adjusted availability of fluid milk and cheese in cup equivalents per capita per day.
Source: Economic Research Service (ERS), U.S. Department of Agriculture (USDA). Food Availability (Per Capita) Data System.
http://www.ers.usda.gov/Data/FoodConsumption.
207
208
Figure D2.19. Distribution of usual daily intakes of potassium, in milligrams, in comparison to Adequate Intake (AI) levels, by age/sex group
Bars show, from left to right, usual potassium intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows AI level for each
age/sex group.
2010 Dietary Guidelines Advisory Committee Report
Source: Moshfegh, Alanna; Goldman, Joseph; and Cleveland, Linda. 2005. What We Eat in America, NHANES 2001-2002: Usual Nutrient Intakes from
Food Compared to Dietary Reference Intakes. U.S. Department of Agriculture, Agricultural Research Service.
2010 Dietary Guidelines Advisory Committee Report
Figure D2.20. Distribution of usual daily intakes of dietary fiber, in grams, in comparison to Adequate Intake (AI) levels, by age/sex group
Bars show, from left to right, usual dietary fiber intakes at the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. Horizontal line shows AI level for each
age/sex group.
Source: Dietary Fiber (g): Usual Intakes from Food and Water, 2003-2006, Compared to Adequate Intakes. Food Surveys Research Group, Agricultural
Research Service, USDA. What We Eat in America, NHANES 2003-2006. Website: http://www.ars.usda.gov/Services/docs.htm?docid=18349 Updated
April 1, 2010, Accessed April 22, 2010.
209
Part D. Section 3: Fatty Acids and
Cholesterol
Contribution to Cumulative
Intake Contribution
Food Item % %
Source: Sources of Saturated Fat Among the U.S. Population, 2005-2006. Risk Factor Monitoring and Methods
Branch Website. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/foodsources Updated November 9, 2009. Accessed April 16, 2010.
Contribution to Cumulative
Intake Contribution
Food Item % %
Source: Sources of Oleic Acid Among the U.S. Population, 2005-2006. Risk Factor Monitoring and Methods
Branch Website. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/foodsources Updated November 9, 2009. Accessed April 16, 2010.
Polyunsaturated Fatty Acids—PUFA, which have Both linoleic acid (LA) (C18:2), an n-6 PUFA, and
two or more sites of unsaturation (double bonds), are a alpha-linolenic acid (ALA) (C18:3), an n-3 PUFA, are
heterogeneous class of fatty acids with chain length and essential fatty acids in the diet.
position of the first double bond affecting important
metabolic outcomes. The double bonds contribute to the The first double bond in n-6 (omega-6) PUFA is at the
lower melting point, making PUFA liquid at room sixth carbon from the methyl end. These PUFA are
temperature. Certain PUFA cannot be synthesized by largely derived from vegetable oils such as corn,
the human body, but are required in small amounts as sunflower, safflower, and soybean oils, but are present
substrates for biological pathways that generate in other foods as well. The foods that contribute the
metabolic products required for structural and most n-6 PUFA to the diets of Americans are listed in
functional purposes. These PUFA are referred to as Table D3.3.
essential fatty acids and must be attained from the diet.
Contribution to Cumulative
Intake Contribution
Food Item % %
Source: Sources of n-6 PUFA Among the U.S. Population, 2005-2006. Risk Factor Monitoring and Methods
Branch Website. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/foodsources Updated November 9, 2009. Accessed April 16, 2010.
The first double bond in n-3 (omega-3) PUFA is at the originate from marine phytoplankton and are found in
third carbon from the methyl end. n-3 PUFA are often seafood. Fish species vary considerably in their EPA
subcategorized based on their plant or marine source. and DHA content (Institute of Medicine [IOM] Seafood
ALA is an essential fatty acid from plant sources, such Choices, 2006). The cold water, oily fish (e.g., salmon,
as soybean oil, canola oil, flaxseed, and walnuts. The trout) have the highest levels of EPA and DHA. As
foods that contribute the most ALA to the diets of described below, these long-chain n-3 PUFA have
Americans are listed in Table D3.4. ALA is poorly distinct properties, with evidence that EPA and DHA
converted to long-chain n-3 PUFA, primarily decrease adult CVD risk, and DHA provides benefits
docosahexaenoic acid (DHA), so increased intake of for infant neurodevelopment (see Questions 7 and 9).
ALA does not substantially improve levels of DHA. The foods that contribute the most EPA and DHA to the
The long-chain n-3 PUFA, eicosapentaenoic acid (EPA) diets of Americans are listed in Table D3.5.
and DHA, which are frequently called “marine oils,”
Contribution to Cumulative
Intake Contribution
Food Item % %
Source: Sources of ALA Among the U.S. Population, 2005-2006. Risk Factor Monitoring and Methods Branch
Website. Applied Research Program. National Cancer Institute. http://riskfactor.cancer.gov/diet/foodsources
Updated November 9, 2009. Accessed April 16, 2010.
Table D3.5. Food sources of EPA and DHA by percent contribution to intake based on National Health and
Nutrition Examination Survey, 2005-2006
Contribution to Cumulative
Intake Contribution
% %
Food Item
Other fish and fish mixed dishes 53.1 53.1
Chicken and chicken mixed dishes 13.8 66.9
Shrimp and shrimp mixed dishes 12.9 79.8
Eggs and egg mixed dishes 5.8 85.6
Tuna and tuna mixed dishes 5.3 91.0
Source: Sources of EPA and DHA Among the U.S. Population, 2005-2006. Risk Factor Monitoring and Methods
Branch Website. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/foodsources Updated November 9, 2009. Accessed April 16, 2010.
Contribution to Cumulative
Intake Contribution
Food Item % %
Source: Sources of Cholesterol Among the U.S. Population, 2005-2006. Risk Factor Monitoring and Methods
Branch Website. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/foodsources Updated November 9, 2009. Accessed April 16, 2010.
Trends in Fat and Cholesterol Intakes in the Guidelines, and the restriction of dietary cholesterol to
American Diet in Relation to Previous U.S. less than 300 milligrams per day appeared in the 1995
Dietary Guidelines Recommendations Guidelines. Recommendations related to total fat
The relationship between dietary saturated fat, trans fat, generally restricted consumption to less than 30 percent
and cholesterol and deleterious health outcomes at the of energy. However, in the 2002 IOM report on
population level has long been recognized, with macronutrient requirements there was the adoption of
recommendations for modification of total fat, SFA, and an Acceptable Macronutrient Distribution Range
cholesterol dating back to the 1980 Guidelines (Table (AMDR) of fat intake of 20 to 35 percent of calories
D3.7). The recommendation for keeping trans fats as because there were no clear differences in health
low as possible appeared in the 2005 DGA. As outcomes in populations consuming dietary fat within
evidence accumulated, the restriction of SFA to less this range. Thus, the 2005 U.S. Dietary Guidelines
than 10 percent of energy first appeared in the 1990 adopted this range of percent energy from total fat.
Note: 130-35% for ages 2-3 years; 25-35% for ages 4-18 years.
Source: Dietary Guidelines for Americans, 1980-2005.
Despite the consistency of advice, a comparison of the an increase in total carbohydrate intake. Given the onset
recommendations to trends in the American diet over of a national epidemic of obesity over this time period,
the same period of time shows no reduction in the it is unlikely that total fat alone was an important
intake of total fat, SFA, or cholesterol. Tables D3.8 and contributory factor.
D3.9 show USDA estimates from large samples of the
U.S. population on consumption of fats and cholesterol, Dietary cholesterol intake has been stable over time,
beginning with the Nationwide Food Consumption reaching and exceeding the Guideline target of less than
Survey in 1977-78 through the most recent National 300 milligrams per day for men. It should be noted that
Health and Nutrition Examination Surveys (NHANES) cholesterol intake of men and women varied greatly,
in 2005-2006. with average male consumption of cholesterol
exceeding recommended levels and virtually unchanged
Sampling methods, data collection methods, dietary at 350 milligrams per day since 2000, in contrast to
survey instruments, and food composition databases can levels of 240 milligrams per day for women over this
vary from one survey to the next (Guenther, 1994). period.
Especially problematic is detecting changes in
macronutrient distributions, that is, the percentages of Table D3.9 shows the percent of calories from fat as
calories that come from carbohydrate, fat, protein, and unchanged since 1990, with mean SFA at 11 to 12
alcohol. Nonetheless, trends in the estimates can be percent energy (above recommended 10%) and
informative about U.S. dietary intakes over time. Table unchanged for the past 15 years. Similarly, levels of
D3.8 shows a modest increase in total fat intake MUFA (12%) and PUFA (7%) have been stable over
reported from the early 1990s, yet there was a decrease this time. Sex-specific data show no major differences
in the percent of energy from fat over the three decades in SFA, MUFA, and PUFA intake between men and
covered in the table. Over this same time period there women (for detailed tables, see
was an increase in total energy intake, driven mostly by http://www.ars.usda.gov/ba/bhnrc/fsrg).
Total Fat (g) 84.6 (0.83) 71.8 74.4 (0.7) 81.0 ( 0.54) 82.7 (0.71) 81.9 (1.35)
SFA (g) NA5 25.7 25.6 (0.3) 26.7 (0.25) 27.7 (0.24) 27.8 (0.49)
PUFA (g) NA 13.8 14.6 (0.2) 16.1 (0.13) 17.2 (0.25) 17.0 (0.31)
MUFA (g) NA 26.7 28.6 (0.3) 30.1 (0.22) 31.0 (0.29) 30.1 (0.48)
Cholesterol
(mg) NA 270 256 (3) 273 (2.7) 273 (4.6) 278 (3.3)
Data sources: Published USDA, ARS Reports What We Eat In America-National Health and Nutrition
Examination Surveys (NHANES), Continuing Surveys of Food Intakes by Individuals (CSFII), and Nationwide
Food Consumption Survey (NFCS), 1 day data. 1Includes all persons from birth.
2
Includes all persons from birth; excludes breast-fed children.
3
Includes persons 2 years and over; excludes breast-fed children.
4
SE= Standard error.
5
Unpublished data from Food Surveys Research Group, ARS, USDA.
This table is available at: http://www.ars.usda.gov/ba/bhnrc/fsrg.
Table D3.9. Mean intake of fats as percent of energy, USDA national survey of all persons in U.S., 1977-2006
Total Fat (%) 40.1 (0.16) 34.4 32.8 (0.1) 33 ( 0.3) 33.4 (0.25) 33.6 (0.19)
SFA (%) NA5 12.3 11.3 (0.1) NA 11.2 (0.11) 11.4 (0.09)
PUFA (%) NA 6.6 6.4 (0.01) NA 7.0 (0.09) 7.0 (0.08)
MUFA (%) NA 12.7 12.5 (0.1) NA 12.5 (0.09) 12.3 (0.07)
Energy (kcal) 1854 (12.9) 1839 2002 (16) 2178 (16.1) 2195 (15.6) 2157 (29.0)
Data sources: Published USDA, ARS Reports What We Eat In America-National Health and Nutrition
Examination Surveys (NHANES), Continuing Surveys of Food Intakes by Individuals (CSFII), and Nationwide
Food Consumption Survey (NFCS), 1 day data. 1Includes all persons from birth.
2
Includes all persons from birth; excludes breast-fed children.
3
Includes persons 2 years and over; excludes breast-fed children.
4
SE= Standard error.
5
Unpublished data from Food Surveys Research Group, ARS, USDA.
This table is available at: http://www.ars.usda.gov/ba/bhnrc/fsrg.
Note: Estimated changes (percent with 95% confidence intervals) in risk of coronary heart disease (CHD)
associated with isocaloric dietary substitutions. Adjusted for coronary risk factors and total energy intake.
Sat=SFA, Carbo=carbohydrate, Mono=MUFA, Poly=PUFA, Trans=trans fatty acids, Sat-Carbo=substitute
carbohydrates for SFA.
Source: Hu et al., 2001. J Amer Col Nutr 20:5-19. Used with permission, the American College of Nutrition.
The NEL review of the literature published since 2000 or PUFA replacement. The Hu review concluded that
on the association of dietary SFA and T2D identified 12 higher intake of PUFA (and potentially long-chain n-3
studies conducted in the U.S., Europe, Canada, and PUFA) were beneficial; whereas, higher intakes of SFA
China that examined the effect of dietary SFA on altered and trans fatty acids impaired glucose metabolism and
glucose metabolism, markers of insulin resistance, and increased insulin resistance. Four randomized controlled
T2D risk. Two were methodologically strong review trials showed MUFA-enriched diets improved glucose
articles including one which evaluated 15 trials, nine uptake and insulin sensitivity: Lopez et al. (2008) showed
trials in 358 non-diabetic participants and six trials in 93 that increased dietary MUFA improved insulin sensitivity
participants with T2D (Galgani, 2008), and one and promoted pancreatic beta cell function; Paniagua et
reviewing 14 prospective cohort and five cross-sectional al. (2007) showed a diet high in MUFA improved blood
studies (Hu, 2001). Nine were randomized clinical trials glucose and Homeostatic Model Assessment (HOMA) –
ranging in size from 11 to 522 participants, including six Insulin Resistance (IR) (HOMA-IR) scores over both
methodologically strong studies (Han, 2001; Lindstrom, SFA and carbohydrates in insulin resistant individuals;
2006a, 2006b; Lopez, 2008; Perez-Jimenez, 2001; and Perez-Jinenez et al. (2001) showed a MUFA-enriched
Vesby, 2001) and three methodologically neutral studies diet improved glucose uptake in peripheral tissues and
(Paniagua, 2007; Shah, 2007; and St-Onge, 2003). The insulin sensitivity; and Vesby et al. (2001) showed SFA
one prospective cohort study with 84,204 participants decreased, whereas MUFA did not change, insulin
from the Nurses’ Health Study was methodologically sensitivity. Three studies provided evidence that
strong (Salmeron, 2001). The Galgani review of decreased SFA intake may decrease risk of T2D; two
randomized controlled trials indicated that three studies large randomized controlled trials (Lindstrom, 2006a,
provided evidence that MUFA or PUFA replacement of 2006b) and one prospective cohort study (Salmeron,
SFA improved insulin sensitivity, including one high- 2001). One randomized controlled trial by Shah et al.
powered study that indicated a 10 percent decrease in (2007) showed that insulin responsiveness was improved
insulin sensitivity on high SFA, versus high MUFA, with either MUFA- or PUFA-enriched diets in
diets. However, nine studies showed no effect of MUFA individuals with T2D.
Ten studies published since 2004 were reviewed to Four prospective cohort studies showed that higher
determine the effect of PUFA on health outcomes. PUFA intake was associated with lower risk of CHD
These studies were conducted in the U.S., Canada, and total mortality (Hodge, 2007; Laaksonen, 2005;
228 2010 Dietary Guidelines Advisory Committee Report
Mozaffarian, 2005; Oh, 2005). A pooled analysis of 11 Question 5: What Are the Effects of Dietary
prospective cohort studies showed that risk of coronary Stearic Acid on LDL Cholesterol?
events and coronary death was lowest with 5 percent
energy substitution of SFA with PUFA>MUFA>
Conclusion
carbohydrate (Jakobsen, 2009).
Moderate evidence from a systematic review indicates
The NEL review for this question included a
that when stearic acid is substituted for other SFA or
prospective study with nested case-cohort analyses on
trans fatty acids, plasma LDL cholesterol levels are
the effects of a dietary PUFA on T2D risk. The authors
decreased; when substituted for carbohydrates, LDL
reported an inverse association between dietary LA and
cholesterol levels are unchanged; and when substituted
T2D, compared to a positive association for stearic acid
for MUFA or PUFA, LDL cholesterol levels are
and total saturated fatty acids (Hodge, 2007). In
increased. Therefore, the impact of stearic acid
addition, the review for this question is supplemented
replacement of other energy sources is variable
by evidence from question 1 on SFA and T2D risk that
regarding LDL cholesterol, and the potential impact of
reviewed the literature from 2000. This, and the fact
changes in stearic acid intake on cardiovascular disease
that blood lipids are intermediate markers of risk for
risk remains unclear.
both CVD and T2D, further supports the association
between PUFA intake and decreased T2D risk.
Implications
Contribution to Cumulative
Intake Contribution
Food Item % %
Source: Sources of Saturated Fat, Stearic Acid, and Cholesterol Raising Fat Among the U.S. Population, 2005-
2006. Risk Factor Monitoring and Methods Branch Website. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/foodsources Updated November 9, 2009. Accessed April 16, 2010.
FLAPS
Food 2004a 2006-2007a
Cakes
Number of samples n = 10 n = 11
Mean TFA levels g/100 g (SE)b 2.85 (1.03) 0.98 (0.47)
Biscuits
Number of samples n=5 n=5
Mean TFA levels g/100 g (SE) 4.40 (0.25) 5.41 (0.70)d
Margarines and Spreads
Number of samples n=7 n=9
Mean TFA levels g/100 g (SE) 12.24 (1.06) 4.37 (2.36)c
Cookies
Number of samples n = 12 n = 14
Mean TFA levels g/100 g (SE) 4.5 (0.62) 1.9 (0.84)
Crackers
Number of samples n = 11 n = 17
Mean TFA levels g/100 g (SE) 5.20 (0.51) 0.71 (0.39)c
Potato Chips
Number of samples n=8 n = 10
Mean TFA levels g/100 g (SE) 0.45 (0.45) 0.0 (0) NSe
Tortilla Chips
Number of samples n=8 n=9
Mean TFA levels g/100 g (SE) 1.76 (0.6) 0.0 (0)c
Frozen Potato Products
Number of samples n=6 n=7
Mean TFA levels g/100 g (SE) 1.97 (0.48) 0.74 (0.24)c
Cereal and Granola
Number of samples n=8 n=9
Mean TFA levels g/100 g (SE) 1.70 (0.8) 0.0 (0)c
Tortillas
Number of samples n=6 n=7
Mean TFA levels g/100 g (SE) 0.76 (0.39) 0.22 (0.22)f
a
Trans fat levels for 2004 are from Satchithanandam et al. 2004a, and were analyzed from food products. The
levels from FLAPS are values from food labels.
b
SE = Standard error.
c
Significant decrease at p< 0.05.
d
Significant increase at p< 0.05.
e
NS = Not significant.
f
Mean is NS, but median is significant decrease at p< 0.05.
Source: Mossoba et al. (2009). J. of AOAC International, 92 (5), 1284-1300. Used with permission, AOAC
International.
Figure D3.2a. Relationship between intake of fish or fish oil and relative risks of CHD death in prospective cohort
studies and randomized clinical trials
Note: Absolute coronary heart disease (CHD) mortality rates vary more than 100-fold across different populations
(due to differences in age, prior CHD, and other risk factors), but the relative effects of intake of fish or fish oil are
consistent, whether for primary or secondary prevention, for cohort studies or randomized trials, or for comparing
populations at higher or lower absolute risk. Compared with little or no fish intake, modest consumption (~250-500
mg/d eicosapentaenoic acid [EPA] plus docosahexaenoic acid [DHA]) is associated with lower risk of CHD death,
while at higher levels of intake, rates of CHD death are already low and are not substantially further reduced by
greater intake.
Source: Mozaffarian and Rimm, JAMA 2006;296:1885-1899. Used with permission, American Medical
Association, Chicago, IL.
Note: The relationship between intake of fish or fish oil and relative risk of coronary heart disease (CHD) death in
a pooled analysis of the prospective studies and randomized trials show that fatty fish consumption at about two
servings per week (about 250 mg EPA+DHA/d) decreases risk of CVD events. Intakes above this level appeared to
result in no significant additional decreases in risk CVD events.
Source: Mozaffarian and Rimm, JAMA 2006;296:1885-1899. Used with permission, American Medical
Association, Chicago, IL.
Evidence from prospective cohort studies was incidence of T2D (Kaushik, 2009). This is the only
substantial and focused on primary CVD prevention in observational evidence regarding risk of T2D, but the
healthy adults. Ten prospective cohort studies examined randomized controlled trial on fatty vs. lean fish by
the association between fatty fish and CVD outcomes Lankinen et al. (2009) examined markers of insulin
and found a positive association between seafood and resistance and can be added to the evidence regarding
seafood-derived n-3 fatty acid consumption and T2D.
decreased CVD incidence/risk (Levitan, 2009;
Virtanen, 2008; Yamagishi, 2008; Streppel, 2008; The 2005 DGA indicated there was sufficient evidence
Turunen, 2008; Järvinen, 2006; Iso, 2006; Mozaffarian, to suggest that n-3 PUFA consumption provided
2005; Lemaitre, 2003; Albert, 2002). Three prospective protection for persons with existing CVD. For the
cohort studies examined fish and fish-derived fatty acid current 2010 review, conclusions related to persons
consumption and atrial fibrillation and found either no with CVD relied on the ADA evidence-based review
association between fish n-3 fatty acid intake and referred to above, as a NEL search did not yield
reduced risk of atrial fibrillation (Brouwer, 2006; Frost additional studies that met the inclusion criteria. Four
and Vestergaard, 2005) or a inverse association between studies were reviewed by the ADA that addressed the
consumption of tuna or other broiled or baked fish (but relationship between consumption of fish-derived n-3
not fried fish) and incidence of atrial fibrillation fatty acids and risk of CVD events in persons with
(Mozaffarian, 2004). Virtanen et al. (2009) reported n-3 CVD. One was a methodologically strong meta-analysis
fatty acids (especially DHA) to be effective in reducing covering 11 randomized controlled trials (Bucher,
atrial fibrillation in men. One prospective cohort study 2002) and three studies were methodologically strong
examined the association between fatty fish intake and prospective cohort studies conducted in the U.S. with
intermediate markers of CVD risk and found moderate cohort size ranging from 228 to 415 participants
intake of fatty fish was inversely associated with serum (Erkkila, 2003, 2004, 2006). All of these articles
lipids and blood pressure (Panagiotakos, 2007). One provided evidence of the protective effects of
prospective cohort study assessed fish n-3 FA intake on consuming long-chain n-3 fatty acids on risk of CVD
CVD and CHD mortality and found no independent events in persons with known CVD. Erkkila et al.
association with CHD or stroke mortality (Folsom and (2003) found blood levels of ALA, EPA and DHA were
Demissie, 2005). One prospective cohort study found a associated with a reduction in risk of all-cause
positive association between fish intake and increased mortality, but associations with combined fatal and non-
Figure D3.3. Estimated EPA/DHA content and methyl mercury content of 3 oz. portions of seafood
• Scenario 1: 4 ounces per week of seafood high in n- Evidence is currently insufficient to make a formal
3 fatty acids. guideline to increase n-3 intake from plant sources
• Scenario 2: 8 ounces per week of seafood, including without additional evidence from randomized clinical
seafood both low and high in n-3 fatty acids in trials and prospective observational studies among
proportions to those currently consumed by participants with a broad range of n-3 intake. As
Americans. relatively little ALA converts to EPA and DHA,
• Scenario 3: 12 ounces per week of seafood low in n- evidence is lacking that plant-derived n-3 fatty acids
3 fatty acids. alone will provide the same cardioprotective effects as
EPA and DHA consumed at the recommended level
One goal of this modeling analysis was to quantify discussed above. This increases the need for efficient
seafood consumption recommendations for the general and ecologically friendly strategies to allow for greater
public—something not done previously because of a lack consumption of seafood n-3 fatty acids, unless plant-
of strong evidence on the role of seafood consumption in derived sources of EPA or DHA can be developed.
population health. The three scenarios were modeled to
determine the amounts of foods to include in the Meat Review of the Evidence
and Beans group so as to meet nutrient recommendations
without altering the calorie level of the patterns. (See the The NEL conducted an evidence review to determine the
Seafoods report, online Appendix E3.10, available at relationship between consuming plant-derived n-3 PUFA
www.dietarygsuidelines.gov). The analysis showed that and the risk of CVD events. This review relied upon an
the amounts of seafood in the base USDA Food Patterns evidence-based review conducted by the ADA on the
could be increased to 8 ounces per week without any relationship between n-3 fatty acids and CVD, covering
negative impact on nutrient adequacy. The total amounts the literature from 2004 to 2007 (ADA, 2008). Overall,
of EPA and DHA for the three seafood scenarios five studies were reviewed by ADA that addressed this
modeled were 292 milligrams per day for 4 ounces of question. These included two methodologically strong
high n-3 seafood (Scenario 1); 253 milligrams per day for case control studies (Lemaitre, 2003, Rastogi, 2004), and
8 ounces of the current mixture of low and high n-3 three prospective cohort studies (two were
seafood (Scenario 2); and 201 milligrams per day for 12 methodologically strong [Albert, 2005; Mozaffarian,
ounces of low n-3 seafood (Scenario 3). This analysis did 2005] and one was methodologically neutral [Folsom and
not incorporate the methyl mercury content of fish Demissie, 2005]). In addition, the NEL reviewed three
included in the patterns; however, the amounts of methyl studies since 2008, including one methodologically
mercury found in the seafood varieties used in the strong case-control study conducted in the U.S.
patterns are zero to minimal (see Part D.8: Food Safety (Lemaitre, 2009), one methodologically strong
and Technology for a detailed discussion of the risks and prospective cohort study covering 2,682 men in Finland
benefits of seafood consumption.) (Virtanen, 2009), and one methodologically strong
systematic review of 14 randomized controlled trials, 25
prospective cohort studies, and seven case-control studies
Question 8: What Is the Relationship (Wang, 2006).
Between Consumption of Plant n-3 Fatty
Lemaitre et al. (2009) reported that an increase in red
Acids and Risk of CVD?
blood cell membrane ALA corresponding to 1 standard
deviation was associated with 32 percent higher risk of
Conclusion
sudden cardiac arrest (odds ratio = 1.32, 95% confidence
interval: 1.07 - 1.63) after adjusting for confounding
ALA intake of 0.6 to 1.2 percent of total calories will
variables. Virtanen et al. (2009) found that red blood cell
meet current recommendations and may lower CVD
membrane ALA and intermediate chain n-3 PUFA did
238 2010 Dietary Guidelines Advisory Committee Report
not have any association with atrial fibrillation. Wang et with regard to exposure of the fetus and infant to heavy
al. (2006) conclude from their systematic review that metals during the most sensitive period of
increased intake of n-3 fatty acids from fish or fish-oil neurodevelopment. The current evidence, however,
supplements, but not of ALA, reduces the rates of all- favors consumption of fish for pregnant and lactating
cause mortality, cardiac and sudden death. women, particularly in the context of women making
educated choices to consume seafood that is high in n-3
Two studies of persons with CVD were part of the 2008 fatty acids and low in environmental pollutants. The
ADA review. One methodologically neutral randomized benefits of fish consumption are maximized with fatty
controlled trial (Baylin, 2003) and one methodologically fish high in EPA and DHA but low in methyl mercury.
neutral case control study (De Lorgeril, 1999) found a These conclusions are consistent with those found in the
diet high in plant-derived n-3 fatty acids protective discussion of seafood benefits and risks in Part D.8:
against recurrence of myocardial infarction. Both studies Food Safety and Technology. The previously described
used biomarkers. Baylin et al. (2003) found an inverse modeling analysis of seafood identified scenarios of
relationship between adipose tissue ALA and risk of type and quantity of fish that provide 250 milligrams
nonfatal acute myocardial infarction. The greatest per day of EPA + DHA.
protection was found in those individuals who also had
low total trans fatty acids in adipose tissue. Study Review of the Evidence
participants in the top quintiles of adipose tissue ALA
(0.72% of fatty acids) had a lower risk of myocardial Since the 2005 DGAC Report, a number of
infarction than those in the lowest quintile (0.35% of fatty organizations have rendered expert opinions on the
acids). The difference in adipose tissue ALA corresponds subject of n-3 PUFA supplements during pregnancy and
to approximately 0.3 gram per day of dietary intake. De lactation, including a Cochrane Database Systematic
Lorgeril et al. (1999) found a decreased rate of cardiac Review (Makrides, 2009), ADA Evidence Analysis
death and nonfatal myocardial infarction in those Library review (Kaiser, 2008), and the European Union
following a Mediterranean diet versus a Western diet Perinatal Lipid Intake Working Group assessment
(1.24 vs. 4.07 per hundred patients per year). The (Koletzko, 2007). The 2010 DGAC reviewed these
experimental group had a significantly lower intake of reports as well as a background paper by Brenna and
total lipids and SFA, and increased intake of oleic acid, Lapillonne (2009), which provided context on the
LA and ALA. The plasma concentration of ALA and effects of supplemental long-chain n-3 PUFA during
DHA tended to be inversely associated with recurrence of pregnancy and lactation. This background paper
myocardial infarction. covered 23 randomized controlled trials on
supplemental DHA at physiological and pharmacologic
levels, and highlighted the benefits of maternal DHA
Question 9: What Are the Effects of consumption on infant/child intelligence scores, among
Maternal Dietary Intake of n-3 Fatty Acids other positive outcomes.
From Seafood on Breast Milk Composition
and Health Outcomes in Infants? For the purposes of this review, the DGAC excluded
studies with long chain n-3 PUFA given in
“supplement” form (e.g., fish oil, cod liver oil, fish oil
Conclusion capsules). This removed most randomized clinical trials
during pregnancy and lactation from consideration.
Moderate evidence indicates that increased maternal Also not included were breast feeding versus infant
dietary intake of long chain n-3 PUFA, in particular formula feeding studies (before DHA addition), and
docosahexaenoic acid (DHA), from at least two studies of pre-term versus full-term infants.
servings of seafood per week during pregnancy and
lactation is associated with increased DHA levels in Overall, nine articles were reviewed since 2000 to
breast milk and improved infant health outcomes, such determine the effect of n-3 fatty acids on breast milk
as visual acuity and cognitive development. composition and infant health outcomes. There were
seven methodologically strong prospective cohort
Implications studies conducted in the U.S., Europe, and Canada in
healthy women with low-risk pregnancies, healthy
There has been controversy and concern over the mother/infant pairs, or healthy children up to 8 years in
consumption of fish during pregnancy and lactation cohort sizes ranging from 211 to 50,276 participants
2010 Dietary Guidelines Advisory Committee Report 239
(Drouillet, 2009; Hibbeln, 2007; Innis, 2001; Oken, One prospective cohort study showed that low maternal
2005, 2008a, 2008b; Olsen, 2006). In addition, the fish intake was associated with increased risk of
evidence included one methodologically strong children being in the lowest quartile for verbal
randomized controlled trial of 350 mother/infant pairs intelligence quotient (IQ), and increased risk of
in the U.S. (Colombo, 2004) and one methodologically suboptimal outcomes for fine motor skills and
strong meta-analysis of 65 international studies communication/social development scores (Hibbeln,
(Brenna, 2007). 2007). Hibbeln et al. (2007) estimated incidence of
suboptimal verbal IQ in children eight years of age as a
The prospective cohort studies focused on maternal function of maternal seafood consumption during
DHA consumption during pregnancy and, overall, the pregnancy in 11,875 women. The study was conducted
evidence for benefits from maternal DHA consumption in British women and analysis controlled for 28
during pregnancy was strong. Because randomized potentially confounding variables, such as birth weight,
controlled trials with DHA supplements were excluded, alcohol use during pregnancy, and smoking. Children of
there were fewer studies on maternal DHA intake mothers reporting the highest seafood consumption,
during lactation. However, one study examined both estimated using a food frequency questionnaire and
pregnancy and duration of breastfeeding with improved estimated n-3 intake, were significantly less likely to
infant cognitive outcomes (Oken, 2008b) and another score in the lowest quartile for verbal IQ compared to
measured breastfeeding with associated DHA women who reported no seafood consumption during
biomarkers in infants with improved cognitive pregnancy (Figure D3.4).
outcomes (Innis, 2001).
Figure D3.4. Effect on children’s verbal IQ of maternal seafood consumption during pregnancy
p
36
34
32
low verbal IQ, WISC-III UK , 8y
Percentage of children with
30
28
26
24
22
20
18
0 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.45 0.50 0.5
Note: Prevalence of children with low verbal IQ according to mothers’ consumption of n-3 fatty acids from
seafood. Estimated maternal consumption of long chain n-3 fatty acids is expressed as proportion of total calories
(en %). Maternal seafood consumption was grouped into six categories: mothers with no reported consumption
plus five equal groups of the remaining population. Means and 95% CI for proportion of children in the lowest
quartile for verbal IQ.
Source: Hibbeln et al., 2007 Lancet. Feb 17;369(9561):578-85. Used with permission from Elsevier, publisher of
The Lancet, Oxford, UK.
Table D3.12. Estimated mean daily intakes of tree nuts and peanuts1 by adults 20 years and over, U.S. 2005-2006
Figure D3.5. Frequency of nut consumption and coronary heart disease risk reduction in a dose-response manner
Evidence analysis was also conducted on specific types improved total cholesterol, LDL cholesterol and the
of nuts including almonds, walnuts, macadamia nuts, LDL:HDL cholesterol ratio (Banal and Hu, 2009;
and pistachios. Overall, studies showed that almond Rajaram, 2009; Olmedilla-Alonso, 2008). Olmedilla-
consumption improved total cholesterol (Phung, 2009; Alonso et al. (2008) found that meat products with
Wein, 2003), decreased LDL cholesterol and the walnuts decreased body weight. However, one
LDL:HDL cholesterol ratio (Wein, 2003), or was randomized crossover trial found that a walnut
neutral regarding LDL and LDL:HDL cholesterol ratio supplemented diet (12% energy from walnuts) provided
(Phung, 2009; Kurlandsky and Stote, 2006). Regarding more calories per day and increased body weight and
walnuts, studies showed that walnut consumption BMI (Sabate, 2005). Energy-adjusted results were not
10. Elucidate further the role of polyphenolic Appel LJ, Sacks FM, Carey VJ, Obarzanek E, Swain
compounds as major active ingredients in the health JF, Miller ER 3rd, Conlin PR, Erlinger TP, Rosner BA,
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Quick CJ, Gillen LJ, Charlton KE. Long-term effects of Serum long-chain n-3 polyunsaturated fatty acids and
increased dietary polyunsaturated fat from walnuts on risk of hospital diagnosis of atrial fibrillation in men.
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Effects of low habitual cocoa intake on blood pressure from fish or fish-oil supplements, but not alpha-
and bioactive nitric oxide: a randomized controlled trial. linolenic acid, benefit cardiovascular disease outcomes
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systematic review. Am J Clin Nutr. 2006 Jul;84(1):5-17.
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and linoleic acids have comparable effects on markers Weggemans RM, Zock PL, Katan MB. Dietary
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fats high in palmitic acid or high in myristic and lauric Almonds vs complex carbohydrates in a weight
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As calorie intake decreases, however, it is essential to very severe, careful food selection is essential. If high-
increase the percentage of calories from protein so as quality protein sources cannot be consumed in the
to consume the RDA for protein. Thus, the wide diet, other options for high-quality protein sources
recommended range of 10 to 35 percent of total must be explored (see Part D. Section 8. Food Safety
calories coming from protein for adults is based on the and Technology).
large range of calories consumed, which depends on
physical activity and body size. For example, low- Food Sources of Proteins
calorie, protein-sparing, modified fast diets contain Diets adequate in protein can be designed in many
mostly protein as it is necessary to get the RDA for ways and are reflected in eating patterns around the
protein. In contrast, extremely active people, such as world. Since the adults (19 years and older) RDA for
endurance athletes, consume high-calorie diets and protein is 0.8 gram/kilogram body weight, a 150-
their RDA for protein does not change. A lower pound adult would require 54 grams of high quality
percentage of energy from protein is therefore protein daily. Three ounces (the recommended serving
appropriate for them and these additional calories size) of lean meat or poultry contain about 25 grams of
would typically come from carbohydrates. protein, while 1 cup of milk or yogurt contains 8
grams of protein. Cereals, grains, nuts, and vegetables
The data are conflicting on the potential for high- contain about 2 grams of protein per serving. When
protein diets to produce gastrointestinal effects, protein needs are high, as during growth and
change nitrogen balance, alter mineral absorption, or development, consumption of animal products will
affect chronic diseases, such as osteoporosis or renal provide both greater quantity and quality of protein
stones. than plant products. Plant products can be combined
to improve protein quality, but the number of calories
Food allergies exist for protein foods including milk, that must be consumed to get adequate intakes must be
eggs, peanuts, tree nuts, soy, fish, and shellfish (DRI, considered.
2002). Gluten-free diets are recommended for those
with gluten intolerance, which limits intake of wheat Thus, proteins are the most important macronutrient in
and certain other grain products. Lactose intolerance, the diet because they provide both essential amino
although not medically diagnosed, can limit acids and are a source of energy. They are particularly
consumption of dairy products. Care must be taken to important during growth and development.
determine the cause of the intolerance to a food
product (e.g., is the individual sensitive to the sugar in
milk or the protein in milk) and make appropriate
dietary changes. Often, children allergic to one protein
source develop allergies to other protein sources.
Many protein sources, including milk, wheat, or soy,
must be avoided as a result. As protein allergies can be
1. What is the relationship between the intake of Recent literature has begun to examine the relationship
animal protein products and selected health between protein and health outcomes. The Committee
outcomes? addressed this topic in three separate questions: animal
2. What is the relationship between vegetable protein protein products, vegetable protein, and vegetarian
and/or soy protein and selected health outcomes? versus animal-based diets. Question 1 considers animal
3. How do the health outcomes of a vegetarian diet protein products, including red meat, processed meat,
compare to that of a diet which customarily and poultry. Although milk and milk products are
includes animal products? sources of animal protein, their relationship to selected
health outcomes is addressed separately in Question 4.
PROTEIN-RELATED FOOD GROUPS AND Seafood, another source of animal protein, is discussed
HEALTH OUTCOMES in detail in Part D. Section 3. Fatty Acids and
Cholesterol and in Part D. Section 8. Food Safety and
4. What is the relationship between the intake of milk Technology. The health outcomes considered in
and milk products and selected health outcomes? Question 1 were type 2 diabetes (T2D), cardiovascular
5. What is the relationship between the intake of disease (CVD), hypertension, body weight, and cancer.
cooked dry beans and peas and selected health For many sections of this Report, the relationship
outcomes? between dietary intakes and cancer outcomes are
discussed using conclusions from the World Cancer
Research Fund/American Institute for Cancer Research
report (WCRF/AICR, 2007). The WCRF/AICR report
Methodology
examined the relationship between meat and numerous
types of cancer in a thorough review of the literature of
For the first time, the 2010 DGAC included a chapter various study designs with humans and animals.
focusing solely on the relationship between protein and However, some controversy has surrounded the
health. Most of the questions addressed here cover new WCRF/AICR conclusions for red meat and colorectal
topics. The Committee reviewed evidence from January cancer. Thus, the Committee decided to conduct a
2000 to 2009. Because the 2005 DGAC reviewed the review parallel to other reviews in this Report and
topic of milk and milk products, the 2010 Committee included only prospective cohort studies with humans
agreed with those recommendations and provided here published since 2000. In addition to colorectal cancer,
only an updated review of evidence from June 2004 to prostate and breast cancers were reviewed.
2009.
Question 2 concerns the relationship of vegetable
All of the questions addressed in this section were protein and selected health outcomes and was
answered using a Nutrition Evidence Library (NEL) conducted to complement the Committee’s review of
evidence-based systematic review. A description of the animal protein products. Because much of the research
NEL evidence-based review process can be found in on vegetable protein has focused on soy protein, soy
Part C: Methodology. For each question considered in protein was included in the search as a separate term.
this section, the following general criteria applied. With However, articles examining soy foods, rather than soy
minor exceptions noted below, all study designs were protein specifically, were considered under the
originally included in the searches, but cross-sectional Committee’s review of cooked dry beans and peas
studies were later excluded from the review if there was (Question 5). The Committee considered a variety of
sufficient evidence from studies with stronger designs. health outcomes in the vegetable protein search, but
Also, original research articles included in systematic available evidence was sufficient to permit only a
reviews or meta-analyses were not included as review of chronic disease, blood pressure, blood lipids,
individual articles in the review, so as not to count the and body weight.
study twice. Finally, the Committee excluded studies
that considered only participants diagnosed with Question 3 considers research that directly compares
chronic disease, hyperlipidemia, hypertension, and health outcomes among individuals consuming a diet
2010 Dietary Guidelines Advisory Committee Report 261
which customarily includes animal products to those positive evidence for processed meats and CHD.
consuming a vegetarian, including vegan, diet. The Moderate evidence found no clear association between
Committee recognized that additional research on this intake of animal protein products and blood pressure in
topic was published before 2000, but felt research prospective cohort studies. Limited inconsistent
published since 2000 represented current plant-based evidence from prospective cohort studies suggests that
dietary patterns and provided sufficient context to intake of animal protein products, mainly processed
discuss the relationship between these dietary patterns meat, may have a link to T2D. Insufficient evidence is
and health. For an in-depth discussion of the available to link animal protein intake and body weight.
relationship between various dietary patterns and health Moderate evidence reports inconsistent positive
outcomes, see Part D. Section 2: The Total Diet: associations between colorectal cancer and the intake of
Combining Nutrients, Consuming Food. certain animal protein products, mainly red and
processed meat. Limited evidence shows that animal
As noted, Questions 4 and 5 address specific food protein products are associated with prostate cancer
groups. Milk and milk products and cooked dry beans incidence. Limited evidence from cohort studies shows
and peas are significant protein sources in the American there is no association between the intake of animal
diet, and they also are important sources of other protein products and overall breast cancer risk.
nutrients. Additional information about other nutrient However in subgroups of breast cancer patients, limited
contributions of these food groups can be found in Part evidence suggested a relationship between the intake of
D. Section 2: Nutrient Adequacy. It should be noted that animal protein products and risk of developing breast
the Committee considered only studies that directly cancer.
assessed the relationship between food group intake and
health; studies examining dietary patterns that were Implications
high in a particular food group were considered as
dietary patterns, not under reviews for the individual Americans may choose animal products as part of their
food groups. The review of milk and milk products diet based on the body of evidence showing a general
considered bone health, cardiovascular outcomes, lack of relationship between animal protein
metabolic syndrome, T2D, and body weight. All the consumption and selected health outcomes. However,
evidence reviews covered children and adults, except attention should be given to quantity and preparation, as
for body weight, which included only adults. The some forms of meat (well done and processed) may be
relationship between the consumption of milk and milk linked to specific cancers. In addition, animal protein
products and childhood adiposity is discussed in Part products contain saturated fat and proportionately, a
D. Section 1: Energy Balance and Weight high calorie load, so serving sizes should be
Management. Outcomes considered in the review of appropriate.
cooked dry beans and peas were body weight, CVD,
and T2D. Although “legumes” includes dry beans and Review of the Evidence
peas as well as peanuts, peanuts were not considered in
this question but are a part of the review of nuts in Part Intake of animal protein products shows few links to
D. Section 3: Fatty Acids and Cholesterol. negative health outcomes in epidemiologic studies.
Most people consume protein from both animal and
plant sources, making separation of protein intake into
ANIMAL AND PLANT PROTEINS AND animal and plant sources difficult in epidemiologic
HEALTH OUTCOMES studies. The WCRF/AICR report (WRCF/AICR, 2007)
examined the relationship between meat, poultry, and
eggs and a variety of different cancers including
Question 1: What Is the Relationship colorectal, prostate, and breast. They concluded that the
Between the Intake of Animal Protein evidence that red meats and processed meats are
Products and Selected Health Outcomes? causally related to colorectal cancer is convincing.
Additionally, they found that limited evidence suggests
Conclusion that processed meat is causally related to prostate
cancer, and there was limited suggestive evidence that
Limited evidence from prospective cohort studies shows foods containing animal fat are associated with
inconsistent relationships between intake of animal postmenopausal breast cancer.
protein products and CVD with somewhat more
262 2010 Dietary Guidelines Advisory Committee Report
In a systematic review and meta-analysis published relationship between intake of animal protein and
subsequent to our review, Micha et al. (2010) examined hypertension was observed in the Seguimiento
the association between the consumption of red and Universidad de Navarra (SUN) cohort in Spain
processed meat and the risk of incident CHD and T2D. (Alonso, 2006). Similarly, no association between
They found that intake of red meat was not associated intake of animal protein and systolic or diastolic blood
with CHD or T2D. However, processed meat was pressure was observed in the PREMIER Study (Wang,
associated with a 42 percent higher risk of CHD and 19 2008b), and no association between the intake of red or
percent higher risk of T2D. Associations for total meat processed meat and systolic or diastolic blood pressure
intake and these outcomes were intermediate. was observed in a cohort in the United Kingdom
(Wagemakers, 2009).
The review provided below summarizes the evidence
from literature published since 2000 related to animal In contrast, in the Women’s Health Study (Wang,
protein products, specifically total meat, red meat, 2008c), total red meat intake was positively associated
processed meat, poultry, and eggs, acknowledging the with risk of developing hypertension. In addition, each
wide variation in how types of meat and meat products individual unprocessed and processed red meat item,
were grouped and analyzed. including hot dogs, hamburgers, and bacon, beef, or
lamb as a main dish was positively associated with the
Animal Protein Products and Cardiovascular risk of developing hypertension. Similarly, the
Disease CARDIA study (Steffen, 2005) found a positive
Prospective cohort studies show inconsistent association between consumption of total meat and red
relationships between intake of animal protein products and processed meat (combined) and risk of developing
and cardiovascular disease. The evidence review for this elevated blood pressure. The Chicago Western Electric
question included seven articles (Djousse, 2008; Study also showed a positive association between
Halton, 2006; Keleman, 2005; Nakamura, 2004, 2006; systolic and diastolic blood pressure and red meat, but
Qureshi, 2007; Sinha, 2009), which represented observed no association with processed meat.
prospective cohorts from the U.S. and Japan published
since 2000. Regarding the relationship between the Differences in dietary assessment methodology likely
intake of total animal protein and coronary heart affected the results in this review. Assessment methods
disease, no relationship was observed in the Nurses’ included 24-hour recalls, 5-day diaries, diet histories,
Health Study (Halton, 2006) or Iowa Women’s Health interviews, and food frequency questionnaires. Studies
Study (Keleman, 2005). However, a positive association that used 24-hour recalls (Wang, 2008b) and 5-day
between red meat and processed meat and CVD diaries (Wagemakers, 2009) observed no associations
mortality was observed in the National Institutes of between animal protein products and systolic or
Health-AARP (NIH-AARP) Diet and Health Study diastolic blood pressure.
(Sinha, 2009), and substituting red/processed meat
(combined) for carbohydrate-dense foods was positively Animal Protein Products and Body Weight
associated with coronary heart disease (CHD) mortality Few studies exist to link animal protein products and
in the Iowa Women’s Health Study (Keleman, 2005). body weight. After applying our review criteria, only
Studies found no association between egg intake and three articles (Mahon, 2007; Wagemakers, 2009; Xu,
CVD (Djousse, 2008; Nakamura, 2006, 2004; Qureshi, 2007) published since 2000 were identified that
2007). Thus, limited information is available on this examined the relationship between animal protein
relationship, and risk may depend on type of meat or products and body weight. Inconsistent findings were
meat products consumed and the type of CVD. reported in a cohort of British adults (Wagemakers,
2009) on whether meat intake was associated with body
Animal Protein Products, Blood Pressure, and mass index (BMI) and waist circumference who were
Hypertension studied between 1989 and 1999. Red and processed
No clear association was found between intake of meat consumed in 1999 was significantly associated
animal protein products and blood pressure in with increased BMI in women only. In a cross-sectional
prospective cohort studies. This conclusion is based on study in China (Xu, 2007), red meat consumption was
the review of six articles (Alonso, 2006; Miura, 2004; associated with excess body weight. In the only U.S.
Steffen, 2005; Wagemakers, 2009; Wang, 2008b, study found (Mahon, 2007), overweight
2008c) representing prospective cohorts from the U.S., postmenopausal women were successful in weight loss
United Kingdom, and Spain published since 2000. No with either a meat-containing or vegetarian protein
2010 Dietary Guidelines Advisory Committee Report 263
intervention. Thus, existing research is sparse and finds observed between red or processed meats and colorectal
little link between meat intake and body weight, and cancer in the Breast Cancer Detection Demonstration
meat-containing diets work as well as calorie controlled Project (Flood, 2003). The European Prospective
vegetarian diets in enhancing weight loss in intervention Investigation into Cancer and Nutrition (EPIC) study
studies. observed no association between red meat and
colorectal cancer, but did observe a positive association
Animal Protein Products and Type 2 Diabetes for processed meat. Further risk may vary depending on
Prospective cohort studies suggest that intake of animal subsite. Some studies found a relationship with rectal
protein products, mainly processed meat, may have a cancer and red meat intake (Chao, 2005; English,
link to T2D, although results are not consistent. This 2004), while others found no association (Kojima,
review included seven articles (Djousse, 2009; Fung, 2004; Larsson, 2005; Lee, 2009b; Wei, 2004; Wu,
2004; Halton, 2008; Schulze, 2003; Song, 2004; van 2006).
Dam, 2002; Vang, 2008) published since 2000
representing prospective cohorts from the U.S. In the Studies also report inconsistent results for the intake of
three studies examining total animal protein intake, two poultry and colorectal cancer at various subsites, with
reported a positive association with T2D (Song, 2004; studies reporting a positive association (Jarvinen, 2001;
Vang, 2008) and one reported no association (Halton, Kojima, 2004; Sato, 2006), no association (Flood,
2008). All five studies that reported on the relationship 2003; Lee, 2009b; Norat, 2005; Wu, 2006), or an
between the intake of processed meats and T2D inverse association (Chao, 2005; English, 2004;
reported a positive association (Fung, 2004; Schulze, Larsson, 2005).
2003; Song, 2004; van Dam, 2002; Vang, 2008).
Inconsistent findings were reported related to the intake In general, the studies showed no consistent findings on
of red meat and poultry. Some of the reported risk type of meat or meat product and colorectal cancer.
found in these studies may be attributed to obesity or Little information also is available about how much
weight gain, but controlling for this supported meat meat is consumed, and the association may differ
intake as an important risk factor for diabetes. Other depending on amount as well as the way it is cooked.
dietary factors, such cereal fiber, fat, and total calories, Further, although it has been suggested that animal
also are strong in this relationship and the association protein products have a different effect in different sites
between T2D and animal protein is attenuated when of the colon and rectum, no consistent findings are
there is adjustment for these factors. available. Future studies should consider the subsite of
the cancer.
Animal Protein Products and Colorectal
Cancer Animal Protein Products and Prostate Cancer
Inconsistent positive associations have been reported Little evidence is available that animal protein products
between colorectal cancer and the intake of certain are associated with prostate cancer incidence. The
animal protein products, mainly red and processed Committee reviewed six articles (Cross, 2005; Koutros,
meat. This review included 13 studies (Chao, 2005; 2008; Michaud, 2001; Park, 2007; Rodriguez, 2006;
Cross, 2007; English, 2004; Flood, 2003; Jarvinen, Rohrmann, 2007) examining the relationship between
2001; Kojima, 2004; Larsson, 2005; Lee, 2009b; Norat, animal protein products and incidence of prostate
2005; Oba, 2006; Sato, 2006; Wei, 2004; Wu, 2006) cancer published since 2000. All of the studies
representing prospective cohorts from the U.S., Europe, represented prospective cohorts from the U.S. Most
Australia, Finland, Japan, China, and Sweden published studies reported no association between total, red,
since 2000. In studies examining total meat intake, none processed, or white meat consumption, meat-cooking
reported a relationship with overall colorectal cancer method and risk of total prostate cancer, incident
risk (Flood, 2003; Jarvinen, 2001; Lee, 2009b; Oba, cancer, or advanced disease. However, in the Health
2006; Sato, 2006) or risk associated with specific Professionals Follow Up Study (Michaud, 2001),
subsites (Lee, 2009b; Sato, 2006; Wu, 2006). positive associations between metastatic prostate cancer
and red and processed meats were observed. Also, in
However, more varied results were reported for red and the Cancer Prevention Study (Rodriguez, 2006), red
processed meats. For example, in the NIH-AARP Diet meat (including processed red meat) and cooked
and Health Study, positive associations between red processed meats were positively associated with
meat and processed meat and colorectal cancer were prostate cancer in Black, but not White, men.
observed (Cross, 2007). However, no associations were Rohrmann and colleagues (2007) reported a positive
264 2010 Dietary Guidelines Advisory Committee Report
association between the intake of processed meat and processed meat. Thus, results are conflicting and future
total and advanced prostate cancer but did not observe research should further investigate the relationship
relationships between cancer and other animal protein between the intake of animal protein products and
products. breast cancer specifically related to menopausal and
receptor status.
Mixed results were observed regarding the level of
doneness of meat. Well and very well done meat were
associated with prostate cancer in the Prostate, Lung, Question 2: What Is the Relationship
and Colorectal and Ovarian (PLCO) Screening Trial Between Vegetable Protein and/or Soy
(Cross, 2005) and the Agricultural Health Study Protein and Selected Health Outcomes?
(Koutros, 2008), but level of doneness was not related
to cancer risk in the Multiethnic Cohort Study (Park,
Conclusion
2007) or Cancer Prevention Study (Rodriguez, 2006).
Thus, cohort studies of animal protein products and
Few studies are available, and the limited body of
prostate cancer since 2000 show little link between total
evidence suggests that vegetable protein does not offer
meat intake and prostate cancer although there may be a
special protection against T2D, coronary heart disease,
link between processed meat products as well as well
and selected cancers. Moderate evidence from both
done meat and prostate cancer.
cohort and cross-sectional studies show that intake of
vegetable protein is generally linked to lower blood
Animal Protein Products and Breast Cancer
pressure. Moderate evidence suggests soy protein may
Cohort studies show little association between intake of
have small effects on total and low density lipoprotein
animal protein products and overall breast cancer risk.
cholesterol in adults with normal or elevated blood
However, in premenopausal and estrogen receptor
lipids, although results from systematic reviews are
positive individuals, meat intake may alter risk of
inconsistent. A moderate body of consistent evidence
certain types of breast cancer. This review included six
finds no unique benefit of soy protein on body weight.
studies published since 2000 (Cho, 2006; Ferrucci,
A limited and inconsistent body of evidence shows that
2009; Fung, 2005; Kabat, 2009; Linos, 2008; Taylor,
soy protein does not provide any unique benefits in
2007). Results were often reported based on
blood pressure control.
menopausal status (premenopausal or postmenopausal)
and/or estrogen receptor status (positive or negative). In
Implications
the Nurses’ Health Study (Cho, 2006), overall, there
was no association between total meat intake and risk of
Our review indicated that intake of vegetable protein is
breast cancer. However, there was a positive association
generally linked to lower blood pressure, but this could
for ER (estrogen receptor)+/PR (progesterone
be due to other components in plant foods, such as
receptor)+ breast cancer and no association for ER-/PR-
fiber, or other nutrients. Individual sources of vegetable
. Similarly, they reported positive associations between
protein have no unique health benefits so choice of
ER+/PR+ breast cancer and individual red and
plant protein sources can come from a wide range of
processed meats, but not for ER-/PR-. Ferrucii et al.
plant-based foods. Consumption of plant proteins of
(2009) found a stronger association between red meat
lower quality is generally fine as long as calorie needs
intake and ER+/PR+ breast cancer compared to
are met and effort is made to complement the
negative receptor status in the PLCO Screening Trial.
incomplete vegetable proteins. Consumption of lower-
quality or incomplete protein is of greater concern when
In additional analyses from the Nurses’ Health Study,
protein needs are high. Thus, consumption of lower-
Linos et al. (2008) found a positive association between
quality vegetable protein must be carefully considered
premenopausal breast cancer and red meat, and this
during pregnancy, lactation, and childhood.
relationship was stronger among estrogen receptor
Additionally, recommendations to lower calorie intake
positive participants. In the UK Women’s Cohort Study
to combat obesity by increasing plant-based food intake
(Taylor, 2007), positive associations between total meat
must be linked to cautionary messages to maintain
and premenopausal and postmenopausal breast cancer
protein total intake of sufficient quality at recommended
were observed. Non-processed meat also was positively
levels.
associated with premenopausal breast cancer. However,
postmenopausal but not premenopausal breast cancer
was associated with the intake of red meat and
2010 Dietary Guidelines Advisory Committee Report 265
Review of the Evidence Vegetable Protein and Chronic Disease
Few studies are available, and the limited data
Background collectively suggest that vegetable protein does not offer
Smit et al. (1999) estimated intakes of animal plant special protection against T2D, coronary heart disease
protein intake in U.S. adults, based on the Third (CHD), and selected cancers. This conclusion was
National Health and Nutrition Examination Survey based on seven studies, including six prospective cohort
(NHANES III), 1988–1999. The main protein source in studies (Halton, 2006, 2008; Keleman, 2005; Sluijs,
the American diet is animal protein (69%). Meat, fish, 2010; Song, 2004; Lee, 2009a) and one ecological
and poultry protein combined contributed the most to study (Nagata, 2000). Five studies addressed vegetable
animal protein (42%), followed by dairy protein (20%). protein (Halton, 2006, 2008; Keleman, 2005; Sluijs,
Grains (18%) contributed the most to plant protein 2010; Song, 2004) and two studies focused on soy
consumption. Results found that the percentage of total protein (Lee, 2009a; Nagata, 2000). Five of the seven
energy from protein was similar among race-ethnicities studies only included women (Halton, 2006, 2008;
and between men and women, their sources of protein Keleman, 2005; Song, 2004; Lee, 2009a).
were different. But, typically animal protein provides
about 70 percent of the protein in the American diet. Three studies examined the relationship between
vegetable protein and CHD. In the Nurses’ Health
In epidemiologic studies, food frequency questionnaires Study, no association was found with vegetable protein
are often used to assess dietary intake and protein-rich intake and risk of CHD (Halton, 2006). In the Iowa
foods are often divided into vegetable and animal Women’s Health Study, intake of vegetable protein in
sources. Most people consume both types of protein, so the highest quintile decreased CHD mortality by 30
this division is often complicated (see Question 3 for a percent with isocaloric substitution of vegetable protein
discussion of protein and vegan eating patterns). for carbohydrate (Keleman, 2005). An ecological study
Additionally, sources of vegetable protein are typically in Japan found no relationship between the intake of
also associated with intake of dietary fiber and other soy protein and heart disease mortality (Nagata, 2000).
potentially beneficial phytonutrients, thereby
confounding true, isolated comparisons of protein type. Three studies examined the relationship between
vegetable protein intake and the risk of T2D. No
Soy protein has been the focus of much published association was found with vegetable protein intake in
research. Based on earlier studies reporting that large the Nurses’ Health Study (Halton, 2008), Women’
intakes of soy protein (25 g) were required to lower Health Study (Song, 2004), or the Dutch cohort of the
serum lipids in the U.S., the U.S. Food and Drug EPIC study (Sluijs, 2010).
Administration established a health claim stating that 25
grams per day of soy protein can lower serum lipids, Substituting vegetable protein for carbohydrate or
including total cholesterol and low-density lipoprotein animal protein did not affect risk for cancer and was not
(LDL) cholesterol (FDA approves health claim labeling associated with all-cause mortality in the Iowa
for foods containing soy protein. JADA 2000;100:292). Women’s Health Study (Keleman, 2005). In the
No statement regarding isoflavone content or form of Shanghai Women’s Health Study, vegetable protein was
soy protein was issued. protective against premenopausal but not
postmenopausal breast cancer, although only soy
The existing health claim for soy requires that each food protein intake was evaluated (Lee, 2009a). Small
contain at least 6.25 grams of soy protein, based on the protective effects of soy protein were found in men
need for 25 grams of soy protein to show significant against stomach cancer in the Japanese ecological study
lowering of serum total cholesterol and LDL- (Nagata, 2000). However, intake of soy protein was not
cholesterol. Soy foods that meet the 6.25 gram level associated with breast, prostate, or lung cancer mortality
include 4 ounces of whole soybeans, 8 ounces of soy in this study, and intake of soy protein increased
milk, 3.5 ounces soy flour, 8 ounces textured soy colorectal cancer mortality (Nagata, 2000).
protein, 4 ounces tofu, and 4 ounces tempeh (FDA
approves health claim labeling for foods containing soy In summary, few studies have examined the relationship
protein. JADA 2000; 100:292). of vegetable protein intake and chronic diseases and the
results from prospective studies report no relationship to
diabetes, most cancers, and all-cause mortality. Results
are inconsistent for CHD.
266 2010 Dietary Guidelines Advisory Committee Report
Vegetable Protein and Blood Pressure Among 2008); median soy protein in quartile 1 and quartile 4 of
Adults Without Hypertension this study were 3 grams per day and 16 grams per day,
Intake of vegetable protein is associated with lower respectively. Thus, while data suggest that vegetable
blood pressure. This conclusion is based on the review protein plays a role in blood pressure, the data
of six studies, including four prospective observational specifically for soy protein are limited and inconsistent.
and two cross-sectional studies (Alonso, 2006; Elliott, Soy protein does not appear to have any unique benefits
2006; Stamler, 2002; Steffen, 2005; Umesawa, 2009; in blood pressure control.
Wang, 2008b). Alonso et al. (2006) reported in the
SUN cohort in Spain that vegetable protein intake was Soy Protein and Body Weight
associated with less hypertension. In the Chicago Soy protein had no advantage over other proteins when
Western Electric Study, intake of vegetable protein was consumed in isocaloric studies on body weight as based
linked to lower systolic and diastolic blood pressure on one systematic review (Cope, 2008) and three
(Stamler, 2002). In the CARDIA study, an inverse primary citations (Liao, 2007; McVeigh, 2006; Pan,
relationship between the consumption of plant foods 2008). Cope et al. (2008) completed a systematic
and elevated blood pressure was observed (Steffen, review including 91 international references with data
2005). In the PREMIER trial, plant protein had a from in vitro, animal, epidemiologic, and clinical
beneficial effect on blood pressure and was associated studies evaluating the relationship between soy foods,
with a lower risk of hypertension at 6 months, but not at including soy protein, and weight loss. The authors
18 months (Wang, 2008b). Cross-sectional studies reported that studies with overweight and obese
(Elliott, 2006; Umesawa, 2009) also report lower individuals suggest that soy, as a source of dietary
systolic and diastolic blood pressure links to vegetable protein, may be used to achieve significant weight loss.
protein intake. However, there is no convincing evidence to show
whether soy protein is better than other protein sources
Soy Protein and Blood Pressure Among Adults to achieve weight loss when prescribed in isocaloric
Without Hypertension levels.
Some data suggest soy protein may lower blood
pressure in adults with normal blood pressure. This Three additional studies identified in the NEL review
conclusion is based on review of three RCTs (He, 2005; support the conclusion by Cope et al. (2008). No
Liao, 2007; Teede, 2002), one prospective cohort study differences in weight loss were found when a soy diet
(Yang, 2005), and one cross-sectional study (Pan, 2008) was compared to a traditional low-calorie diet
published since 2000. All studies were published (McVeigh, 2006). Pan et al. (2008) examined the effect
outside of the U.S. He et al. (2005) and Teede et al. of soy protein on risk of metabolic syndrome in a cross-
(2002) conducted RCTs that included 40 grams of soy sectional study of older Chinese individuals and found
protein consumed per day over 3 months. In both no differences in body weight. Liao et al. (2007)
studies, participants receiving soy protein conducted a randomized, controlled trial with obese
supplementation experienced a significant decrease in adults, examining the effect of soy protein on weight
systolic blood pressure and diastolic blood pressure loss in obese adults and found no effect. Thus, studies
compared to the control groups. Liao et al. (2007) did consistently find no unique benefit of soy protein with
not observe significant changes in systolic blood weight loss.
pressure or diastolic blood pressure among participants
consuming soy protein as the only protein source versus Soy Protein and Blood Lipids Among Adults
a control diet with animal and plant protein for 8 weeks. Without Hyperlipidemia
The groups consumed an isocaloric diet providing 1200 Soy protein may have small effects on total and LDL-
kilocalories per day. cholesterol in adults with normal or elevated blood
lipids, although systematic reviews report inconsistent
In the Shanghai Women’s Health Study, systolic blood results. This conclusion is based on four meta-analyses
pressure and diastolic blood pressure were lower in (Harland, 2008; Reynolds, 2006; Weggemans, 2003;
women who consumed 25 grams or more of soy protein Zhan, 2005) and consideration of an additional
per day than in women consuming less than 2.5 grams randomized, controlled trial (Liao, 2007) and a cross-
per day (Yang, 2005). In cross-sectional analyses of the sectional study (Pan, 2008). Results from the meta-
Nutrition and Health of Aging Population Project in analyses are somewhat inconsistent. Harland et al.
China, soy protein intake and elevated blood pressure (2008) concluded that 25 grams of soy protein lowered
were inversely associated in men, but not women (Pan, total cholesterol, LDL cholesterol, and triglycerides,
2010 Dietary Guidelines Advisory Committee Report 267
with no change in HDL-cholesterol in adults without Implications
hyperlipidemia. Reynolds et al. (2006) suggested that
soy protein supplementation (20 to >61 g/d) lowered Most people consume diets containing both animal and
total cholesterol, LDL-cholesterol, triglycerides, and plant foods. Few studies exist on the nutritional or
actually increases HDL cholesterol. Zhan et al. (2005) health status of vegetarians and/or vegans. Individuals
concluded that soy protein with isoflavones lowered who restrict their diet to plant foods may be at risk of
total cholesterol, LDL-cholesterol, triglycerides, and not getting adequate amounts of certain indispensable
had no effect on HDL-cholesterol. In contrast, amino acids because the concentration of lysine, sulfur
Weggemans et al. (2003) reported that soy-associated amino acids, and threonine are sometimes lower in plant
isoflavones and soy protein have no effect on either than in animal food proteins. Nutrients of concern in
LDL-cholesterol or HDL-cholesterol. However, unlike vegan diets include calcium, iron, B12, zinc, and long-
others, this review compared soy protein with chain n-3 fatty acids. Vegetarian diets that include
isoflavones only with studies in which control groups complementary mixtures of plant proteins can provide
consumed dairy or other animal protein sources. The the same quality of protein as that from animal protein.
role of isoflavones in lowering lipids is discussed in Education is needed for those designing diets
many of these reviews, but it remains unclear whether containing complementary proteins for consumers
the protein in soy-associated substances (isoflavones, switching to a more plant-based diet. Additionally,
other phytonutrients or substitution for animal protein) individuals consuming vegetarian, particularly vegan,
causes lipid lowering. diets should ensure adequate intake of all nutrients.
Liao et al. (2007) reported a significant decrease in total Review of the Evidence
cholesterol and LDL cholesterol in their weight loss
study with soy protein, but no changes in triglycerides Background
or HDL cholesterol were observed. A cross-sectional The nitrogen requirement for adults eating high-quality
study in China (Pan, 2008) found no relationship plant food proteins is not significantly different than
between soy protein intake and elevated triglycerides. animal protein or protein from a mixed diet. Most
Overall, conclusions suggest that soy protein may have consumers eat protein from a variety of sources and few
small effects on total and LDL cholesterol in adults with cohort studies include enough vegetarians or vegans to
normal or elevated blood lipids but neither the etiology draw any conclusions. Also, many self-described
nor the potential importance of isoflavones in this vegetarians consume milk products or eggs or even
relationship have been clarified. consume processed foods that contain animal protein.
Thus, there is limited accurate data to answer questions
about health differences between vegetarians and non-
Question 3: How Do the Health Outcomes vegetarians.
of a Vegetarian Diet Compare to That of a
Diet Which Customarily Includes Animal In general, plant proteins are less digestible than animal
Products? proteins, but digestibility can be improved with certain
processing methods and food preparation techniques.
Vegetarians typically consume less protein than non-
Conclusion vegetarians and Hadded et al. (1999) found that 10 of
25 vegan women had potentially inadequate intakes.
Limited evidence is available documenting that
vegetarian diets protect against cancer. However, it Most available evidence relates to the nutritional
suggests that vegetarian, including vegan, diets are content and health effects of the average diet of well-
associated with lower BMI and blood pressure. Vegan educated vegetarians living in Western countries (Key,
diets may increase risk of osteoporotic fractures. The 2006). Vegetarian diets are rich in carbohydrates, n-6
effect of vegetarian diets on cardiovascular disease, fatty acids, dietary fiber, carotenoids, folic acid, vitamin
stroke, and mortality are discussed further in Part B. C, vitamin E, and magnesium and relatively low in
Section 2: The Total Diet: Combining Nutrients, protein, saturated fat, n-3 fatty acids, vitamin B12, and
Consuming Food. zinc. Vegans have particularly low intakes of vitamin
B12, iron, and calcium. Most data find little differences
in major causes of death or all-cause mortality when
comparing vegetarians with non-vegetarians from the
268 2010 Dietary Guidelines Advisory Committee Report
same population (Key, 2006b). Animal protein intake Similar results were found in the Swedish
was linked to greater muscle mass index in a Finnish Mammography Cohort (Newby, 2005). Rosell et al.
study (Aubertin-Leheudre & Adlercreutz, 2009) and (2006) reported on 5-year changes in weight in the
there is concern about protein intake during growth and EPIC cohort by dividing participants into groups based
development. Nutrients of concern on vegan diets on their eating patterns. Specifically, they examined
include calcium, iron, B12, zinc, and long-chain n-3 fatty whether participants maintained the same diet (e.g.,
acids. Because some vegetarian diets are low in protein, vegan) over time, or reverted from a vegan or vegetarian
calcium, and other nutrients, research has examined the diet to a diet containing meat, or converted from eating
relationship between plant-based diets and bone health. meat to a vegetarian or vegan diet. Among those who
It is possible to consume complementary plant proteins had not changed their eating patterns over time, the
and have an adequate intake of protein, but education is largest weight gain was seen in meat-eaters. The
needed on how to design adequate diets. smallest weight gain was observed in participants who
converted to a vegetarian or vegan diet, and the highest
We examined studies published since January 2000 weight gains were among participants classified as
with no limits to study design to address these reverted, but mean weight gains were not different than
questions. Few cohort studies were available and there weight gains in meat eaters.
were no randomized, controlled trials. A limitation of
this area is the small number of vegans and semi- Meat eaters had the highest prevalence of hypertension
vegetarians in the cohorts studied. For a more in-depth and vegans the lowest in the EPIC cohort (Appleby,
discussion of vegetarian and vegan eating patterns, 2002), and vegetarians had lower blood pressure than
including review of articles published before 2000 and omnivores in small studies in Taiwan (Chen, 2008) and
using additional search strategies, see Part B. Section 2: Brazil (Teixeira, 2007). Studies from Taiwan and Brazil
The Total Diet: Combining Nutrients, Consuming also showed improvement in cardiovascular biomarkers,
Food. such as total cholesterol, between individuals
consuming vegetarian compared to omnivorous diets
Health Outcomes of a Vegetarian Diet (Chen, 2008; Teixeira, 2007; Yen, 2008).
Compared to a Diet Which Customarily
Includes Animal Products Vegans were found to have a higher risk of fractures
Eighteen studies published since 2000 were reviewed than vegetarians and meat eaters in the EPIC cohort,
that represented eight countries (Alewaeters, 2005; which was related to the lower mean calcium intake in
Appleby, 2002, 2007; Baines, 2007; Chen, 2008; Dos this group (Appleby, 2007). However, those on a
Santos Silva, 2002; Grant, 2008; Hung, 2006; Key, vegetarian diet in Taiwan did not differ from non-
2009a, 2009b; Newby, 2005; Nakamoto, 2008; Rosell, vegetarians in bone mineral density or risk of
2006; Spencer, 2003; Teixeira, 2007; Thorpe, 2008; osteoporosis (Wang, 2008d). In a review of women
Wang, 2008d; Yen, 2008). Most studies in this review from the Adventist Health Study (Thorpe, 2008),
were of a weaker design, including cross-sectional and greater intake of foods rich in protein, whether from
case-control studies. Only five articles were prospective animal or plant sources, was associated with reduced
cohort studies and no Randomized Controlled Trials wrist fractures.
(RCTs) were identified. Six articles provided results
from the EPIC study from the United Kingdom, and Data on cancer are inconsistent with one recent study
four studies were conducted in Taiwan. Other countries finding more colorectal cancer in vegetarians compared
represented were the U.S., Australia, Japan, Sweden, to meat eaters (Key, 2009a). However, the risk of
Belgium, and Brazil. Vegetarian diets varied greatly female breast, prostate, ovarian, and lung cancer were
among countries, and classifications of plant-based diets not significantly different between vegetarians and non-
were inconsistent among studies. However, all studies vegetarians.
compared the health outcomes observed between
individuals who regularly consumed animal products to Overall, Key and colleagues (2009b) found no
those who occasionally, rarely, or never consumed differences in mortality rates between vegetarians and
animal products. non-vegetarians in the EPIC cohort.
In general, studies from the Netherlands did not show as Milk and Milk Product Intake and Body Weight
strong a relationship between the intake of milk and The Committee reviewed 18 studies conducted since
milk products and blood pressure. Engberink et al. 2004 that examined the link between the intake of milk
(2009a) followed more than 20,000 participants for 5 and milk products and body weight and concluded that
years in the Netherlands and concluded that dairy intake evidence supporting the hypothesis of a relationship
has little effect on population blood pressure. Snijder et between intake of milk and milk products and decreased
al. (2008) concluded that dairy consumption was not body weight is not convincing. This conclusion is based
associated with changes in metabolic variables in their on one systematic review (Lanou, 2008), one RCT
study with a Dutch elderly population. Engberink et al. (Bowen, 2005), four prospective cohort studies
(2009b) followed older Dutch participants for 6 years, (Rajpathak, 2006; Rosell, 2006; Snijder, 2008;
and they concluded that low-fat dairy may be related to Vergnaud, 2008), and eight cross-sectional studies
hypertension prevention, but high-fat dairy and cheese (Azadbakht, 2005; Beydoun, 2008; Brooks, 2006;
did not show the same effect. Houston, 2008; Marques-Vidal, 2006; Mirmirin, 2005;
Murakami, 2006; O’Neil 2009). The Committee also
reviewed three studies that looked at energy intake as an
2010 Dietary Guidelines Advisory Committee Report 273
outcome (Dove, 2009; Harper, 2007; Hollis, 2007), and type of dairy product influences the associations
one study (Olsen, 2007) that addressed pregnancy. between dairy product consumption and anthropometric
changes. Eight cross-sectional studies (Azadbakht,
Lanou et al. (2008) reviewed the body of evidence on 2005; Beydoun, 2008; Brooks, 2006; Houston, 2008;
the effect of dairy product or calcium intake, with or Marques-Vidal, 2006; Mirmirin, 2005; Murkami, 2006;
without energy restriction, on body weight or adiposity. O’Neil, 2009) were reviewed, and were more likely to
Of the 49 randomized clinical trials reviewed, 42 found support that calcium and/or dairy consumption was
no effect on weight of dairy or calcium consumption, related to lower BMI.
and only four trials showed a potential effect of dairy
products or calcium on weight loss. Of the 16 clinical Other studies included in the review measured whether
trials, 15 showed no difference in body fat change consumption of milk or milk products was related to
between consumers of high and low levels of dairy or energy intake as an outcome. Dove et al. (2009)
calcium. One study found greater fat loss among high- concluded that consumption of skim milk, in
dairy consumers compared to low-dairy consumers. comparison with a fruit drink, leads to increased
Overall, their review does not support a connection perceptions of satiety and to decreased energy intake at
between dairy or calcium consumption and weight or fat a subsequent meal. Harper et al. (2007) conducted a
loss. randomized cross-over design study to compare the
effect on appetite and energy intake of consuming either
In the Bowen et al. (2005) RCT, the effects on weight, a sugar-sweetened beverage (cola) or chocolate milk
body composition, metabolic parameters, and risk drink. The authors concluded that consuming chocolate
markers of two isocaloric, energy-restricted high-protein milk increased subjective ratings of satiety and fullness
diets that differed in dietary calcium and protein source compared with cola and decreased hunger and later
on weight loss and body composition in healthy, consumption of food. However, this enhanced satiety
overweight adults were compared. The authors did not translate into differences in ad libitum energy
concluded that weight loss following energy-restricted, intake. Hollis and Mattes (2007) assessed the effect of
high protein diets is not affected by dietary calcium or daily intake of one or three portions of dairy foods on
protein source. energy intake and appetite. The authors concluded that
increasing dairy consumption from one to three portions
The following four prospective cohort studies did not each day led to increased energy intake. Thus, dairy
strongly support the hypothesis that increasing milk and foods may have some benefit for satiety when compared
milk products would result in a decrease in weight. to fruit drinks, but increased consumption of any extra
Rajpathak et al. (2006) evaluated the association calories (versus substitution), including dairy products,
between calcium and dairy intakes and 12-year weight will lead to increased energy intake.
change among men in the U.S. Their results indicate
that increasing calcium or dairy consumption is not Olsen et al. (2007) examined whether milk consumption
associated with lower long-term weight gain in men. during pregnancy is associated with greater infant size
Rosell et al. (2006) examined the association between at birth in the Danish National Birth Cohort. Milk
changes in dairy product consumption and self-reported consumption was inversely associated with the risk of
weight change over 9 years among women. They small-for-gestational age birth and directly with both
concluded that the association between the intake of large-for-gestational age birth and mean birth weight.
dairy products and weight gain differed according to the
type of dairy product and the body weight status at
baseline. Snijder et al. (2008) investigated the Question 5: What Is the Relationship
association between dairy consumption and 6.4-year Between the Intake of Cooked Dry Beans
changes in weight and metabolic disturbances in an and Peas and Selected Health Outcomes?
elderly Dutch population. They concluded that higher
dairy consumption does not protect against weight gain
Conclusion
and the development of metabolic disturbances over
time. Vergnaud et al. (2008) investigated the
Limited evidence exists to establish a clear relationship
relationship between dairy consumption and calcium
between intake of cooked dry beans and peas and body
intake with 6-year changes in body weight and waist
weight. There is limited evidence that intake of cooked
circumference in a French population. The authors
dry beans and peas lowers serum lipids. Limited
concluded that sex, overweight status at baseline, and
274 2010 Dietary Guidelines Advisory Committee Report
evidence is available to determine a relationship cooked dry beans and peas show promise for use in
between the intake of cooked dry beans and peas and control of blood glucose for individuals with T2D.
T2D.
We examined studies from January 2000 to present for
Implications this review. Overall, our review suggests that little
evidence is available on the relationship between intake
Legumes and soybeans, including dried beans and peas, of cooked dry beans and peas and health outcomes.
are typically recommended foods because of their
content of dietary fiber, protein, vitamins, and minerals Cooked Dry Beans and Peas and Body Weight
(Mesina, 1999). Because soybeans are particularly high The few intervention studies on the relationship
in isoflavones, a phytoestrogen, they have been more between intake of cooked dry beans and peas (not
extensively studied than other legumes. Legumes are including soy) and body weight find mixed results. This
also promoted as a complementary protein source to conclusion is based on the review of one meta-analysis
grains since legumes are low in methionine and grains (Anderson and Major, 2002), one systematic review
are low in lysine. Thus, legumes play an important role (Williams, 2008), four trials (Crujeiras, 2007; Pittaway,
in vegan diets for enhancing protein quality. They may 2006, 2007, 2008), and one cross-sectional study
also provide a beneficial contribution to the general (Papanikolaou, 2008) for beans and peas. Additionally,
population in part to increase total vegetable the Committee reviewed one systematic review (Cope,
consumption and dietary fiber intake. 2008) and one cohort study (Maskarinec, 2008)
specifically pertaining to soy foods.
Review of the Evidence
In a meta-analysis of 11 studies, Anderson and Major
Background (2002) found that the intake of non-soy legumes was
Beans and peas are sources of protein, dietary fiber, associated with decreased body weight. In a systematic
minerals, and vitamins. As dietary fiber is linked to review examining the role of whole grains and legumes
lower body weight, intake of beans and peas would be in preventing and managing overweight and obesity,
expected to also be linked to lower body weight. Williams et al. (2008) concluded that weight loss is
Consumption of dry beans, peas, and lentils is low in achievable with energy-controlled diets high in legumes
the U.S., with only 8 percent of adults consuming dry but felt there was insufficient evidence to draw
beans and peas on any one day (Mitchell, 2009), conclusions about the protective effect of legumes on
making it difficult to see relationships in existing weight.
cohorts. Dry beans and peas are concentrated sources of
soluble dietary fiber, which is known to lower serum Results from feeding trials with beans and peas are
lipids. Vegetable protein from legumes has also been mixed, but diet treatments with beans and peas are
found to lower serum lipids, and the U.S. has an generally no more successful in weight loss than the
existing health claim for the ability of soy protein to control or comparison treatment. In two randomized
lower serum lipids. Most of the research in the lipid- crossover trials comparing chickpea- to wheat-
lowering benefits of soy protein was done in supplemented diets, no significant differences between
hyperlipidemic individuals. dietary interventions was observed (Pittaway, 2006,
2007). In a study that included chickpea-supplemented
Unfortunately, few consumers include cooked dry beans ad libitum, a non-significant decrease in body weight
and peas in their daily diet, and soy products are also was observed during the chickpea phase compared to
not commonly consumed in the U.S. This makes it the control phase (Pittaway, 2008). In a RCT comparing
difficult to determine the protectiveness of intake of hypocaloric diets high in non-soybean legumes to a diet
cooked dry beans and peas and soy when most without legumes, both groups lost weight with greater
prospective cohort studies include few participants who weight loss achieved by those consuming legumes. A
are consuming these products. comparison of bean eaters from NHANES 1999-2002
suggest that bean consumers had lower body weights,
Soluble fibers are thought to slow absorption of and waist circumferences in comparison to non-
carbohydrates and lower the glycemic index of foods. In consumers (Papanikolaou, 2008).
the original studies of glycemic index, intake of
legumes was associated with the lowest glucose In a systematic review of soy foods and weight loss,
response. Independent of glycemic index and load, Cope et al. (2008) concluded that there was limited
2010 Dietary Guidelines Advisory Committee Report 275
evidence to support the hypothesis that soy foods once a week was associated with a 22 percent lower risk
increase weight loss when fed at isocaloric levels or that of CHD and an 11 percent lower risk of CVD. In the
soy foods affect caloric intake when included as part of Coronary Artery Risk Development in Young Adults
a diet. In a cohort study, women consuming more soy (CARDIA) Study (Steffen, 2005), tertiles of legume
during adulthood had a lower BMI, but the relation was intake were less than 0.1, 0.1 to 0.2, and more than 0.2
primarily observed for Caucasian and postmenopausal times per day, supporting extremely low usual intake of
participants (Maskarinec, 2008). legumes. The authors noted that limited consumption of
legumes and insufficient statistical power precluded
Cooked Dry Beans and Peas and definitive conclusions from being drawn about the
Cardiovascular Outcomes relationship between intake of legumes and elevated
Limited evidence exists that dry beans and peas have blood pressure. However, it is unclear whether null
unique abilities to lower serum lipids; most of the lipid findings were due to the lack of association or limited
lowering seen in studies is related to the soluble fiber range in consumption. In a case-control study in Costa
content of these products. The conclusion reached for Rica, Kabagambe et al. (2005) observed an inverse
this question is based on the review of one meta- association between myocardial infarction and the
analysis (Anderson and Major, 2002), five trials intake of one serving of beans per day (1/3 cup of
(Crujeiras, 2007; Finley, 2007; Pittaway, 2006, 2007, cooked beans) in adjusted analyses. However, no
2008), two prospective cohort studies (Bazzano, 2001; additional benefit was observed with more than one
Steffen, 2005), one case-control study (Kabagambe, serving per day.
2005), and one cross-sectional study (Papanikolaou,
2008). The Committee also considered one randomized In more than 12 years of follow-up of the Japan Public
crossover trial (Welty, 2007), one prospective cohort Health Center-Based Study Cohort I (Kokubo, 2007),
study (Kokubo, 2007), and one longitudinal study investigators saw a decrease in the risk of myocardial
(Nagata, 2000) regarding soy foods. infarction, cerebral infarction, and CVD mortality
among women consuming soy at least five times per
Anderson and Major (2002) quantitatively analyzed week compared to those consuming soy zero to two
changes in serum lipoprotein levels resulting from times per week. However, no associations were
intake of non-soya pulses. The authors concluded that observed for men. In a longitudinal study in Japan,
regular consumption of pulses may have important Nagata et al. (2000) also observed an inverse correlation
protective effects on risk for CVD, including decreases between soy product intake and heart disease mortality
in serum cholesterol, LDL-cholesterol, and in women, but not men.
triacylglyercols, and increases in HDL-cholesterol.
In a randomized crossover trial in which hypertensive,
In the intervention studies, dry beans and peas lowered prehypertensive, and normotensive postmenopausal
serum lipids as expected based on soluble fiber content. women consumed the Therapeutic Lifestyle Changes
In a series of studies including the daily consumption of (TLC) diet alone or with 1/2 cup unsalted soy nuts (25 g
more than 100 grams of chickpeas per day for 5 to 12 soy protein) replacing 25 grams of non-soy protein,
weeks, Pittaway et al. (2006, 2007, 2008) observed benefits to blood pressure and LDL-cholesterol were
improvements in serum total cholesterol and LDL- greater for the hypertensive women than the
cholesterol compared to a control diet without legumes. normotensive participants (Welty, 2007).
Similar improvements in total cholesterol were
observed following an 8-week weight loss intervention Cooked Dry Beans and Peas and Type 2
that included non-soybean legumes four days each Diabetes Mellitus
week, and the decrease in total cholesterol was directly Evidence is insufficient to determine a relationship
correlated with increased fiber intake (Crujeiras, 2007). between dry beans and peas and T2D. Only one study
was found that measured the relationship between dry
Bazzano et al. (2001) found a strong and independent beans and peas and T2D. The association between the
inverse association between dietary intake of legumes consumption of legume and soy foods and T2D was
and risk of CHD in the Nutrition Examination Survey examined over an average follow-up of approximately 5
Epidemiologic Follow-up Study (NHEFS), which is a years in the Shanghai Women’s Health Study (Villegas,
prospective cohort study of the First NHANES 2005). Average daily intake of individual food items
(NHANES I) from 1971 to 1975. Legume consumption was combined for the following food groups: total
four or more times per week compared with less than legumes and three mutually exclusive groups—
276 2010 Dietary Guidelines Advisory Committee Report
soybeans (dried and fresh), peanuts, and other legumes. eating patterns and more specific impacts of dried
The median intake of total legumes was 30.5 grams per beans and peas on health.
day, for soybeans was 11.0 grams per day, for peanuts
was 0.7 gram per day, and for other legumes was 15.5 Rationale: Large U.S. cohorts do not include
grams per day. Total legume consumption and enough vegetarians and vegans to make
consumption of soybeans and other legumes were each comparisons on health outcomes including weight
associated with a decrease in risk of T2D. control and blood pressure. Widespread public
interest and possible public health impacts of this
dietary pattern raise the priority for this research.
Chapter Summary
3. Conduct studies of potential limitations of plant-
Proteins are unique because they provide both essential based diet for key nutrients, including calcium,
amino acids to build body proteins and are a calorie iron, vitamin B12, and protein quality, especially in
source. Because the RDA of protein for any person is children and the elderly.
based on their ideal body weight (0.8 g protein/kg body
weight/day for ages 19 and above), lower-calorie diets Rationale: These data are needed to determine
require higher percentage of protein intake. Protein whether vegan children require dietary supplements
quality varies greatly and is dependent on the amino to attain adequate nutrient status and growth.
acid composition of the protein and the digestibility.
Animal sources of protein, including meat, fish, milk, 4. Examine the role of dairy products in lipid profiles,
and egg, are the highest quality proteins. Plant proteins especially through intervention trials in which all
can be combined to form more complete proteins if types of dairy products, both low and high fat, are
combinations of legumes and grains are consumed. As fed. Bioactive components that alter serum lipid
most Americans consume too many calories, the levels may be contained in milk fat.
percentage of calories from protein may be higher—up
to 35 percent of calories can come from protein on very Rationale: Consumption of milk products may not
low calorie diets. Higher-protein diets tend to assist in have predictable effect on serum lipids, weight
initial weight loss, but long term studies of weight loss control, and metabolic syndrome. The ability of
or maintenance of weight loss find no differences dairy consumption to increase HDL levels and their
among diets lower or higher in protein. effect on weight gain or weight loss and metabolic
syndrome is also of widespread public health
Needs for Future Research interest and worthy of additional study.
1. Develop standardized definitions for vegetable 5. Develop and investigate potential biomarkers for
proteins and improve assessment methods for objective assessment of vegetable protein intake.
quantifying vegetable protein intake to help clarify
outcomes in epidemiologic studies in this area. Rationale: Few measures of protein status exist in
healthy individuals, so it is difficult to compare
Rationale: Assessing vegetarian eating patterns and protein status of participants in cohort studies with
their protein content is complex and current diverse protein intakes.
methodologies do not capture critical variations.
Therefore, investigators’ ability to quantify any 6. Develop better assessment tools to classify
possible association with health benefits is limited. vegetarian patterns in epidemiologic studies.
Better standardized definitions and improved
assessment methods will improve the ability to Rationale: No assessment methods are currently
quantify health benefits associated with available to classify participants into the wide range
consumption of vegetable protein. of vegetarian eating patterns.
2. Develop better methods of conducting cohort 7. Conduct randomized controlled trials to answer the
studies of populations consuming plant-based diets question whether intake of dairy products alters
compared to animal based diets, including defined blood pressure.
classifications of vegetarian and “near vegetarian”
Rationale: Evidence to date does not suggest that Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi F.
high fat dairy products are more likely than low fat Dairy consumption is inversely associated with the
dairy products to induce metabolic syndrome. prevalence of the metabolic syndrome in Tehranian
Whether there are other protective compounds in adults. Am J Clin Nutr. 2005;82(3):523-30.
milk products, such as calcium, protein, fatty acids,
etc., that provide protection requires further Baines S, Powers J, Brown WJ. How does the health
research. and well-being of young Australian vegetarian and
semi-vegetarian women compare with non-vegetarians?
Public Health Nutr. 2007;10(5):436-42.
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42.
Sugars
Monosaccharides 1 sugar unit • Glucose • Rarely found • Apples (fructose)
• Fructose naturally in • Pears (fructose)
• Galactose foods-except for • Honey (fructose)
fructose
Disaccharides 2 linked • Sucrose (50% glucose, 50% • Occurs naturally • Fruit
sugar units fructose) in foods (sucrose, • Milk
• Lactose (50% galactose, 50% lactose) • Sweet potatoes
glucose) • Produced by
• Maltose (100% glucose- starch digestion
glucose bond) (maltose)
• High fructose corn syrup • Hydrolysis of
(HFCS) (generally 55% corn (HFCS)
fructose – sometimes 42%
fructose – varies)
Oligosaccharides 3-10 linked • Raffinose • May cause • Dry beans and peas
(OS) sugar units • Stachyose intestinal gas • Onions
• Breast milk
• Added to food as
inulin and other OS
Starches
Polysaccharides Many linked • Starch • Most are broken • Starchy vegetables
glucose units • Glycogen – animal starch down to glucose • Grains
for absorption • Dry beans and peas
• Nuts and seeds
• Resistant starch • Resistant starch • Dry beans and peas
does not undergo • Pasta
digestion in the • Refrigerated cooked
small intestine potatoes
Fibers
Polysaccharides/L Many linked • Dietary Fiber, i.e., • Different • Vegetables
ignin sugar units nondigestible carbohydrates chemical • Fruits
and lignin that are intrinsic bonding; human • Whole grains
and intact in plants enzymes cannot • Dry beans and peas
• Functional Fiber, i.e., isolated break bonds; pass • Nuts and seeds
nondigestible carbohydrates relatively intact
that have beneficial through upper
physiological effects in digestive tract
human beings • Can be fermented
• Total Fiber = Dietary Fiber + by colonic
Functional Fiber microflora to
gases and short-
chain fatty acids
The Committee first reviewed the 2005 DGAC Report For Questions 2, 3, 4, 5, and 7, the conclusions
to inform their review process in 2010. Various topics expressed in the 2010 DGAC Report are informed by
in this section were also considered by the 2005 DGAC, the evidence compiled for the 2005 DGAC Report, but
including fiber (Question 1), whole grains (Question 2), are based primarily on the NEL evidence gathered and
vegetables and fruits (Question 3), glycemic index and reviewed since 2004. As described below, for some
load (Question 4), added sugars (Question 5), and questions, the search was extended back further to
liquids versus solids (Question 7). New questions capture a larger body of evidence.
considered by the 2010 Committee include non-caloric
sweeteners (Question 6), satiety (Question 8), and Question 2 examined the relationship between the
prebiotics and probiotics (Question 9). NEL evidence- consumption of whole grains and the incidence of
based systematic reviews were conducted for Questions cardiovascular disease (CVD), T2D, and measures of
2 to 7. The Committee addressed the remaining topics adiposity. These outcomes were selected because they
in the DGAC Report, but given limited time and represent leading causes of morbidity and mortality in
resources, the systematic review methodology was not the U.S. The Committee extended this search back to
applied. Rather, the most current or representative 1995, so that literature reviewed by the 2005 DGAC
evidence was applied. For example, the dietary fiber could also be considered.
question was primarily answered using the 2002 DRI
Report (IOM, 2002) and a recent position paper on fiber Question 3 examined the relationships between intake
from the American Dietetic Association (ADA) (Slavin, of vegetables and fruits, not including juice, and body
2008). These were supplemented by an updated weight, cardiovascular outcomes, and T2D in adults.
literature review. Questions on satiety and pre- and The Committee only considered studies that directly
probiotics also were answered using a general literature assessed the relationship between the intake of
search. vegetables and fruit and health outcomes; studies
examining the intake of vegetables and fruits as a part
For each of the NEL systematic review questions in this of specific dietary patterns are considered in Part D.
chapter, the following general criteria applied. All study Section 2: The Total Diet: Combining Nutrients,
designs were originally included in the searches, but Consuming Food. The childhood adiposity section in
cross-sectional studies were later excluded from the Part D. Section 1: Energy Balance and Weight
review if there was sufficient evidence from studies Management provides additional information about
with stronger study designs. The Committee excluded vegetables and fruits and 100 percent juice, and Part D.
studies that only included participants diagnosed with Section 2: Nutrient Adequacy discusses vegetables and
chronic disease, hyperlipidemia, hypertension, and fruits as food groups of concern for the American
related health conditions. A description of the NEL population. Cancer was not considered in the NEL
evidence-based systematic review process is provided in evidence-based systematic review because the
Part C: Methodology. Additional information about the Committee chose to address this topic using the World
NEL search strategies and criteria used to review each Cancer Research Fund/American Institute for Cancer
question can be found online at Research report (WCRF/AICR, 2007).
www.NutritionEvidenceLibrary.gov.
Similar to 2005, the review of glycemic index/load
Many systematic reviews and meta-analyses of primary (Question 4) included the outcomes of body weight and
research articles were considered by the Committee, and incidence of T2D, CVD, and cancer. Reviews for CVD
care was taken not to review the same study twice in the and T2D were extended to January 2000 because
NEL evidence-based review. For most questions, insufficient evidence was available to draw conclusions
systematic reviews and meta-analyses were included, from publications since 2004.
Background
Conclusion Vegetable and fruit consumption has long been
associated with good health probably due to their high
Consistent evidence suggests at least a moderate inverse vitamin, mineral, fiber, and phytochemical content, yet
relationship between vegetable and fruit consumption the research is surprisingly sparse on the documented
with myocardial infarction and stroke, with significantly associations between vegetables and fruits and specific
2010 Dietary Guidelines Advisory Committee Report 295
health outcomes. Several mechanisms for action were levels below three servings per day, results are
hypothesized in the 2005 DGAC Report, including that ambiguous at three to five servings of vegetables and
certain nutrients may directly improve CVD risk factors fruits per day, and lowest risk is associated with
or protect against cancer; that vegetables and fruits may consumption levels above five servings per day
displace or reduce intake of saturated fat, cholesterol, (Dauchet, 2006; He, 2007), suggesting a linear
and total calories; or that they may influence glucose relationship between vegetable and fruit consumption
metabolism. The study of vegetables and fruits on and CHD. Overall, risk reduction for CHD was
human health is complicated by many factors, including estimated to be as much as 4 percent and 11 percent for
their large variety globally, varying dietary patterns, stroke alone for each serving of vegetables and fruits
different effects for vegetables versus fruits, and added per day (Dauchet, 2006).
interactions with other dietary components. However,
most Americans, in all age-sex groups, consume Five studies investigating blood pressure and vegetable
substantially fewer vegetables and fruits than is and fruit intake were identified in the NEL search.
recommended. These included the PREMIER prospective cohort study
in the U.S. (Wang, 2008), one prospective study in
The 2005 DGAC Report noted that increased vegetable Spain (Nuñez-Cordoba, 2009),cross-sectional studies in
and fruit intake was associated with a reduced risk of Iran (Mirmiran, 2009), Japan (Utsugi, 2008), and India
stroke and perhaps other CVD. Moreover, the report (Radhika, 2008). Two studies showed no association
emphasized the role of vegetables and fruits in between total vegetable and fruit intake and blood
protecting against cancer, but noted that it is difficult to pressure (Mirmiran, 2009) and hypertension (Nuñez-
distinguish the role of vegetables and fruits per se Cordoba, 2009). Utsugi et al. (2008) showed a
(versus their fiber content) in preventing T2D or significant positive relationship with vegetable and fruit
glucose intolerance. Additionally, vegetables and fruits consumption and lower risk of home-measured
were noted to have a protective effect against weight hypertension. The Wang et al. (2008) study showed
gain probably mediated through reduced calorie intake. vegetable and fruit consumption was inversely
associated with both systolic and diastolic blood
Since 2004, a relatively small volume of work has been pressure at 6 months but not at 18 months.
published regarding vegetables and fruits. The evidence
from 2004 to 2009 is summarized below. The U.S. results support the work reviewed in the 2005
DGAC Report, but the international studies do not. The
Vegetable and Fruit Intake and Cardiovascular variation in results may be due to differences between
Disease these international population samples and typical
Evidence suggests at least a moderate inverse American patterns in baseline consumption levels of
relationship between vegetable and fruit consumption vegetables and fruits, types of vegetables and fruits
with myocardial infarction and stroke, with significantly consumed, and overall dietary patterns.
larger, positive effects noted above five servings of
vegetables and fruits per day. This evidence is based on Blood lipids are traditionally used as an intermediate
12 reports, including four meta-analyses (Dauchet, indicator or marker for CVD. The evidence testing the
2005, 2006; He, 2006, 2007) of U.S. and European effect of vegetable and fruit intake on blood lipids is
participants; six prospective studies, four of which were sparse, but suggests an associative trend between an
conducted in the U.S. (Genkinger, 2004; Hung, 2004; increased consumption of vegetables and fruits with
Joshipura, 2009; Tucker, 2005) and two in Japan lower total and LDL-blood cholesterol levels. The
(Nakamura, 2008; Takachi, 2008), and two evidence is based on three reports since 2004, including
international case-control studies (Galeone, 2009; one limited trial (Kelley, 2006) and two cross-sectional
Nikolic, 2008). Results varied by sex, with a significant studies (Mirmiran, 2009; Radhika, 2008). The trend is
decrease for men and women reported in all-cause apparent for total and LDL-cholesterol, and persists
cardiovascular death (Genkinger, 2004; Hung, 2004; even after adjustment for education, physical activity,
Joshipura, 2009), for men only (Tucker, 2005), for men and fat intakes. However, significance occurs only
only in terms of vegetable intake (Nakamura, 2008), when the highest levels of vegetable and fruit intake are
and for women only in terms of fruit intake (Nakamura, compared to the lowest levels of intake and the
2008). In addition, Takachi (2008) found significant mechanisms of action are unknown.
results for higher fruit (but not vegetable) intake in men
and women. Risk for CVD is highest at consumption
296 2010 Dietary Guidelines Advisory Committee Report
Vegetable and Fruit Intake and Body Weight (Bazzano, 2008) to 1.04 (Wang, 2006) and 1.21
A modest association with decreased weight gain over 5 (Halton, 2006b) when comparing lowest quintiles to
or more years in middle adulthood has been reported highest quintiles. However, the evidence is
with increased vegetable and fruit intake. However, insufficiently strong to draw firm conclusions.
based on current studies, no conclusions can be drawn
about the efficacy of increasing vegetable and fruit Vegetable and Fruit Intake and Cancer
consumption in achieving weight loss nor can any The DGAC chose not to conduct an independent
distinction be made about the relative influence of fruits systematic review of vegetables and fruits and cancer
versus vegetables on weight status. due to the comprehensive and recent report by the
WCRF/AICR (2007). The DGAC chose instead to
The review of evidence regarding weight gain and review the WCRF/AICR findings (see summary Table
vegetable and fruit consumption was based on 11 D4.2 at the end of the chapter). Types of cancer
studies (Bes-Rastrollo, 2006; Buijee, 2009; Davis, examined by the WCRF/AICR Panel include cancers of
2006; Fujioka, 2008; Goss, 2005; He, 2004; Ortega, the esophagus, stomach, colorectum, pancreas, liver,
2006; Radhika, 2008; Tanumibardjo, 2009; Vioque, prostate, cervix, endometrium, ovary, breast, skin, and
2008; Xu, 2007). These studies were conducted around mouth, pharynx, larynx, and nasopharynx. Broadly
the globe and varied considerably in length of speaking, there is no general agreement on classification
observation. Two of the RCTs (Fujioka, 2008; Ortega, of vegetables and fruits to drive comparisons in the
2006) collected data at an endpoint of only 6 weeks; a research questions. The WCRF/AICR Panel examined
third RCT evaluated participants at 3, 12, and 18 the evidence by starchy and non-starchy vegetables. In
months. All indicated small, but significant, and their analysis, starchy vegetables were combined with
nonsustainable weight loss over time with an intensive cereal grains, roots, tubers, and plantains. The non-
addition of vegetables and fruits to the diet. Similar starchy vegetables were categorized into subtypes
results showing weak inverse relationships between (cruciferous, allium [e.g., garlic], green leafy, tomatoes,
vegetable and fruit consumption and weight gain were and white or pale vegetables) and whether they are
noted in the prospective (Buijsee, 2009; He, 2004; eaten in raw (salad) or cooked forms. Studies also were
Vioque, 2008), case control (David, 2006), and cross- separated by whether the conclusions were based on
sectional studies (Bes-Rastrollo, 2006; Goss, 2005; vegetable intakes alone or vegetables and fruits
Radhika, 2008) that followed participants over a longer combined. In addition, evidence was examined in
time. The evidence is insufficient to ascertain the value vegetables and fruits containing certain micronutrients,
of vegetable and fruit consumption in weight loss diets. including folate, carotenoids (spinach, kale, butternut
squash, pumpkin, red bell pepper, carrots, tomatoes,
Vegetable and Fruit Intake and Type 2 Diabetes cantaloupe, and sweet potatoes), lycopene (tomatoes),
In a review of five articles describing prospective cohort other flavinoids or phytochemicals, vitamin C, and
studies, the evidence is inconsistent but suggests an other vitamins.
inverse association between the development of T2D
and total vegetable and fruit consumption (Liu, 2004), a The WCRF/AIRC Panel found that non-starchy
direct association with potato (French fry) consumption vegetables as a group as well as non-starchy vegetables
(Halton, 2006b), and no significant effect of tomato- and fruits in combination had a significant and
based products (Wang, 2006). Another study indicated consistent protective effect against cancer of the mouth,
that total vegetables as well as vegetable subgroups, but pharynx, and larynx, as well as esophageal cancer at
not fruit, may have a preventive effect (Villegas, 2008). least among the highest consumers of vegetables and
Conversely, the Nurses’ Health Study (Bazzano, 2008) fruits. Some studies suggested a dose response.
indicated no association between T2D risk and total Cruciferous vegetables, green leafy vegetables, and
vegetable and fruit consumption, but total fruit and tomatoes did not have a significant association for these
green leafy vegetables were inversely associated. The cancers as a separate exposure, but 16 of 18 cohort
number of vegetable and fruit servings in these five studies of carrot consumption indicate a statistically
studies ranged from about 2.5 servings to more than 10 significant effect. Raw vegetables show a consistent
servings per day and sample sizes were large in all five association (16 of 16 case-control studies) with
cohort studies ranging from 35,000 to 84,000 decreased risk of esophageal cancer. A decreased risk of
participants (Bazzano, 2008; Halton, 2006b; Liu, 2004; stomach cancer was associated with green-yellow
Villegas, 2008; Wang, 2006). The effect size was vegetables, but not with green, leafy vegetables,
variable ranging from a multivariate relative risk of 0.82 tomatoes, or white or pale vegetables. Data about an
2010 Dietary Guidelines Advisory Committee Report 297
association with nasopharyngeal cancer are too sparse cancer and stomach cancer, whereas a substantial
and the data relating non-starchy vegetables to amount of data indicate it may protect against colorectal
colorectal cancer are too inconsistent to draw a firm cancer, but these studies are from case-control designs
conclusion. Limited evidence suggests that non-starchy only.
vegetables protect against lung, ovarian, and
endometrial cancers. The evidence is sparse but fairly Part of the healthful effect of vegetables and fruits,
consistent that allium vegetables (such as onions, garlic, including protection against cancer risk, may be due to
leeks, and chives) probably protect against stomach and the effect of phytochemicals. Technically,
colorectal cancer and that carrots may protect against phytochemicals are not essential to the diet, so no daily
cervical cancer. requirement has been established for them, but they are
bioactive and there may be as many as 100,000
In their analysis, the WCRF/AICR Panel combined different compounds. Future research will require
starchy vegetables with other starchy plant foods, assessment of these compounds and the possible
including grains, tubers (including potatoes), plantains mechanisms that may be associated with health. Only
(excluding bananas), and roots, recognizing that these then can the amounts needed for a public health effect
foods have to be prepared or cooked in some way to be noted, both in foods and in herbs and spices.
make them edible. The panel concluded that all foods in
the starchy vegetable group as well as starchy
vegetables and fruits in combination have an Question 4: What Is the Relationship
insubstantial effect on the risk of any cancer. Between Glycemic Index or Glycemic Load
and Body Weight, Type 2 Diabetes,
According to the WCRF/AICR Panel, fruits as a group, Cardiovascular Disease, and Cancer?
including fruit subtypes, show consistent evidence
suggesting that they protect against mouth, pharynx,
larynx, and esophageal cancer, though most of the Conclusion
studies are case-control designs. The evidence for a
protective effect of fruits on lung cancer is convincing Strong and consistent evidence shows that glycemic
with a dose-response relationship. Evidence linking index and/or glycemic load are not associated with body
fruits to nasopharyngeal cancer, pancreatic cancer, weight and do not lead to greater weight loss or better
colorectal, and liver cancer is too sparse and/or weight maintenance. Abundant, strong epidemiological
inconsistent to draw conclusions. evidence demonstrates that there is no association
between glycemic index or load and cancer. A moderate
Micronutrients in vegetables and fruits that have been body of inconsistent evidence supports a relationship
studied for risk of cancer include beta-carotene and between high glycemic index and T2D. Strong,
lycopene, folate, vitamin C, vitamin D, vitamin E, convincing evidence shows little association between
quercetin, pyridoxine, and selenium (see Part D. glycemic load and T2D. Due to limited evidence, no
Section 2: Nutrient Adequacy for additional information conclusion can be drawn to assess the relationship
on folate and health outcomes). Foods containing between either glycemic index or load and
carotenoids probably protect against cancers of the cardiovascular disease.
mouth, pharynx, larynx, and esophagus as well as lung
cancer with a dose-response relationship, but they are Implications
unlikely to have a substantial effect on prostate cancer
or non-melanoma skin cancer. Foods containing folate When selecting carbohydrate foods, there is no need for
probably protect against pancreatic cancer. A concern with their glycemic index or glycemic load.
substantial amount of consistent evidence indicates that What is important to heed is their calories, caloric
foods containing lycopene, especially cooked tomato density, and fiber content.
products, probably protect against prostate cancer.
Review of the Evidence
Studies about the effect of dietary vitamin E show non-
significant decreased risk of esophageal and prostate Background
cancer and much of the evidence is of poor quality. A There has been a great deal of interest as to whether
sparse amount of evidence for foods containing glycemic index and glycemic load can predict the risk
selenium suggest this mineral may protect against lung of chronic disease. The Committee felt that the question
Other fibers added to drinks do change satiety. Pelkman Food Form and Satiety
et al. (2007) added low doses of a gelling pectin- The physiological effects of solids versus liquids are
alginate fiber to drinks and measured satiety. The drinks covered in Question 7, but the satiety effects of liquid
were consumed twice a day over 7 days and energy diets will be described here. Overall, inconsistent
intake at the evening meal was recorded. The 2.8 gram evidence suggests that energy from liquids is less
dose of pectin alginate caused a decrease of 10 percent satiating than energy from solids (Benelam, 2009).
in energy intake at the evening meal. Thus, it generally Soups appear to have a particularly satiating effect,
2010 Dietary Guidelines Advisory Committee Report 309
which may be due to their lower energy density. Mattes which are referred to as the microbiota. Although the
(2005) has suggested that soups are seen as part of a importance of the microbiota has been accepted for
meal and consumed in response to hunger, compared diseases of the large intestine, it is now thought that the
with drinks, which are consumed to address thirst or to microbiota play a role in obesity control and other
accompany foods. The impact of intense sweeteners on chronic diseases such as autism. Because of these new
satiety and energy intake, as reviewed by Drewnowski ideas, consumer interest in altering the microbiota is
and Bellisle (2007), is mixed, with some studies finding high.
increases in appetite and/or energy intake, some
decreases, but most finding no significant effects. Prebiotics are defined as “a non-digestible food
Differences in study design make it difficult to reach ingredient that beneficially affects the host by
any overall conclusions about the effect of intense selectively stimulating the growth and/or activity of one
sweeteners on satiety, but it seems that intense or a limited number of bacteria in the colon, and thus
sweeteners do not enhance satiety. improves host health” (De Vrese, 2008).
Oligosaccharides such as fructo-oligosaccharides and
Thus, many factors affect satiety and most studies are galacto-oligosaccharides are generally accepted as
conducted in laboratory settings to control for variables. prebiotics and are often added to infant formula and
Therefore, results may not be generalized to the more other food products.
complicated eating environment of the outside world.
Foods high in dietary fiber generally are more satiating Probiotics are defined viable microorganisms, sufficient
than low-fiber foods, although some fibers added to amounts of which reach the intestine in an active state
drinks have little impact on satiety. Overall, small and thus exert positive health effects (De Vrese, 2008).
changes in the macronutrient content of the diet are Synbiotics are combinations of both probiotics and
unlikely to significantly alter satiety. prebiotics. The idea to suppress and displace harmful
bacteria in the intestine by orally administered
“beneficial” ones and thus improve microbial balance,
Question 9: What Is the Role of Prebiotics health, and longevity has been around for more than a
and Probiotics in Health? century. Tissier (1906) recommended the administration
of bifidobacteria to infants suffering from diarrhea,
claiming that bifidobacteria supersede the putrefactive
Conclusion
bacteria causing the disease. He showed the
bifidobacteria were predominant in the gut of breast-fed
Gut microflora play a role in health, although the
infants, the rationale for adding prebiotics to infant
research in this area is still developing. Foods high in
formula. Nobel Prize winner Elie Metchnikoff (1907)
prebiotics (wheat, onions, garlic) may be consumed, as
also suggested that intake of lactobacilli-containing
well as food concentrated in probiotics (yogurt), within
yogurt results in reduction of toxin-producing bacteria
accepted dietary patterns.
in the gut which increased longevity in the host.
Implications
For this review, we completed a non-NEL review since
2004 of systematic reviews on prebiotics and probiotics
The lack of epidemiologic studies that support a role for
and health. We conclude that the importance of the gut
changes in gut microflora and health outcomes limits
microbiota is an important emerging area of research,
any specific dietary recommendations in this area.
but not enough research is available to make dietary
Foods high in prebiotics and probiotics are linked to
recommendations for either prebiotics or probiotics. All
health benefits. For example, fiber is a prebiotic linked
prebiotics are dietary fibers, but not all dietary fibers are
to health benefits. Many probiotic-containing foods,
prebiotics. Recommended intakes of dietary fiber can
such as dairy foods, also are linked to health benefits
provide prebiotics to the diet. Also, recommended
and are recommended for inclusion in the diet.
foods, such as yogurt, are probiotics, so by observing
guidelines for dairy food consumption and picking
Review of the Evidence
yogurt or other fermented dairy products, probiotics will
be included in the diet.
Evidence that the intestinal microbiota is linked with
overall health is emerging (Davis, 2009b). The adult
Some of the proposed health benefits of prebiotics and
human gut contains 100 trillion microbial organisms,
probiotics include reduction in diarrhea incidence,
310 2010 Dietary Guidelines Advisory Committee Report
improvements in gut health, elimination of allergies, energy from added sugars is suggested, based on trends
and prevention of infections. It is accepted that the gut indicating that people with diets at or above this level of
microflora have a potential role in immune function, but added sugars are more likely to have poorer intakes of
studies showing an improvement in immunity with important essential nutrients. Active Americans should
consumption of either prebiotics or probiotics are consume diets at the high end of the AMDR range
limited. Despite the continued interest in enhancing the (65%) while Americans on low calorie diets will need
gut environment, there are no cohort studies where fecal to consume diets at the low end of the range (45%).
samples have been collected and higher levels of Usually proteins will replace carbohydrate on low
bifidobacteria or lactobacillus in feces linked to calorie diets.
improved health status.
Americans should choose fiber-rich foods such as
A systematic review of randomized controlled trials whole grains, vegetables, fruits, and cooked dry beans
evaluating the relationship between probiotics and and peas as staples in the diet. Dairy products are also a
constipation concluded that until more data are nutrient-dense source of carbohydrates in the diet and
available, the use of probiotics for the treatment of provide high quality protein, vitamins, and minerals.
constipation should be considered investigational
(Chmielewska and Szajerska, 2010). Probiotics may Carbohydrates are the primary energy source for active
play a role in preventing and treating acute diarrhea in people. Sedentary people, including most Americans,
both children and adults, although results are should decrease consumption of caloric carbohydrates
inconsistent (Cummings, 2009). A systematic review to balance energy needs and attain and maintain ideal
and meta-analysis of probiotics in the treatment of weight. The high-energy, non-nutrient-dense
irritable bowel syndrome found that probiotics could carbohydrate sources that should be reduced to aid in
potentially play a role in irritable bowel syndrome calorie control include SSB, desserts, including grain-
treatment, but results of trials are inconsistent and many based desserts, grain products, and other carbohydrate
questions remain on the type of probiotics, dose, and foods and drinks that are non-nutrient-dense.
whether certain subgroups of patients are more likely to
benefit from probiotics (Hoveyda, 2009).
Needs for Future Research
The effect of prebiotics on immune function, infection,
and inflammation was reviewed (Lomax and Calder, 1. Develop and validate carbohydrate assessment
2009a). Again, results are mixed in human trials. Ten methods. Explore and validate new and emerging
trials involving infants and children have mostly biomarkers to elucidate alternative mechanisms and
reported benefits on infectious outcomes, while in 15 explanations for observed effects of carbohydrates
adult trials, little effect was seen. A similar review was on health.
conducted on probiotics (Lomax and Calder, 2009b).
Overall, the data are mixed with large species and strain Rationale: Studies of carbohydrates and health
differences of probiotic treatments influencing results. outcomes on a macronutrient level are often
inconsistent or ambiguous due to inaccurate
Thus, the DGAC believes that the gut microbiota do measures and varying food categorizations and
play a role in health, although the research in this area is definitions. The science cannot progress without
still developing. No recommendations for intake of further advances in both methodology and theory.
prebiotics or probiotics for the American people can be
made, although foods high in prebiotics (wheat, onions, 2. Develop definitions for whole grain foods and
garlic) should be consumed, as well as food criteria for whole grain foods that can be
concentrated in probiotic (yogurt). universally accepted.
3. Conduct intervention and research studies with 7. Develop methods for use in epidemiologic studies
strong designs that include sufficient sample sizes to measure accurately or quantify intake of liquids,
over time and specific measures of vegetable and either caloric or non-caloric.
fruit intake, including specific types of vegetables
and fruits, overall dietary patterns, exercise, sex, Rationale: There has been an increase in the
and other confounding factors to evaluate the number of beverages available, and it would be
impact of consuming vegetables and fruits on valuable to know how these beverages are
health. contributing to satiety, energy intake, and body
weight. Drinks can include a wide range of
Rationale: Rigorous methods of assessing dietary macronutrients and artificial sweeteners, and are
intake are needed along with rigorous measures of difficult to assess with food frequency instruments.
outcomes. Strong designs that control for The type of drinks consumed now includes sport
confounding variables will provide deeper insight drinks, designer coffees and teas, smoothies and
into the effect vegetables and fruits have on health. juices, and carbonated beverage with different
Plausible mechanisms for these effects also need to sugars or artificial sweeteners.
be studied in depth. Traditional markers, such as
blood lipids, while useful for risk factor assessment, 8. Determine whether the effects of vegetables and
appear to have limited explanatory value. fruits in the overall dietary pattern are due to
displacement of other foods in the diet or to the
4. Conduct long-term, randomized controlled trials to action of vegetables and fruits per se on specific
resolve whether use of nonnutritive sweeteners can health outcomes.
actually aid weight loss or prevent weight gain.
Rationale: The mechanism(s) of action for the
Rationale: Currently available data are insufficient effects of vegetables and fruits have not been
to recommend non-nutritive sweeteners as an aid to determined and, therefore, may vary for different
weight loss, except on a theoretical basis for calorie health outcomes. The observed effects could be a
reduction. simple displacement of these foods with other foods
that cause poorer outcomes or vegetables and fruits
5. Develop standardized assessment tools to determine may contribute specific benefits or a combination of
accurate intake of added sugars. the above may explain the observations made thus
far in the literature. Only further research can
Rationale: This is challenging because provide more definitive answers.
carbohydrate methods are also limited as total
carbohydrate is measured “by difference.” Unless 9. Identify whether a progressive, inverse relationship
efforts are made to define and measure of fruits and vegetable consumption exists with the
carbohydrates and carbohydrate fractions with prevention of chronic disease(s) or whether there is
potential health benefits, it will be difficult to a threshold effect that may vary depending on
determine if different carbohydrates types have factors such as disease, sex, and dietary pattern.
different health effects.
Rationale: The evidence suggests that there may be
6. Develop innovative methods to evaluate “food a threshold effect of vegetables and fruits, at least
form” as a variable in food intake studies for the within the American dietary pattern, but further
field to progress. research is needed to verify this hypothesis and to
test whether the threshold varies among a variety of
Rationale: Unless macronutrients are carefully dietary patterns and/or among the specific variety of
controlled, it is not possible to answer the question vegetables and fruits consumed.
on how food form affects energy intake. These
questions will remain unless RCTs are conducted
Substantial
effect on
Foods containing beta-carotene9: prostate; skin (non-melanoma)
risk
unlikely
1
Judgements on vegetables and fruits do not include those preserved by salting and/or pickling.
2
Includes both foods naturally containing the constituent and foods which have the constituent added (see chapter
3.5.3).
3
Mostly contained in tomatoes and tomato products. Also fruits such as grapefruit, watermelon, guava, and apricot.
4
Also found in some roots and tubers—notably potatoes. See chapter 4.1.
5
Also found in cereals (grains) and in some animal foods. See chapters 4.1 and 4.3.
6
Also found in plant seed oils. See chapter 4.5.
7
Including soya and soya products.
8
Vitamin B6. Also found in cereals. See chapter 4.1.
9
The evidence is derived from studies using supplements and foods containing beta-carotene: see chapter 4.10.
For an explanation of all the terms used in the matrix, please see chapter 3.5.1, the text of this section, and the
Glossary.
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Introduction POTASSIUM
Dietary intakes of sodium, potassium, and water have 2. What are the effects of potassium intake on blood
substantial health effects. Excessive sodium intake, pressure in adults?
especially when accompanied by inadequate potassium
intake, raises blood pressure, a well-accepted and WATER
extraordinarily common risk factor for stroke, coronary
heart disease, and kidney disease (see below for 3. What amount of water is recommended for health?
background information on the problem of elevated
blood pressure and its control). Adverse effects of
sodium on blood pressure appear to begin early in life. Methodology
Because of worsening blood pressure levels in children
in the United States (U.S.), the 2010 Dietary Guidelines The 2005 DGAC based its conclusions regarding these
Advisory Committee (DGAC) decided to evaluate questions on evidence extracted from Dietary Reference
available research on the health effects of sodium in Intakes for Water, Potassium, Sodium, Chloride, and
children, as well as update the 2005 DGAC’s review of Sulfate, an extensive, systematic review of the scientific
research on the health effects of sodium in adults. literature conducted by an expert panel for the Institute
Inadequate potassium intake raises blood pressure and of Medicine (IOM) (IOM, 2005). The conclusions
increases the blood pressure response to excess sodium expressed in the 2010 DGAC Report are based on that
intake. evidence plus subsequent evidence, especially regarding
diet and blood pressure in children. Thus, while the vast
In addition to their effects on blood pressure, excessive majority of research on the health effects of sodium,
sodium and insufficient potassium likely have other potassium, and water on adults was published before
health consequences. Excess sodium intake has been 2005 and synthesized in the 2005 Report, this 2010
linked to an increased incidence of gastric cancer. Report builds upon those findings and adds relevant
Inadequate potassium intake may increase the risk of new literature from updated searches. Additional
kidney stones and perhaps osteoporosis. Americans information about the search strategies and criteria used
consume excessive sodium and insufficient potassium to review each question can be found online in the
across the lifespan. Nutrition Evidence Library (NEL) at
www.NutritionEvidenceLibrary.gov. The new focus
Water is the single largest constituent of the human involves considerably more effort in reviewing the
body and is required to maintain adequate hydration. In emerging and growing evidence on the blood pressure
the U.S., water intake appears adequate, without effects of sodium in children. The overall search
evidence of chronic insufficient or excessive intake. strategies used to identify relevant literature and update
scientific evidence appear in Part C. Methodology.
Table D6.1. Sodium recommendations of scientific and public health agencies and organizations
Date
Organizations Published Sodium Recommendation
United States
Adults
American Heart 2010 Sodium: <1500 mg per day for adults; The recommendation for 1500 mg/d does
Association not apply to individuals who lose large volumes of sodium in sweat, such as
competitive athletes and workers exposed to extreme heat stress (e.g., foundry
workers and fire fighters), or to those directed otherwise by their healthcare
provider (Lloyd-Jones, 2010). Web reference (accessed 23 March 2010):
http://circ.ahajournals.org/cgi/content/full/112/13/2061
American Society 2009 Lower sodium intake as much as possible, with a goal of no more than 2300
of Hypertension mg/d in the general population and no more than 1500 mg/d in Blacks, middle-
and older-aged persons, and individuals with hypertension, diabetes, or chronic
kidney disease (Appel, 2009). Web reference (accessed 23 March 2010):
http://www.ash-us.org/assets-new/pub/pdf_files/DietaryApproachesLowerBP.pdf
National High 2002; Reduce dietary sodium intake to no more than 100 mmol per day (2300 mg
Blood Pressure 2003 sodium or 6 g sodium chloride) as a means to prevent hypertension in non-
Education hypertensive individuals (Whelton et al., 2002) and as first line and adjuvant
Program therapy in hypertensive individuals (Chobanian, 2003). Web reference (accessed
23 March 2010): http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf
Children
American 2006 Adopted American Heart Association Position. Sodium recommendation by age:
Academy of 1-3 yrs <1500 mg; 4-8 yrs <1900 mg; 9-13 yrs <2200 mg; 14-18 yrs <2300 mg
Pediatrics (AHA/Gidding et al., 2006). Web reference (accessed 9 March 2010):
http://pediatrics.aappublications.org/cgi/content/full/117/2/544
American Dietetic 2008 The current recommendation for adequate daily sodium intake for children 4-8
Association yrs is 1200 mg/day and for older children 1500 mg/day (ADA, 2008).
http://www.adajournal.org/article/S0002-8223(08)00496-3/abstract
American Heart 2005 Based on Dietary Guidelines for Americans, 2005/ IOM DRI Sodium UL by age:
Association 1-3 yrs <1500 mg; 4-8 yrs <1900 mg; 9-13 yrs <2200 mg; 14-18 yrs <2300 mg
(Gidding et al., 2005). Web reference (accessed 23 March 2010):
http://circ.ahajournals.org/cgi/content/full/112/13/2061
International
Adults or Mixed Populations
Australia and New 2005 Recommends that Australian adults consume less than 2300 mg of sodium per
Zealand day (NHMRC, 2005). Web reference (accessed 9 March 2010):
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/n36.pdf
Date
Organizations Published Sodium Recommendation
International
Adults or Mixed Populations
Canada 2006 Current Health Canada statement is based on IOM DRI Report: People 14 yrs
and older not exceed 2300 mg of sodium per day. Adequate Intakes (AIs) for
good health range from 1000 mg/d sodium for people 1-3 yrs to 1500 mg/d for
people 9-50 yrs. Sodium Reduction Working Group policy update expected in
June 2010 (Health Canada, 2005). Web reference (accessed 9 March 2010):
http://www.hc-sc.gc.ca/fn-an/nutrition/sodium/index-eng.php
European Union 2004 EU Framework for Salt Reduction incorporates WHO/FAO recommendation
for reducing dietary salt intake to <5-6 g per day (2000-2300 mg/d); 21 of 30
nations directly adopted recommendation, 5 countries adopted a higher interim
goal or range, 4 countries reported no dietary sodium guidance (EU, 2009).
Web reference (accessed 9 March 2010):
http://ec.europa.eu/health/archive/ph_determinants/life_style/nutrition/documen
ts/national_salt_en.pdf
Food and 2003 Population nutrient intake goals for preventing diet-related chronic diseases,
Agriculture Sodium chloride (sodium) <5 g per day (Sodium <2000 mg per day) (FAO,
Organization 2003). Web reference (accessed 9 March 2010):
(FAO) http://www.fao.org/docrep/005/AC911E/ac911e07.htm
Pan American 2009 Member nations (n=46) acknowledged WHO/FAO recommendation to reduce
Health dietary sodium intake to <2000 mg per day for cardiovascular disease
Organization prevention through dietary salt reduction (PAHO, 2009). Web reference
(PAHO) (accessed 9 March 2010):
http://new.paho.org/hq/index.php?option=com_content&task=view&id=2015&
Itemid=1757
United Kingdom 2003 Food Standards Agency set a target to reduce the adult population’s average
salt intake to 6g (sodium 2300 mg) per day by 2010 (UK, 2009). Web
reference (accessed 9 March 2010):
http://www.food.gov.uk/healthiereating/salt/salttimeline
World Health 2003 Set an upper limit of 70 mmol (1700 mg) of sodium per day as a means to
Organization lower blood pressure. All individuals should be strongly encouraged to reduce
daily salt intake by at least one-third and, if possible, to <5 g or <90 mmol per
day (WHO, 2003). Web reference (accessed 9 March 2010):
http://www.who.int/cardiovascular_diseases/guidelines/PocketGL.ENGLISH.A
FR-D-E.rev1.pdf
Children
Canada 2006 Adequate Intakes (AIs) of sodium for good health for people aged one year and
over range from 1000 mg/day for children 1-3 yrs to 1500 mg/day for people 9
yrs and older (Health Canada, 2006). Web reference (accessed 9 March 2010):
http://www.hc-sc.gc.ca/fn-an/nutrition/sodium/index-eng.php
Date
Organizations Published Sodium Recommendation
United Kingdom 2003 The Food Standards Agency issues advice for parents on amounts of salt
infants and children should consume: Children: 0-6 months <1 g (400 mg
sodium); 6-12 months - 1g (400 mg sodium); 1-3 yrs - 2g/day (800 mg
sodium); 4-6 yrs - 3 g/day (1200 mg sodium); 7-10 yrs - 5/g day (2000 mg
sodium); 11-14 yrs - 6 g/day (2400 mg sodium) (UK, 2009). Web reference
(accessed 9 March 2010):
http://www.food.gov.uk/scotland/aboutus_scotland/pressreleases/2003/may/1212
53
Review of the Evidence: Sodium Intake and blood pressure tracking, and found strong evidence for
Blood Pressure in Children blood pressure tracking from childhood to adulthood.
They concluded that childhood blood pressure is
Background associated with blood pressure in later life, and
In the U.S. and most other countries, blood pressure therefore, early intervention is important.
slowly rises with age. The age-related increase in blood
pressure begins early in childhood and increases Recent evidence shows that mean blood pressure levels
thereafter. The annual increase during childhood is have increased among U.S. children and adolescents
actually greater than during adult life, increasing 1.9 over the past two decades. Muntner et al. (2004)
millimeters of mercury (mmHg) per year for boys, and compared the blood pressure of U.S. children, aged 8 to
1.5 mmHg for girls, ages 1 to 17 years, compared with 17 years, in the National Health and Nutrition
0.6 mmHg per year for U.S. adults (Appel, 2008; Examination Survey (NHANES) III (1988-94; n=3,496)
National High Blood Pressure Education Program with the blood pressure of similar-aged youth in
Working Group on High Blood Pressure in Children NHANES 1999-2000 (n=2,086). In the latter survey,
and Adolescents, 2004). These data should be viewed in mean systolic blood pressure had increased by 1.4
the context of the high blood pressure epidemic. More mmHg, and mean diastolic blood pressure by 3.3
than 90 percent of U.S. adults 50 years of age or older mmHg (after adjustment for age, race, and sex). After
will develop hypertension in their lifetime (Vasan, further adjustment for body mass index (BMI)
2002). Hence, most children, even those with blood distribution at each time period, the increase in systolic
pressure in the usual range during childhood, are still at blood pressure was reduced by 29 percent and for
high risk of hypertension as adults. Because high blood diastolic blood pressure by 12 percent. Greater increases
pressure is a well established risk factor for were seen among some subgroups of minority youth,
cardiovascular disease, preventing the gradual rise in especially boys. Among non-Hispanic Blacks, mean
blood pressure during childhood and adolescence could systolic blood pressure levels increased by 2.9 mmHg
translate into substantial health benefits for Americans among boys and 1.6 mmHg among girls compared with
of all ages. non-Hispanic Whites. Among Mexican Americans,
mean systolic blood pressure levels increased by 2.7
Blood pressure during childhood exhibits a significant mmHg among boys and 1.0 mmHg among girls
tracking phenomenon. That is, children tend to retain compared with non-Hispanic Whites. During the same
their position in the blood pressure distribution over time period, the prevalence of hypertension 1 increased
time, relative to their peers. Thus, children who tend to
track in the high, borderline high, or high normal 1
Hypertension in children and adolescents is defined as
percentiles of blood pressure for age, sex, and height, systolic or diastolic blood pressure equal to or greater than
are at greater risk of eventual hypertension than are the 95th blood pressure percentile of sex-, age- and height-
children who tend to track in the lower ranges of blood specific blood pressure percentiles. Pre-hypertension is
pressure. Chen and Wang (2008) conducted a meta- defined as systolic or diastolic blood pressure equal to or
analysis that included 50 pediatric cohort studies of greater than the 90th percentile but less than the 95th
percentile, or a blood pressure of greater than 120/80 but less
330 2010 Dietary Guidelines Advisory Committee Report
by 2.3 percent and the prevalence of pre-hypertension presence of other CVD risk factors, such as obesity,
increased by 1.0 percent among children and dyslipidemia, and cigarette smoking.
adolescents (Din-Dzietham, 2007).
As in adults, several dietary factors likely raise blood
The shift in mean blood pressure levels toward higher pressure in children. In addition to excess sodium
values for U.S. youth, and the increased prevalence of intake, other possible factors include excess weight and
hypertension and pre-hypertension are of public health insufficient potassium intake. Both systolic and
concern, not only because of increased risk of diastolic blood pressure are higher on average among
cardiovascular disease (CVD) morbidity and mortality overweight children and adolescents, compared to
in adult life, but because studies have now shown that normal weight peers (Sorof, 2004). Based on studies in
elevated blood pressure in childhood results in adults, diets rich in potassium might lower blood
significant cardiovascular dysfunction and pathology pressure and lessen the adverse effects of sodium on
during childhood itself (Daniels, 1998; Mahoney, 1996; blood pressure. As discussed below, the largest volume
McCarron, 2000; McGill, 2000; Soto, 1989; Tracy, of research on dietary factors on blood pressure in
1995). For example, in a study of 130 hypertensive children has focused on the effects of excess sodium
children and youth, ages 6 to 23 years, 55 percent were intake.
found to have left ventricular hypertrophy2 (left
ventricular mass index >90th percentile). Additionally, Evidence on the Relationship Between Sodium
14 percent had left ventricular mass index greater than Intake and Blood Pressure in Children
the 99th percentile, and 8 percent had a left ventricular A systematic review of the literature identified 19
mass index above 51 g/m2.7, a cut-point associated with studies (15 trials and 4 prospective observational
a fourfold increase in risk of CVD endpoints in adults studies). Although the vast majority of studies were
with hypertension (Daniels, 1998). The authors also small (and therefore underpowered) or had another
report that sodium intake was significantly higher methodological limitation, they showed a consistent
among youth with severe left ventricular hypertrophy pattern of lower blood pressure in those groups with a
compared with those with normal left ventricular mass reduced sodium intake.
(Daniels, 1998).
Of the 15 trials, 14 were randomized controlled trials
High blood pressure, as well as other CVD risk factors, (RCTs) (Calabrese and Tuthill, 1985; Cooper, 1984;
when present in childhood, have been shown to be Gillum, 1981; Hofman, 1983; Howe, 1985,1991;
strongly associated with the extent of early Lucas, 1988; Myers, 1989; Palacios, 2004; Pomeranz,
atherosclerotic fatty streaks and fibrous plaques in the 2002; Sinaiko, 1993; Trevisan, 1981; Tuthill and
aorta and coronary arteries. The Bogalusa Heart Study Calabrese, 1985; Whitten and Stewart, 1980). Five of
group performed autopsies on 204 young people, aged 2 the RCTs were methodologically strong (Gillum, 1981;
to 39 years, most of whom died from trauma. Hofman, 1983; Howe, 1991; Sinaiko, 1993), seven
Investigators had data on childhood ante-mortem risk were methodologically neutral (some potential for bias)
factor status for 93 of these individuals. Systolic blood (Calabrese and Tuthill, 1985; Cooper, 1984; Howe,
pressure, diastolic blood pressure, BMI, and serum lipid 1985; Myers, 1989; Palacioset al. 2004; Pomeranz,
and lipoprotein concentrations in childhood were all 2002; Whitten and Stewart, 1980), and two were
strongly associated with the extent of fatty streaks and methodologically weak (Lucas, 1988; Trevisan, 1981).
fibrous plaques in the aorta and coronary arteries seen at The 15th trial, a methodologically strong study (Ellison,
autopsy (Berenson, 1998). Thus, high blood pressure in 1989), was the largest and longest trial, a two-period
youth promotes the development of atherosclerosis, the cross-over study conducted in two boarding schools.
progression of which is greatly enhanced in the
Four other studies provided evidence that supported this
conclusion. One, a methodologically strong study, was a
15-year follow-up of an infant RCT conducted by
than the 95th percentile of sex-, age- and height-specific Hofman et al. (1983) in the Netherlands (Geleijnse,
blood pressure percentiles (National High Blood Pressure 1997). Three additional studies were prospective
Education Program Working Group on High Blood Pressure longitudinal cohort studies (Brion, 2008 [neutral
in Children and Adolescents, 2004).
2 quality]; Geleijnse, 1990 [positive quality]; and Smith,
Left ventricular hypertrophy is an enlargement of the muscle
tissue that makes up the wall of the left ventricle, the heart’s 1995 [negative quality]).
main pumping chamber.
2010 Dietary Guidelines Advisory Committee Report 331
Ten of the 14 RCTs achieved contrasts in sodium intake The final study included in this evidence review was a
of 40 percent or more between treatment groups or 15 year follow-up study by Geleijnse et al. (1997) of an
periods (Cooper, 1984; Hofman, 1983; Howe, 1985, RCT conducted among infants who participated in the
1991; Lucas, 1988; Myers, 1989; Palacios, 2004; initial trial between birth and age 6 months (Hofman,
Pomeranz, 2002; Tuthill and Calabrese, 1985; Whitten 1983). In this methodologically strong long-term
and Stewart, 1980). Two other RCTs achieved contrasts follow-up study, systolic blood pressure and diastolic
of 7 to 12 percent (Calabrese and Tuthill, 1985; blood pressure at follow-up were still lower among
Trevisan, 1981), and two achieved less than a 2 percent children initially assigned to the low sodium diet during
difference between treatment groups (Gillum, 1981; infancy, compared with the higher sodium group. The
Sinaiko, 1993). Although the extent of sodium difference for systolic blood pressure was statistically
reduction often appeared large, the data often came significant (p<0.05) and for diastolic blood pressure
from dietary recalls or dietary histories (in which was of borderline significance (p=0.08). These results
intakes are often underreported), rather than from 24- support the hypothesis that a programming effect of
hour urine collections, which are considered more sodium intake in early life on blood pressure may exist,
accurate reflections of sodium intake. because the difference in blood pressure between
treatment groups persisted for 15 years, even though all
Twelve of the 15 intervention studies showed a infants resumed their usual diet when the double-blind
decrease in systolic blood pressure and or diastolic trial ended at 6 months of age.
blood pressure on the low sodium diet (Calabrese and
Tuthill, 1985; Cooper, 1984; Ellison, 1989; Hofman, Infancy may be a particularly sensitive period with
1983; Howe, 1985, 1991; Myers, 1989; Palacios, 2004; respect to the effect of dietary sodium on later blood
Pomeranz, 2002; Sinaiko, 1993; Trevisan, 1981; pressure. Young infants, before the age of 4 to 6
Whitten and Stewart, 1980). Three studies reported no months, are less able to respond physiologically to
change in blood pressure on a low sodium diet (Gillum, varying concentrations of salt solutions, thus are at
1981; Lucas, 1988; Tuthill and Calabrese, 1985). greater risk of hypernatremia with higher intakes of
dietary sodium. Human milk has a low concentration of
Of the 12 intervention studies that showed a decrease in sodium, at about 15 milligrams per 100 milliliter
systolic blood pressure and/or diastolic blood pressure (Sutton, 2008). In a meta-analysis of 15 studies,
on the low sodium diet, the decrease was statistically breastfeeding during infancy was found to be associated
significant for all, or a subset, of the study population in with lower blood pressure at follow-up 3 to 60 years
eight of the studies (Calabrese and Tuthill, 1985; later, compared with bottle feeding (Martin, 2005).
Ellison, 1989; Hofman, 1983; Howe, 1985; Myers, Although the differences were small (systolic blood
1989; Pomeranz, 2002; Sinaiko, 1993; Trevisan, 1981). pressure -1.4/ diastolic blood pressure -0.5 mmHg) they
were statistically significant. The composition of
Results from two of the three prospective cohort studies commercial infant formulas, however, has changed
tend to support the results of the intervention trials. The significantly over the past several decades, and although
studies by Brion et al. (2008) and Geleijnse et al. (1990) sodium levels of formulas were higher than breast milk
involved prospective cohorts that were followed for 7 before approximately 1980, formulations with sodium
years. In the study by Brion et al. (2008), higher sodium levels comparable to human milk were introduced in the
intake at age 4 months (but not at 7 months or 7 years) U.S. and elsewhere beginning in the mid-1970s
was associated with increased systolic blood pressure at (Martin, 2005). Several studies of infants born since
age 7 years. This was consistent with infants younger 1980, however, still show a blood pressure-lowering
than age 4 months having greater difficulty excreting a effect of breastfeeding compared with formula feeding,
sodium load. In the cohort study by Geleijnse et al. suggesting that breastfeeding may benefit blood
(1990), a higher sodium/potassium ratio was associated pressure through a complex variety of mechanisms in
with a greater increase in slope of blood pressure addition to the low sodium content of breast milk. The
change over time. In the methodologically weak infant association of breastfeeding with healthier patterns of
cohort study by Smith et al. (1995), neither the contrast infant weight gain and decreased obesity is likely to be
in sodium intake, nor the actual blood pressure was another blood pressure-protective mechanism (Arenz,
provided. The authors indicate that in the multivariate 2004).
analysis, the amount of sodium added to the diet
approached clinical significance (p=.0751). In aggregate, these data document that sodium
reduction modestly lowers blood pressure in infants and
332 2010 Dietary Guidelines Advisory Committee Report
children. While the degree of reported blood pressure hypertension (Lewington, 2002; Vasan, 2001). Nearly a
lowering was usually modest, in the range of -1 to -5 third of blood pressure-related deaths from coronary
mmHg, such an effect, if sustained over time, could heart disease occur in people who do not have
translate into reduced blood pressure in adults, and thus hypertension (Stamler, 1993).
reduced prevalence of hypertension. Furthermore, if a
reduced sodium intake blunts the age-related rise in High blood pressure occurs as a result of environmental
blood pressure in children, then the effects of sodium and genetic factors and their interactions. Available
reduction will be greater than projected from these evidence indicates that dietary factors play a critical
studies. Although most of the studies had one or more role. Although this chapter focuses on the adverse
methodological limitations, particularly small sample effects of excessive sodium and insufficient potassium
size (and consequently, inadequate statistical power), intake on blood pressure, other dietary factors, such as
brief duration (typically < 1 month), and inadequate or overweight/obesity and excess alcohol consumption,
uncertain contrast in sodium intake, these data as a raise blood pressure. In individuals without
whole point to potential public health benefits of hypertension, dietary changes lower blood pressure and
considerable magnitude. prevent hypertension, which can reduce the risk of
related adverse health outcomes. In individuals with
Review of the Evidence: Sodium Intake and stage I hypertension (systolic blood pressure of 140-159
Blood Pressure in Adults mmHg and/or diastolic blood pressure of 90-99
mmHg), dietary changes can be an initial therapeutic
Background approach before blood pressure medication is
High blood pressure is highly prevalent among prescribed. Among hypertensive individuals who
American adults. According to the most recent national already are on medication, dietary changes can further
survey data (1999-2004), nearly a third (32%) of adult lower blood pressure and help reduce the number or
Americans have hypertension, and roughly another third amount of medications necessary. In general, dietary
are pre-hypertensive (Wang and Wang, 2004; Cutler, changes have a greater effect on blood pressure in
2008). These data also show that the prevalence of people with hypertension than in those without. These
hypertension is increasing. Rates of controlled individual changes could have a huge positive effect on
hypertension remain low (< 40%) but are improving the health of American adults if they translated into
slightly (Cutler, 2008). even a small reduction in blood pressure across the
population.
As stated earlier, in the U.S., blood pressure generally
increases with age throughout the lifespan. As a result, Evidence on the Relationship Between Sodium
hypertension typically occurs in middle-aged and older Intake and Blood Pressure in Adults
adults. Adults 50 years of age and older now have a 90 The 2005 DGAC Report previously examined the
percent lifetime risk of becoming hypertensive (Vasan, relationship between sodium intake and blood pressure.
2002). Some populations are disproportionately affected As documented in that report, evidence included results
by hypertension and its adverse health outcomes. For of more than 50 clinical trials, as well as meta-analyses
example, pre-hypertensive individuals are at high risk of that synthesized results (see IOM, 2005, Tables 6-12, 6-
developing hypertension (Vasan, 2001). Blacks 13, 6-15, 6-16, and Appendix I). Several of those trials
generally have higher blood pressure than do other were dose-response studies that examined the
racial-ethnic groups in the U.S. (Fields, 2004). Blacks relationship of progressively higher levels of sodium
also have a higher risk of blood pressure-related intake with blood pressure. A few large trials also tested
complications, particularly stroke (Ayala, 2001; Giles, the effects of sodium reduction as a means to prevent
1995) and kidney failure (Klag, 1996). hypertension.
Hypertension is one of the leading causes of death The 2010 DGAC performed an updated literature
around the world. This is because high blood pressure is search to identify new research on the relationship
a strong, consistent, continuous, independent, and between sodium intake and blood pressure. The NEL
etiologically relevant risk factor for cardiovascular and search identified 47 potential articles (15 reviews/meta-
renal diseases (Chobanian, 2003). Notably, the risk of analyses and 32 primary studies). A total of 13 articles,
cardiovascular disease resulting from hypertension has 12 primary studies, and one systematic review/meta-
no threshold. It increases progressively from normal analysis, met the eligibility criteria and were reviewed.
blood pressure through pre-hypertension to Of the 12 primary studies, nine were randomized trials
2010 Dietary Guidelines Advisory Committee Report 333
(Cappuccio, 2006; China Salt Substitute Collaborative mmol/d) lowered systolic/diastolic blood pressure by
Group, 2007; Dickinson, 2009; Forrester, 2005; Gates, 2.0/1.0 mmHg in non-hypertensive and by 5.1/2.7
2004; He, 2009; Makela, 2008; Pimenta, 2009; Swift, mmHg in hypertensive adults.
2005), two (He, 2009; Schmidlin, 2007) were studies
that tested different levels of sodium intake but in fixed In aggregate, these studies reinforce and further
order, and one was an observational analysis of a strengthen the previous conclusions from the 2005
previously published trial (Cook, 2005). Of the 12 DGAC Report that sodium reduction lowers blood
primary studies, eight were methodologically strong and pressure and benefits extend to both non-hypertensive
four were methodologically neutral. Enrollment criteria and hypertensive individuals. As discussed below, the
differed substantially by study, with blood pressure effects of blood pressure reduction are heterogeneous.
criteria that often bridged traditional classification
schemes. Still, it appears that five of the studies enrolled Inter-individual Variability in Blood Pressure
normotensive individuals, six enrolled hypertensive Response
individuals, and one explicitly enrolled both Evidence from a variety of studies, including
normotensive and hypertensive individuals. Trials were observational studies and clinical trials, has
conducted in Jamaica, Northern China, U.S., Australia, demonstrated heterogeneity in the blood pressure
Finland, Great Britain, and Nigeria. Populations were responses to sodium intake. Such a phenomenon is
demographically heterogeneous (e.g., enrolling Black, commonplace because the effects of dietary factors, not
White, and Asian hypertensives living in Great Britain). just sodium, vary by individual. Those individuals with
the greatest reductions in blood pressure in response to
Because previous trials had already confirmed that decreased sodium intake have been termed “salt
sodium reduction lowers blood pressure, the individual sensitive.” Despite the use of the terms “salt sensitive”
trials typically addressed other issues, such as the and “salt resistant” to classify individuals in earlier
effects of public health interventions in economically research studies, the change in blood pressure in
developing countries or the effects of sodium reduction response to a change in sodium intake is not binary.
on other variables (e.g., vascular function, arterial Rather, the reduction in blood pressure from a reduced
compliance, proteinuria, and heart rate variability). sodium intake has a continuous distribution across
Nonetheless, each reported the effects of sodium individuals. Because no standardized diagnostic criteria
reduction on blood pressure. In total, a significant and tests exist and blood pressure is highly variable, it is
reduction in either systolic or diastolic blood pressure impossible to classify individuals as salt sensitive or
occurred in all but one of these studies, and significant not. Nonetheless, some general observations about
reductions in both systolic and diastolic blood pressure sodium sensitivity with respect to subgroups of the
in five studies. The eight methodologically strong population can be made.
studies all showed a significant reduction in systolic or
diastolic blood pressure, and significant blood pressure Individuals with hypertension, diabetes, and chronic
reduction in both systolic and diastolic blood pressure kidney disease, as well as middle- and older-aged
occurred in five of the studies. In several studies, persons and Blacks tend to be more sensitive to sodium
relatively few blood pressure measurements were than their healthier, younger, White counterparts.
obtained. Hence, in some cases, the absence of Genetic factors also influence the blood pressure
significant findings might have resulted from imprecise response to sodium. Each of the 14 identified genes that
or inadequate blood pressure measurement. affect blood pressure affects renal sodium handling.
Such evidence provides indirect support of an etiologic
The methodologically strong systematic review/meta- role of sodium in blood pressure homeostasis (Lifton,
analysis of 34 randomized controlled trials (He, 2004), 2002).
which pooled data for 23 trials of hypertensive and 11
trials of normotensive subjects, demonstrated that a Sodium sensitivity is modifiable. On average, the rise in
modest reduction in sodium intake for 4 or more weeks blood pressure from increased sodium intake is
had a significant effect on blood pressure in both attenuated in the setting of a high potassium intake
hypertensive and normotensive subjects. It also found a (4700 mg of supplemental potassium per day in one
significant dose-response relationship between sodium trial [Morris, 1999]; 6700 mg per day in another trial
reduction and both systolic and diastolic blood pressure. [Schmidlin et al., 1999]). The rise in blood pressure
In this meta-analysis, a median reduction in urinary from increased sodium intake is also attenuated in the
sodium of approximately 1.8 grams per day (78 setting of the DASH diet, which is rich in potassium
334 2010 Dietary Guidelines Advisory Committee Report
(4600 mg of potassium per day) as well as other dietary intake, results from prospective observational
minerals (Bray, 2004; Karanja, 1999; Sacks, 2001; studies have been inconsistent and occasionally
Vollmer, 2001). Nonetheless, a dose-response paradoxical. The “gold standard” to assess dietary
relationship between sodium intake and blood pressure sodium intake is urinary excretion of sodium as
persisted. assessed from multiple, complete 24-hour urine
collections. Yet only four of the 13 studies collected 24-
Relevant Contextual Issues hour urines, and none of these studies obtained more
than one collection. More importantly, several studies
Relationship Between Sodium Intake and had evidence of substantial, non-systematic
Cardiovascular Disease underreporting of sodium intake, and most other studies
Evidence of a direct relationship between dietary provided no data on the completeness of dietary
sodium intake and cardiovascular disease in humans has assessment. In view of the methodological limitations of
been sparse, in large part, because of methodological observational epidemiologic evidence, policy makers
challenges. Direct evidence includes results from have relied on the robust body of evidence that links
clinical trials and prospective observational studies in salt intake with blood pressure to guide policy.
which outcomes are cardiovascular disease events. To
date, three trials conducted in general populations have Relationship Between Sodium Intake and
reported the effects of reduced sodium interventions on Gastric Cancer
such outcomes. Two of these trials tested lifestyle Beyond sodium and blood pressure research,
interventions that focused on reducing sodium intake, observational studies have noted a close relationship of
and one trial tested the effects of a reduced sodium/high sodium intake and cancer of the stomach. For example,
potassium salt. In each instance, a 21 to 41 percent an ecologic analysis of 39 populations in 24 countries
reduction in clinical cardiovascular disease events documented a direct association between urinary
occurred in those who received a reduced sodium sodium excretion and mortality from stomach cancer
intervention (significant reduction in two trials [Chang, (Joossens, 1996). High doses of sodium result in
2006; Cook, 2007] and non-significant trend in the third destruction of the mucosal barrier of the stomach such
[Appel, 2001]). Hence, direct evidence from trials, that the mucus membrane is easily invaded by
albeit limited, is consistent with evidence on the blood carcinogens (Correa, 1975). The World Cancer
pressure lowering effects of sodium reduction. Research Fund/American Institute for Cancer Research
(WCRF/AICR), recently reviewed the available
In a meta-analysis, Strazzullo et al. (2009) synthesized evidence and concluded that sodium chloride and foods
results from prospective observational studies that high in sodium chloride are probable causes of stomach
evaluated the relationship of sodium intake with stroke cancer (WCRF/AICR, 2007).
and CVD. In their analysis of 13 cohort studies with 19
independent samples, a higher sodium intake was Relationships Between Sodium Intake and
associated with an increased risk of stroke and likely Other Health Outcomes
cardiovascular disease. Specifically, a 2000 milligrams As documented by the IOM (IOM, 2005), an increased
per day increased intake of sodium was associated with sodium intake might have adverse effects on additional
a 23 percent higher risk of stroke (CI = 1.06-1.43; health outcomes. These include subclinical
p=0.007). The relationship of CVD with sodium intake cardiovascular disease (i.e., left ventricular mass), early
was not statistically significant (14% greater risk of kidney disease (i.e., proteinuria), and disordered
CVD, CI = 0.99-1.32; p=0.07). However, in sensitivity mineral metabolism (e.g., increased urinary calcium
analyses that excluded one study with particularly excretion, potentially leading to osteoporosis). Cross-
unreliable estimates of sodium intake, the sectional studies consistently document an association
corresponding effect size was 17 percent and the between urinary sodium excretion and left ventricular
relationship was statistically significant (p=0.02). mass, but only one small controlled trial assessed the
effects of sodium reduction on this endpoint. At least
The disparate and often poor quality of dietary sodium two trials have documented that a reduced sodium
measurements likely contributed to the significant intake lowers proteinuria (He, 2009; Swift, 2005).
heterogeneity in study results observed by Strazzullo et Numerous trials document that a reduced sodium intake
al. (2009). Because of large day-to-day variation in lowers urinary calcium excretion (IOM, 2005, Table 6-
sodium consumption, imprecise and inaccurate 19), but urinary calcium excretion, by itself, is not a
measurement techniques, and incomplete assessment of
2010 Dietary Guidelines Advisory Committee Report 335
well-accepted surrogate marker for bone mineral density Additional direct evidence of a link between sodium
or dietary induced osteoporosis. intake and CVD comes from prospective observational
studies and the few available trials with clinical CVD
Overall Public Health Impact of Reducing outcomes (see above).
Sodium Intake
Several studies have estimated the potential overall Studies that evaluated the potential benefits and costs of
health and cost benefits of a reduced sodium intake reducing sodium intake have reached the conclusion
(Bibbins-Domingo, 2010; Danaei, 2009; Palar and that the projected benefits are substantial and that
Sturm, 2009; Smith-Spangler, 2010). A feature of these sodium reduction is cost-effective. In the most recent
studies is the use of statistical modeling with a set of and comprehensive of such analyses (Bibbins-Domingo,
linked assumptions, namely that sodium reduction 2010), a national effort that reduces sodium intake by
lowers blood pressure, and lower blood pressure 1200 milligrams per day in the U.S. is projected to have
reduces the risk of stroke and coronary heart disease. substantial health benefits (Tables D6.2 and D6.3).
Although evidence of a direct effect of sodium Even if the intervention reduced sodium intake by just
reduction on CVD outcomes is preferred, policy makers 400 milligrams per day, the benefits still would be
consider blood pressure as one of the few surrogate substantial and warrant implementation. Importantly,
outcomes that is sufficiently robust to guide policy. such a program should generate cost savings.
Table D6.2. Annual projected benefits, costs, and cost-savings from sodium reduction: higher estimate of benefit
Sodium Reduction of Sodium Reduction of
Benefit 400 mg/day 1200 mg/day
Table D6.3. Annual projected benefits, costs, and cost-savings from sodium reduction: lower estimate of benefit
Sodium Reduction of Sodium Reduction
Benefit 400 mg/day 1200 mg/day
The above estimates do not include the projected long- through a reduced sodium intake should translate into
term benefits from reducing sodium intake in children. additional health benefits, beyond those documented
As noted above, higher levels of blood pressure in above for U.S. adults.
children are strongly associated with early stages of
atherosclerosis. Also, blood pressure exhibits a Sodium Intake
substantial tracking phenomenon—blood pressure In 2005-2006, the estimated average intake of sodium
levels in children track into adulthood. For these for all persons in the U.S. ages 2 years and older was
reasons, efforts to lower blood pressure in children 3436 milligrams per day (USDA/ARS/FSRG, 2008a).
Figure D6.1. Estimated mean daily sodium intake, by age/sex group, 2005-2006
Previous NHANES results have indicated that the medications typically contributes a very small amount
average daily sodium intake among persons in the U.S. of sodium. When total intake of sodium is decreased,
ages 2 years and older increased from 3329 milligrams discretionary salt use is fairly stable, even when freely
in 2001-2002, to 3436 milligrams in 2005-2006, available (Mattes, 1997). Therefore, at the
exceeding in each period even the higher sodium intake environmental level, programs for reducing the sodium
limit of 2300 milligrams per day recommended in 2005. consumption of a population should concentrate
primarily on reducing the sodium used during food
Sources of Sodium processing (IOM, 2010) and, at the individual level,
On average, the natural sodium content of food focus on changes in food selection (e.g., more fresh,
accounts for only 10 percent of total intake, while less-processed items, lower sodium foods) and
discretionary salt use (i.e., table and cooking salt) preparation (Mattes, 1997).
provides another 5 to 10 percent of total intake. The
remaining 75 percent is derived from salt added in food Many foods contribute to the high intake of sodium.
processing by manufacturers (Mattes and Donnelly, While some foods are extremely high in sodium, the
1991; Mattes, 1997). Sodium in water softeners and problem of excess sodium reflects frequent
Source: Sources of Sodium Among the U.S. Population, 2005-2006. Risk Factor Monitoring and Methods Branch
Website. Applied Research Program. National Cancer Institute.
http://riskfactor.cancer.gov/diet/foodsources/sodium/. Updated January 2010. Accessed May 6, 2010a.
Figure D6.3. Sodium and energy levels in U.S. diets, USDA Food Patterns at three levels of sodium and DASH
diets at two levels of sodium
Source: USDA, ARS, Food Surveys Research Group, Correlations: Energy & Sodium and Energy & Potassium.
2010a. Available at http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/Meeting5/Correlations-
SodiumAndPotassium-2005-2006.pdf. Accessed April 15, 2010.
The correlation between sodium and energy intakes in Salt Taste Preferences
the U.S. among free-living adults is estimated to be 0.80 Taste preference for sodium is neither fixed nor innate.
(USDA/ARS/FSRG/2010a). The menus of controlled Rather, it is a malleable trait that is influenced by
feeding studies, such as the DASH-Sodium trial, dietary exposure. At birth, there is no indication that
illustrate how sodium and potassium levels can be salty substances are distinguishable or preferred
designed to be perfectly correlated with energy, that is, (Beauchamp, 1986). Initial appearance of preference for
the goals for sodium and potassium in DASH-Sodium the salty taste occurs at about 4 months postnatal
were set on a per calorie basis. Given the above (Beauchamp, 1994, 1986; Harris and Booth, 1987) but
considerations, it is therefore reasonable, for practical based on the limited evidence available, sodium
purposes, to adjust sodium targets based on calorie preferences in infants and children appear to be shaped
level, given the high correlation between sodium and by dietary exposure (Beauchamp, 1990; Stein et al.,
energy intakes. 1996). Likewise, sodium preferences in adults and
children are influenced by dietary exposure. Studies
2010 Dietary Guidelines Advisory Committee Report 339
have demonstrated that reducing dietary sodium intake Question 2: What Is the Effect of
over a time period of as little as 3 to 4 weeks can Potassium Intake on Blood Pressure in
decrease preference for salty foods and increase Adults?
acceptance of foods with reduced sodium content
(Bertino, 1982; Cooper and Sanger, 1984).
Conclusion
Several studies document a temporary increased
preference or craving for salt over the initial period A moderate body of evidence has demonstrated that a
when sodium intake is reduced (Bertino, 1981; higher intake of potassium is associated with lower
McCance, 2001; Teow, 1985–1986; Yensen, 1959). blood pressure in adults.
However, subsequently, a shift in preference occurs
such that by 8 to 12 weeks, or sooner in some Implications
individuals, preference for less salty foods is established
(Bertino, 1982; Mattes and Donnelly, 1991; Mattes, Increasing dietary potassium intake can lower blood
1997). This phenomenon also has been demonstrated in pressure. A higher intake of potassium also attenuates
long-term studies lasting 1 year or more (Blais, 1986). the adverse effects of sodium on blood pressure. Other
In aggregate, such evidence argues for gradual, step- possible benefits include a reduced risk of developing
wise reductions in sodium intake to maximize kidney stones and decreased bone loss. In view of the
acceptance of products that are reduced in sodium health benefits of adequate potassium intake and its
content. relatively low current intake by the general population,
increased intake of dietary potassium is warranted. The
Strategies to Reduce Sodium Intake IOM set the AI for potassium for adults at 4700
Recently, the IOM issued a report that provides a milligrams per day. Available evidence suggests that
roadmap to lower the Americans’ intake of sodium Blacks and hypertensive individuals especially benefit
(IOM Report, 2010). This document noted that from an increased intake of potassium.
activities to reduce sodium intake of the U.S. population
have been ongoing for more than 40 years. However, Review of the Evidence
these efforts have been unsuccessful. A major reason is
that these efforts were not broad enough in scope to As documented in Question 1, elevated blood pressure
fully address the public health problem of excessive is a highly prevalent, etiologically relevant, and
sodium intakes. The current focus on individuals modifiable risk factor for cardiovascular and renal
selecting lower-sodium foods and availability of diseases. A low intake of dietary potassium, especially
reduced-sodium “niche” products cannot result in in the presence of high sodium intake, has been
intakes consistent with the Dietary Guidelines for implicated in the pathogenesis of elevated blood
Americans by themselves. They must be accompanied pressure. The 2005 DGAC reviewed available evidence
by an overall reduction of the level of sodium in the from the relationship between potassium intake and
food supply. In other words, the level of sodium to blood pressure and concluded that an increased intake
which consumers are exposed on a daily basis from of potassium lowers blood pressure. The Committee
processed and restaurant foods must be reduced. To included evidence from 36 clinical trials and 17 cohort
date, efforts by food processors and the restaurant and studies (IOM, 2005) in their review. Most of these trials
foodservice sectors to voluntarily reduce the sodium tested potassium supplements, not food sources,
content of the food supply face obstacles, are not typically in the form of potassium chloride pills (Tables
consistently undertaken by all, are not readily sustained, 5-4 and 5-5, IOM, 2005). On the basis of these data and
and have proven unsuccessful in lowering overall in conjunction with other data showing that an
sodium intake. The IOM made a series of increased potassium intake should attenuate the adverse
recommendations, many of which involved regulatory effects of salt on blood pressure, reduce the risk of
actions to gradually lower the sodium content of the developing kidney stones, and possibly decrease bone
food supply. Given safety considerations as well as loss, the IOM set the AI for potassium at 4700
differences in the amount and function of sodium by milligrams per day for adults.
type of food product, reductions in sodium intake will
differ by foods (see Part D. Section 8. Food Safety and The 2010 DGAC performed a search of literature
Technology for further information). published since 2005 to identify new research on the
relationship between potassium intake and blood
+
4700 mg is the Adequate Intake (AI) for potassium intakes set by the IOM. For children younger than 14 years
old, the AI is less than 4700 mg per day.
Source: USDA, ARS, 2005-2006. WWEIA, NHANES. http:/www.ars.usda.gov/ba/bhnrc/fsrg.
Rationale. A few studies suggest that increased Beauchamp GK, Cowart BJ, Mennella JA, Marsh RR.
fluid consumption might reduce the risk of bladder Infant salt taste: developmental, methodological, and
cancer, urinary tract infections, kidney stones, and contextual factors. Dev Psychobiol. 1994
colon cancer. However, this evidence was Sep;27(6):353-65.
insufficient to make recommendations on fluid
intake. Beauchamp GK, Bertino M, Burke D, Engelman K.
Experimental sodium depletion and salt taste in normal
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ALCOHOL INTAKE AND HEALTH OUTCOMES Based on the literature dating back to November 1994,
one randomized control trial (RCT) (Flechtner-Mors,
1. What is the relationship between alcohol intake and 2004) and seven prospective observational studies
weight gain? (Koh-Banerjee, 2003; Liu, 1994; Sammel, 2003;
2. What is the relationship between alcohol intake and Sherwood, 2000; Tolstrup, 2008; Wannamethee, 2004;
cognitive decline with age? Wannamethee and Shaper, 2003) from the U.S.,
3. What is the relationship between alcohol intake and Germany, Denmark, and the United Kingdom directly
coronary heart disease? addressed the question of alcohol consumption and
4. What is the relationship between alcohol intake and weight gain. The RCT was in the setting of an energy-
bone health? restricted diet and was designed to test whether weight
loss would be different if the energy-restricted diet
ALCOHOL INTAKE AND UNINTENTIONAL contained 10 percent of energy from white wine or
INJURY grape juice. The authors reported that everyone in the
study lost weight as designed and the magnitude of the
5. What is the relationship between alcohol intake and weight loss was similar between groups.
unintentional injury?
The remaining studies were mostly large scale
ALCOHOL INTAKE AND LACTATION prospective studies which followed people over time
and examined whether a baseline report of alcohol was
6. Does alcohol consumption during lactation have associated with subsequent weight gain after accounting
adverse health effects? What is the relationship for other lifestyle characteristics typically associated
between alcohol consumption and the quality and with body weight. For a subset of the first National
quantity of breast milk available for the offspring? Health and Nutrition Examination Study (NHANES),
What is the relationship between alcohol Liu et al. (1994) reported that drinkers were less likely
consumption and postnatal growth patterns, sleep to have either major weight gain or weight loss than
patterns, and/or psychomotor patterns of the nondrinkers over 10 years of follow-up. Similar results
offspring? were reported in several other smaller studies (Sammel,
2003; Sherwood, 2000).
Despite the lack of evidence to support a strong Question 2: What Is the Relationship
association between moderate alcohol consumption and Between Alcohol Intake and Cognitive
weight gain, there is still concern that diets of Decline With Age?
individuals who drink may be inadequate if calories
from alcoholic beverages replace calories from foods
Conclusion
which may be more nutrient-dense. The NIAAA and
the USDA Center for Nutrition Policy and Promotion
Moderate evidence suggests that compared to non-
used the Healthy Eating Index-2005 (a gauge of
drinkers, individuals who drink moderately have a
adherence to the 2005 Dietary Guidelines) to examine
slower cognitive decline with age. Although limited,
the relationship of alcohol consumption with nutrient
evidence suggests that heavy or binge drinking is
intakes and diet quality, as measured by the Healthy
detrimental to age-related cognitive decline.
Eating Index-2005 (HEI-2005). In this recently
published cross-sectional study (Breslow, 2010) using
Implications
data from NHANES, the authors described the
following:
Alcohol, when consumed in moderation, did not
quicken the pace of age-related loss of cognitive
• Among men, there was not a clear difference
function. In most studies, it was just the opposite—
between current drinkers and non-drinkers for total
moderate alcohol consumption, when part of a healthy
energy intake or HEI-2005 scores.
diet and physical activity program, appeared to help to
• Among women, current drinkers had significantly
keep cognitive function intact with age. Despite the
higher total energy and lower HEI-2005 scores.
potential benefit at moderate consumption levels, heavy
• Among all drinkers, as the average number of drinking and episodes of binge drinking impairs short-
drinks per day increased, total energy increased and and long-term cognitive function and should be
HEI-2005 scores decreased. avoided.
This study was based on alcohol consumption over the Review of the Evidence
past year, and a 24-hour dietary intake. It did not take
into account physical activity as an important source of Over the past 10 years, a substantial new body of
energy expenditure, but it does highlight the important evidence has supported a modest beneficial association
concept that alcoholic beverages supply calories but few between alcohol consumption and cognitive function.
nutrients. The energy contribution from alcoholic The DGAC restricted its search to prospective studies to
beverages varies widely. Specifically, some alcoholic reduce bias associated with reverse causation of effect
beverages, such as dessert wines and mixed drinks, (i.e., the bias that individuals with reduced cognitive
provide almost three times as many calories as do the function may be less capable and less likely to drink).
standard drink portions: 12 fluid ounces of regular beer, Based on the included literature dating back to 2001,
5 fluid ounces of wine, or 1.5 fluid ounces of distilled one systematic review/meta-analysis (Peters, 2008) and
spirits. Individuals who drink should be aware of the seven additional U.S. and international prospective
total calories of alcoholic beverages (see Table D.1.6 in cohort studies (Bond, 2005; Deng, 2006; Mehlig, 2008;
Part D. Section 1. Energy Balance and Weight Ngandu, 2007; Solfrizzi, 2007; Stott, 2008; Wright,
Management for a list of selected alcoholic beverages 2006) directly addressed the question related to alcohol
and their caloric content) and carefully assess how intake and cognitive decline. Results from Peters et al.
alcohol fits into their overall dietary pattern, especially (2008), a systematic review and meta-analysis of 23
with respect to the number of calories needed to studies conducted primarily in the U.S., Canada, and
maintain a healthy weight. Europe, found that in older adults, small to moderate
amounts of alcohol consumption were associated with
For those who choose to drink an alcoholic beverage, it reduced incidence of dementia and Alzheimer’s disease
is advisable to consume it with food to slow alcohol (Peters, 2008). Small amounts of alcohol may be
absorption. Data suggest that the presence of food in the
358 2010 Dietary Guidelines Advisory Committee Report
protective against dementia and Alzheimer’s disease, Drinking (NIAAA, 2003), an extensive review of the
but not for vascular dementia or cognitive decline. literature conducted by scientific staff of the NIAAA
and reviewed by 14 outside experts. In addition to
Several prospective cohort studies (Bond, 2005; Deng, recognizing the apparent mortality benefit of moderate
2006; Stott, 2008; Wright, 2006) found similar results alcohol consumption among middle-aged and older
that suggest that individuals who drink lightly to adults, the report concludes, “Except for those
moderately have a decreased risk or reduced severity of individuals at particular risk…, consumption of [up to]
dementia and/or cognitive decline especially in 2 drinks a day for men and 1 for women is unlikely to
comparison to non-drinkers. increase health risks” (NIAAA, 2003). Individuals at
particular risk include persons who cannot restrict their
drinking to moderate levels, children and adolescents,
Question 3: What Is the Relationship persons taking prescription or over-the-counter
Between Alcohol Intake and Coronary medications that can interact with alcohol, and
Heart Disease? individuals with special medical conditions (e.g., liver
disease). In this 2010 DGAC Report, individuals who
may be at risk (particularly with respect to unintentional
Conclusion
injury and lactating women) are more clearly defined.
Strong evidence consistently demonstrates that
Many of the observational studies which have
compared to non-drinkers, individuals who drink
documented a benefit of moderate alcohol consumption
moderately have lower risk of coronary heart disease.
on CVD prevention are summarized in the 2005 DGAC
Insufficient evidence was available to determine if any
Report in Table D8-1, but are not summarized again
one single drinking pattern was predictive of lower or
here. The inverse association has been demonstrated in
higher risk of coronary heart disease, although there was
a variety of populations and is independent of many
moderate evidence to suggest that heavy or binge
other cardiac risk factors, including age, sex, race/ethnic
drinking is detrimental.
group, smoking habits, physical activity, diet, and body
mass index (Corrao, 2000; Marmot, 2001; Mukamal,
Implications
2001). Similar to the evidence summarized above for
alcohol and weight gain, the majority of prospective
An average daily intake of one to two alcoholic
studies of alcohol and CHD assess average weekly
beverages is associated with a low risk of coronary heart
intake over the past several months or year and are not
disease among middle-aged and older adults. Binge or
based on a daily maximum of one to two drinks for the
heavy irregular drinking should be avoided.
definition of moderate. On average, the relative risk of
CHD associated with moderate drinking as defined by
Review of the Evidence
the DGAC is between 0.50 and 0.80 and is directly
related to the benefits of alcohol on HDL-C, glucose,
The issue of moderate alcohol consumption and risk of
and clotting factors such as fibrinogen (Mukamal,
cardiovascular disease (CVD) was updated from the
2001).
2005 DGAC and also addressed alcohol consumption
patterns. The NEL review searched published literature
The DGAC pursued evidence to support a specific
dating back to 1995 to 2009 and included six systematic
guideline for patterns of consumption. The same NEL
reviews/meta-analyses conducted in the U.S. and
review identified two meta-analyses (Bagnardi, 2008;
internationally (Bagnardi, 2008; Britton, 2000;
Corrao, 2000) that addressed alcohol pattern
Cleophas, 1999; Corrao, 2000; Di Castelnuovo, 2002;
consumption. Bagnardi et al. (2008) served as the
Rimm, 1999). Overall, the evidence shows that
strongest summary of the evidence. Based on somewhat
compared to those who abstain from alcohol, regular
similar measures of patterns of consumption from four
light to moderate drinking can reduce the risk of CHD;
prospective studies and two case-control studies,
whereas, heavy irregular or binge drinking increases
Bagnardi et al. (2008) concluded that among
risk of CHD.
individuals who consumed alcohol on more than 2 days
per week, risk of coronary heart disease was lowered
The overall conclusion of general benefit from
even when alcohol was consumed at intake levels
moderate intake of alcohol is also supported by the
greater than two drinks a day. However, among
State of the Science Report on the Effects of Moderate
irregular drinkers, moderate alcohol consumption was
2010 Dietary Guidelines Advisory Committee Report 359
still inversely associated with CHD, but binge (or abstainers (RR=0.91 [95% CI, 0.76-1.09]). However,
heavy) drinking was associated with an excess risk of persons consuming more than two drinks per day had an
CHD. elevated risk for fracture (RR=1.39, [95% CI 1.08-
1.79]).
Question 4: What Is the Relationship In the meta-analysis of bone mineral density, a linear
Between Alcohol Intake and Bone Health? relationship existed between alcohol consumption and
bone density of the femoral neck and vertebral spine.
With limited data, the authors could not assess relative
Conclusion
associations between alcohol consumption and bone
density in moderate compared with heavy drinkers.
Moderate evidence suggests a J-shaped association
Even though there is a positive effect of alcohol
between alcohol consumption and incidence of hip
consumption on hip fracture and femoral neck/vertebral
fracture; there was a suggestion that heavy or binge
spine bone density, the exact range of alcohol
drinking was detrimental to bone health.
consumption that is beneficial cannot be determined.
Implications
3. Focus further research to avoid unintentional injury Bedford D, O’Farrell A, Howell F. Blood alcohol levels
on effective communication policies that expand in persons who died from accidents and suicide. Ir Med
current messages on drinking and driving to inform J. 2006 Mar;99(3):80-3.
individuals of other unintentional risks associated
with alcohol consumption. Berg KM, Kunins HV, Jackson JL, Nahvi S, Chaudhry
A, Harris KA Jr, Malik R, Arnsten JH. Association
Rationale: The documented benefit of drunk between alcohol consumption and both osteoporotic
driving campaigns is a public health success; yet fracture and bone density. Am J Med. 2008
alcohol related injury is still substantial in other May;121(5):406-18.
areas and should be addressed with the same
vigilance and governmental support. Berger K, Ajani UA, Kase CS, Gaziano JM, Buring JE,
Glynn RJ, Hennekens CH. Light-to-moderate alcohol
consumption and risk of stroke among U.S. male
physicians. N Engl J Med. 1999 Nov 18;341(21):1557-
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1
The DGAC defines a “risky food” as a food consumed in
such a way (e.g., undercooked) that it poses a
microbiological hazard for human health.
2010 Dietary Guidelines Advisory Committee Report 369
Lastly, food allergens were identified by the DGAC as 7. To what extent do specific subpopulations practice
an important food safety issue. The National Institute of unsafe food safety behaviors?
Allergy and Infectious Disease (NIAID) of the National
Institutes of Health (NIH) established a Coordinating FOOD SAFETY TECHNOLOGIES
Committee to oversee the development and approval of
Guidelines for the Diagnosis and Management of Food 8. To what extent are recently developed technological
Allergy. The Coordinating Committee used an Expert materials that are designed to improve food safety,
Panel of specialists from a variety of clinical, scientific, effective in reducing exposure to pathogens and
and public health arenas relevant to this topic. The decreasing the risk of foodborne illnesses in the
Expert Panel used an independent systematic literature home?
review, as well as expert opinion, when needed, to
develop the guidelines. Due to the extensive literature SEAFOOD
review conducted through this NIAID initiative, the
DGAC deferred completing an evidence review on food 9. What are the benefits in relationship to the risks for
allergy. A draft report of the Guidelines for the seafood consumption?
Diagnosis and Management of Food Allergy was
released by NIAID in March 2010
(www.niaid.nih.gov). A short review of the topic by the Methodology
Food Safety and Technology subcommittee is available
online at http://www.cnpp.usda.gov/DGAs2010- The information used to develop the Food Safety
DGACReport.htm. chapter written for the 2005 DGAC was gleaned from a
literature review and review of educational tools for
conveying messages to consumers about safe food
List of Questions handling and preparation. The Committee emphasized
information from the national food safety education
BEHAVIORS MOST LIKELY TO PREVENT campaign Fight BAC!®. Thus, unlike other chapters in
FOOD SAFETY PROBLEMS AND THE EXTENT the 2005 DGAC Report, which reflected evidence-
TO WHICH U.S. CONSUMERS FOLLOW THESE based reviews, the food safety recommendations
BEHAVIORS stemmed primarily from educational tools developed by
the USDA. The 2010 DGAC emphasized systematic
1. CLEAN: What techniques for hand sanitation are evidence-based assessments for all aspects of the
associated with favorable food safety outcomes and Report, and leveraged, for the first time, the systematic
to what extent do U.S. consumers follow them? review process using the Nutrition Evidence Library
(NEL) and the careful quality weighing of that
2. CLEAN: What techniques for washing fresh evidence. A description of the NEL evidence-based
produce are associated with favorable food safety systematic review process is provided in Part C:
outcomes and to what extent do U.S. consumers Methodology.
follow them?
Using the NEL system for the first time for the Food
3. CLEAN: To what extent do U.S. consumers clean Safety and Technology chapter provided a platform for
their refrigerators? evaluating evidence that has not been previously
available and sets the standard for future Committees.
4. SEPARATE: What techniques for preventing cross- Through this process, research strengths and
contamination are associated with favorable food weaknesses were identified, thus providing significant
safety outcomes? direction for national policy development and guidance
for future investigations in food safety and food
5. COOK AND CHILL: To what extent do U.S. technology.
consumers follow adequate temperature control
during food preparation and storage at home? The Food Safety and Technology subcommittee
assessed the quality of the available evidence pertinent
6. AVOID RISKY FOODS: To what extent do U.S. to the three primary families of questions focused on (a)
consumers eat raw or undercooked animal foods? in-home food safety behaviors, (b) new technologies
2
Tables D8.1 through D8.8 can be found at the end of this
chapter.
2010 Dietary Guidelines Advisory Committee Report 371
• Seafood: Implications of dietary selenium and the 2008; Kosa, 2007; Towns, 2006). For example,
potential health risks of methyl mercury exposure research conducted among Hispanic women in
from seafood Connecticut has shown that few consumers are aware of
• Seafood: Implications of aquacultural practices and the term “cross-contamination,” even after exposure to
a safe, nutritious food supply the Fight BAC!® campaign (Dharod, 2004). This is a
• On-line resource (accessible at cause of public health concern because the risk of cross-
http://www.cnpp.usda.gov/DGAs2010- contamination in home kitchens in some Hispanic
DGACReport.htm): (Dharod, 2007a) and other (FDA/FSIS, 2006)
http://www.dietaryguidelines.gov/Implications of communities is substantial. Hands play a central role in
food allergens and a safe food supply the chain of transmission of microbial pathogens
• On-line resource (accessible at through food and other vehicles. Thus, proper hand
http://www.cnpp.usda.gov/DGAs2010- hygiene before, during, and after food preparation is
DGACReport.htm): one of the key measures for preventing foodborne
Conventional and organically produced foods diseases. Hand hygiene can be based on hand washing
with plain soap (i.e., detergents that do not contain
antimicrobial agents or contain low concentrations of
BEHAVIORS MOST LIKELY TO PREVENT antimicrobial agents that are effective solely as
preservatives, Centers for Disease Control and
FOOD SAFETY PROBLEMS AND THE
Prevention [CDC], 2002) and water (physical removal
EXTENT TO WHICH U.S, CONSUMERS
of microbes) and/or the use of rinse-free alcohol-based
FOLLOW THESE BEHAVIORS hand sanitizers (killing of microbes).
Annually, foodborne illness affects more than 76 On the other hand, consumers often do not translate
million individuals in the U.S. leading to 325,000 their food safety knowledge into safe practices (Abbot,
hospitalizations and 5,200 deaths at a cost of $7 billion 2009; Byrd-Bredbenner, 2007; Cates, 2006; Dharod,
to the Nation (IOM, 2006). Because foodborne illness 2004, 2007a; Godwin, 2006; Kwon, 2008; Patil, 2005;
outbreaks are difficult to trace and characterize, the Redmond, 2003; Towns, 2006; Trepka, 2007; Yarrow,
proportion of outbreaks that can be attributed to unsafe 2009). This is perhaps explained at least in part by the
food safety practices at home remains unknown, “not in my kitchen” optimistic bias (Cates, 2006; Levy,
although it is believed to be substantial (Redmond, 2008; Miles, 2003; Redmond, 2004; Roseman, 2006)
2003; Roseman, 2007). An indirect way of assessing and the lack of consumers’ internal locus of control
this risk is by documenting consumers’ food safety with regard to food safety, namely the belief that its
practices at home. This topic is of relevance as the vast mainly the responsibility of industry and government to
majority of consumers has a refrigerator and a stove or prevent foodborne illness (Cates, 2006). Improvements
microwave at home, and prepare and/or consume at in consumers’ knowledge and also their attitudes and
least some of their meals at home (FDA/FSIS, 2006). intentions toward reducing home-based food safety
risks are needed.
Foodborne illness continues to be a major public health
threat to U.S. consumers who are aware of the Higher socio-economic status has been associated with
importance of food safety for human health (Mead, more food safety knowledge, but often with the worst
1999), but they do not believe that their home kitchens food safety behaviors (Patil, 2005). Being a member of
are an actual source of foodborne outbreaks (Levy, a racial/ethnic minority group has been associated with
2008; Miles, 2003; Redmond, 2004). Risky food safety better food safety behaviors (FDA/FSIS, 2006; Patil,
behaviors at home are likely to translate into home- 2005). Improper home food safety behaviors have been
based foodborne illness outbreaks. identified in different stages of the life cycle, such as
pregnancy (Kwon, 2008; Trepka, 2007), college
On the one hand, consumers are not aware, or they lack students (Abbot, 2009; Byrd-Bredbenner, 2007, 2008;
specific knowledge regarding pathogens (e.g., Listeria, Yarrow, 2009), and older adults (Almanza, 2007; Kosa,
Campylobacter) (Cates, 2006), food contamination 2007; Roseman, 2007). Overall, men are more likely
vehicles and potential transmission routes (e.g., cross than women to practice risky food safety behaviors at
contamination) (Dharod, 2004), and proper cold storage home. Thus, all segments of the U.S. population could
temperatures and refrigerator cleaning (Bryd- benefit from improved food safety education based on
Bredbenner, 2008; Godwin, 2006; Kilonzo-Nthenge, effective behavioral change theories.
372 2010 Dietary Guidelines Advisory Committee Report
The 2010 DGAC’s evidence-based review of behaviors area needs to address safe food practices in the different
that are likely to prevent food safety problems and U.S. environments in which individuals are likely to
consumers’ actions in this regard has led it to one consume the different products. Education should also
overarching conclusion, which has implications for address food safety issues that have emerged due to
current and future consumer education efforts. The trends toward local- and regional-based food
sections that follow present specific conclusions and production.
evidence reviews for each of the four Fight BAC!
constructs (i.e., clean, separate, cook and chill), plus the Of subpopulations in the U.S., older adults may be at
“avoiding risky foods” construct. greater risk because of the age-related reduction in
immunity. Pregnant women also have altered immune
Overarching Conclusion status which may render the fetus more susceptible to
infection. Foodborne illnesses affecting pregnant
Evidence shows that proper hand sanitation techniques, women can have extremely serious consequences for
proper washing of vegetables and fruit, prevention of the fetus as illustrated by the still births resulting from
cross-contamination, and appropriate cooking and listeriosis. Foodborne illness outbreaks among college
storage of foods in the home kitchen are most likely to students have the potential to rapidly spread within the
prevent food safety problems. Food safety behaviors student body as a result of the group arrangements in
least practiced by consumers are hand sanitation, cross- which they often live.
contamination prevention, and use of cooking,
refrigerator, and freezer thermometers. Food safety
knowledge of U.S. consumers is not being translated Question 1: CLEAN: What Techniques for
into improved food safety practices at home. Hand Sanitation Are Associated With
Favorable Food Safety Outcomes and to
Implications What Extent Do U.S. Consumers Follow
Them?
All segments of the U.S. population could benefit from
improved food safety education based on effective
behavioral change theories. Food safety education is Conclusion
needed to not only improve consumers’ knowledge, but
also their attitudes and intentions toward reducing Strong, clear, and consistent evidence shows that hand
home-based food safety risks. In particular, consumers washing with plain soap for 20-30 seconds followed
need to take more responsibility regarding food safety. by proper hand drying is an effective hand hygiene
Together, with sound government policies and technique for preventing cross-contamination during
responsible food industry practices, foodborne illness food preparation. Strong, clear, and consistent
can be prevented. evidence shows that alcohol–based, rinse-free hand
sanitizers are an adequate alternative when proper
Food safety behaviors that particularly need additional hand washing with plain soap is not possible.
promotion are hand sanitation, use of cooking and Moderate, consistent evidence shows that U.S.
refrigerator/freezer thermometers, and prevention of consumers do not follow recommended hand
cross-contamination. Produce washing practices can sanitation behaviors.
vary significantly for different vegetables and this
behavior needs to be substantially improved. Additional Review of the Evidence
guidance is needed to provide detailed
recommendations on the frequency of refrigerator The conclusion on recommended techniques for hand
cleaning to decrease pathogen growth and potential for sanitation is derived from 17 studies, including four
cross-contamination. It is important to educate meta-analyses or literature reviews (Aiello, 2007,
consumers on appropriate cooking temperatures and the 2008; Haas, 2005; Meadows, 2004), six randomized
reasons to avoid consuming raw or undercooked animal controlled trials (Aiello, 2004; Fischler, 2007; Larson,
protein products. The consumption of certain risky 2004; Sandora, 2005, 2008; Vessey, 2007), five quasi-
foods (e.g., cookie dough containing raw eggs) is likely experimental studies (Brown, 2007; Schaffner, 2007;
to occur at home, but the consumption of other foods Thorrold, 2007; Tousman, 2007; White, 2005), and
(e.g., raw seafood) is more likely to occur outside the two observational prospective studies (Dharod, 2009;
home. Thus, consumer food safety education in this Lee, 2005). Studies were conducted in schools and
The conclusion regarding consumers’ adherence to The conclusion regarding techniques for washing fresh
recommended hand sanitation is derived from five produce is derived from three studies, including two
cross-sectional studies (Abbot, 2008; Anderson, 2008; non-randomized trials (Kilonzo-Nthenge, 2006; Parnell,
Comer, 2009; Dharod, 2007a; Thumma, 2009). The 2005), and one cross-sectional study (Dharod, 2007b).
FDA/FSIS Food Safety Survey (2006) provided Washing fresh produce at home is the last opportunity
additional evidence. In the Food Safety Survey that consumers have to reduce potential pathogen loads
(FDA/FSIS, 2006) three-quarters of respondents in these products before consuming them and is likely
indicated that they always washed their hands before to help reduce food safety risks (Dharod, 2007b;
starting food preparation. Gender did not influence the Kilonzo-Nthenge, 2006; Parnell, 2005). One of the few
hand washing report, but this behavior was more studies that examined this issue among free-living
likely to be reported by those with lower levels of individuals while preparing a family meal at home
education and by those who identified themselves as provides relevant insights. Dharod et al. (2007b)
White. Close to 88 percent reported washing the demonstrated a significant reduction in total microbial
cutting board after placing raw meat on it. This and coliform counts associated with washing lettuce and
behavior was more common among those with lower tomato under running water in Puerto Rican
levels of education, females, and non-Hispanics than households’ home kitchens during preparation of a
among those in other population groups. Studies have “chicken and salad” meal. Guidance for consumers for
consistently shown that proper hand washing washing produce, adapted from information available
associated with food preparation (Abbot, 2008; from the FDA, can be seen in Table D8.3.
Dharod, 2007a; Thumma, 2009) and bathroom use
(Anderson, 2008; Thumma, 2009) is far less than The conclusion regarding consumer behaviors related to
optimal and needs to be better promoted (Comer, washing fresh produce is derived from two cross-
2009). Two studies involving direct observation of sectional studies (Dharod, 2007a; Anderson, 2004) and
hand washing behaviors during food preparation an analysis of responses from the FDA/FSIS Food
among college students (Abbot, 2008) and Puerto Safety Survey (2006). Dharod et al. (2007a) found that
Rican home meal preparers (Dharod, 2007a) found a among Puerto Rican home meal preparers, 87 percent
high degree of overreporting of desirable hand washed the lettuce and 85 percent washed the tomatoes
washing behaviors during food preparation. This under running water while preparing salad. In their
Seafood is a healthy food choice that can be safely On the one hand, seafood consumption has been
promoted provided that the types and sources of seafood associated with health risks for infants, children, and
to be limited or avoided by some consumers are clearly adults. MeHg exposure has been found to impair the
communicated to consumers. Consumers may be able to neurological development of the fetus and young child
eat safely more than 12 ounces per week of seafood if (IOM, 2007). In addition, it has been proposed that
they chose to do so provided they choose the right mix MeHg is a risk factor for CVD perhaps as a result of
of seafood that emphasizes the consumption of seafood pro-oxidant mechanisms involving the activation of free
species with relatively low concentrations of radical formation and the inhibition of cellular
contaminants such as MeHg and POPs. Encouraging antioxidant systems (Guallar, 2002). However, the
consumption of seafood in the U.S. is justified, as evidence for this risk is inconsistent (IOM, 2007; Stern,
consumption continues to be far below amounts 2007) with a recent meta-analysis of five prospective
recommended for health by the IOM and by this studies and one retrospective study suggesting no
Committee (see Part D. Section 3: Fatty Acids and overall significant association between coronary heart
Cholesterol). disease (CHD) risk and high MeHg exposure (i.e., top
quartile) in European and U.S. populations
Current Federal advisories on consumption of seafood (Mozaffarian, 2009). However, a Finnish prospective
species with high MeHg levels that vulnerable groups study (Rissanen, 2000) did identify an interaction
2010 Dietary Guidelines Advisory Committee Report 385
between serum n-3 polyunsaturated fatty acids (PUFA) Rawn, 2006; Verger, 2008) which also included a
and hair MeHg on CHD risk. Consuming seafood was risk/benefit analysis; one meta-analysis (Gochfeld,
protective against CHD for those with higher (upper 2005); and one systematic review (Mozaffarian, 2006).
tertile) and lower (two lower tertiles) MeHg exposures, A report from the IOM, Seafood Choices (2007), was
but the benefit was greater for those in the lower MeHg used as evidence before 2006 to develop the conclusion.
exposure group.
Since the publication of the 2005 DGAC Report, five
On the other hand, seafood consumption also offers quantitative (Ginsberg, 2009; Guevel, 2008; Gochfeld,
CVD and neurological development benefits associated 2005; Sioen, 2008; Verger, 2008) and two qualitative
with EPA and DHA consumption (see Part B. Section (IOM, 2007; Mozaffarian, 2006) risk/benefit
2. The Total Diet: Combining Nutrients, Consuming assessments have been published. These studies
Food; Part D. Section 2. Nutrient Adequacy; and Part targeted the U.S. (Ginsberg, 2009; Gochfeld, 2005;
D. Section 3: Fatty Acids and Cholesterol). In March Mozaffarian, 2006), French (Guevel, 2008; Verger,
2004, the EPA and the FDA issued a seafood advisory 2008), and Belgian (Sioen, 2008) populations. The two
based on seafood benefit/risk considerations, entitled, U.S. quantitative benefit/risk analyses modeled
What You Need to Know about Mercury in Fish and neurodevelopmental and CVD benefits and risks
Shellfish (EPA/FDA, 2004). It specifically targeted associated with DHA and MeHg in seafood (mostly
pregnant and nursing women, young children, and non- fish), respectively (Ginsberg, 2009; Gochfeld, 2005).
pregnant women of childbearing age because of their The French study based on the Quality-Adjusted Life
potential vulnerability to the effects of MeHg. The Year (QALY) approach modeled neurodevelopmental
advisory recommended that, in order for women to benefits and risks associated with DHA and MeHg but
receive the benefits of eating seafood and be confident did not include the function describing the potential
that they have reduced their exposure to the harmful harm of MeHg on cardiovascular health (Guevel, 2008).
effects of mercury, they could safely consume up to 12 The Belgian study examined different levels of seafood
ounces (2 average meals) per week of a variety of intake in relationship to the tolerable weekly intake
cooked seafood, but to not exceed white (albacore) tuna levels of MeHg and dioxin-like compounds (Sioen,
consumption beyond 6 ounces per week. The same 2008). The other French study examined seafood intake
advice was given for young children except that they thresholds based on omega-3 PUFA recommendation
would be fed smaller portions. These target groups were and the upper tolerable intake limits for dioxins and
advised to avoid consuming species high in MeHg, polychlorinated biphenyls (PCBs), a type of POP
including shark, swordfish, king mackerel, and tilefish. (Verger, 2008). The two qualitative analyses addressed
This Federal advisory, which is still in effect, also benefit and risks on neurodevelopment and
recognized the importance of state seafood advisories cardiovascular health attributed to DHA and MeHg. In
for informing consumers about the safety of consuming addition, Mozaffarian and Rimm (2006) estimate the
locally caught and harvested seafood. These benefit/risk ratios based on omega-3 PUFA benefits and
recommendations are consistent with those issued by POPs exposure risks.
other national scientific groups (IOM, 2007) and other
countries, including Canada (Health Canada, 2009). A comprehensive assessment of the evidence by the
DGAC indicates that neurodevelopmental and/or
The 2005 DGAC Report concluded that it is possible cardiovascular benefits of seafood consumption
for vulnerable groups to obtain the benefits of seafood outweigh the MeHg risks associated with the same
consumption without exceeding tolerable levels of outcomes provided that consumers stay within amounts
MeHg intakes. Re-addressing this question is relevant recommended for safety, according to the MeHg and
because new evidence has become available and POPs content of the mix of seafood species being
consumers are still receiving conflicting seafood consumed. Furthermore, the benefit threshold for
consumption messages, some of which are inconsistent neurodevelopmental and CVD outcomes appears to be
with Federal advice (Ginsberg, 2009). at seafood intakes below the harm threshold associated
with MeHg consumption (Gochfeld, 2005).
Review of the Evidence
This conclusion is derived from nine studies, including With regard to the risk of POPs exposure, evidence
three quantitative risk/benefit assessment studies suggests that POPs levels at current and recommended
(Ginsberg, 2009; Guevel, 2008; Sioen, 2008); four (EPA/FDA, 2004) levels of seafood consumption in
cross-sectional studies (Dewailly, 2007; Huang, 2006; North America from commercially caught or farmed
386 2010 Dietary Guidelines Advisory Committee Report
seafood are safe (Dewailly, 2007; Mozaffarian, 2006; mercury-selenium ratio in seafood may, in part, explain
Rawn, 2006; Santerre, 2004; Tittlemier, 2004). some of the health benefits and adverse effects of some
However, concerns continue to be raised about the species of seafood consumed as observed in several
higher levels of POPs found in farmed versus wild prospective studies, such as those in the Seychelles
seafood, including salmon (Huang, 2006). Regarding Islands versus Northern Europe (Kaneko, 2007; Myers,
this concern, Mozaffarian and Rimm (2006) 2009; Rice, 2008). However, a recent study of flatfish
documented strong benefit/risk ratios (range: 100 to harvested from the New Jersey coast did not indicate a
1000-fold) associated with the consumption of wild or strong correlation of mercury-selenium ratio, regardless
farmed salmon taking into account cardiovascular of season or geographic location (Burger, 2009). Thus,
benefits associated with DHA consumption and although the review of several recent studies on the
excessive cancer rates attributed to potential exposure to potential benefit-risk relationship of seafood
POPs. Consistent with this finding, Verger et al. (2008) consumption and selenium show an interesting possible
found that recommended intakes of omega-3 PUFA can protective effect of selenium, the data are insufficient to
be met and even exceeded through eating seafood affect the immediate and consistent public health
without going beyond POP’s upper tolerable intake recommendation regarding the consumption of seafood
limits. previously reported in this chapter.
In summary, benefit/risk modeling studies indicate that Implications of Aquacultural Practices for a
if appropriate seafood choices are made, namely Safe, Nutritious Food Supply
emphasizing consumption of seafood low in MeHg and The recommendations of the Committee related to
POPs, consumers may be able to eat 12 ounces or more seafood consumption led to discussions of the role of
of a variety of seafood per week safely, although aquaculture in providing a safe and nutritious food
additional CVD benefits may not be obtained beyond supply. Aquaculture refers to the breeding, rearing, and
12 ounces (Mozaffarian, 2006). Indeed, this is the only harvesting of plants and animals in all types of water
quantitative study that conducted benefit/risk environments, including ponds, rivers, lakes, and the
assessments by seafood species consumed in the U.S. ocean (National Oceanic and Atmospheric
(based on MeHg risk only). Ginsberg and Toal (2009) Administration [NOAA], 2010). Similar to agriculture,
concluded that individuals can consume safely one 6- aquaculture can take place in the natural environment or
ounce meal per day for seven out of the 16 seafood in a manmade environment. Using aquaculture
species modeled taking into account infant techniques and technologies, researchers and the
neurodevelopment, and for nine of these species when aquaculture industry are “growing,” “producing,”
modeling cardiovascular health. “culturing,” and “farming” all types of marine and
freshwater species. About 20 percent of U.S.
Related Contextual Issues aquaculture production is marine species; the rest is
freshwater species. Aquaculture techniques also can be
Implications of Dietary Selenium and the applied to some plants, including vegetables (Cahu,
Potential Health Risks of Methyl Mercury 2004). Aquaculture is the most rapidly growing form of
Exposure From Seafood food production on a global basis. Globally, nearly 50
In reviewing the literature on the benefits and risks percent of the fish consumed comes from aquaculture
related to seafood consumption, the Committee was farms (Naylor, 2009; FAO, 2010). In response to the
interested in the role selenium may play in mitigating rapid growth of and need for aquaculture, the
harmful effects of MeHg and POPs. However, no Committee has included research recommendations on
studies were identified that met the inclusion criteria for this topic.
this question for the topic of selenium. Therefore, a
summation of current evidence is provided here for
context. Chapter Summary
Several investigators have hypothesized that dietary Consumers need to take more responsibility regarding
selenium from seafood may play a possible role in food safety. In doing so, along with sound government
protecting against environmental exposure to MeHg and policies and responsible food industry practices,
PCBs (Berry, 2008; Kaneko, 2007; Ralston, 2008; consumers can help prevent foodborne illness.
Ravoori, 2009). On the other hand, high exposure levels Consumers should better understand their role in
to MeHg can inhibit vital functions of selenium. The
2010 Dietary Guidelines Advisory Committee Report 387
ensuring that the foods they prepare at home or order at Rationale: Studies have consistently documented
food service outlets are handled safely and contain the need to develop cost–effective consumer food
ingredients known to them. Americans could benefit safety behavior change interventions. This research
from improved food safety education on hand needs to take into account the socio-ecological
sanitation, use of food/appliance thermometers, framework that acknowledges the constant
prevention of cross-contamination, and consumption of interaction between environmental forces and
certain risky foods in the home (e.g., cookie dough individuals’ choices on health behaviors (Levy,
containing raw eggs), as well as outside the home (e.g., 2008; Story, 2008). Whenever possible, these
raw fish and shellfish). Even with current and future studies should include objective microbiological
introductions of food safety technologies, food safety food safety indicators to assess the effectiveness of
fundamentals in the home remain foundational. Seafood the interventions.
is a healthy food choice that can be safely promoted
provided that the types and sources of seafood to be 3. Understand whether and how home kitchen
avoided are clearly communicated to consumers. microbial cross-contamination during food
Consumption of at least 12 ounces per week of seafood preparation translates into actual risk for foodborne
can be safe for the general population provided illness.
consumers choose the right mix of seafood,
emphasizing species low in contaminants (e.g., MeHg Rationale: There is indisputable laboratory
and POPs). The Committee supports the evidence demonstrating that potentially harmful
recommendations of the 2004 FDA/EPA seafood bacteria (mostly Campylobacter) present in raw
advisory that states women who may become or who are poultry can be transferred to ready-to-eat foods
pregnant, nursing mothers, and young children can through cross-contamination in the home kitchen.
safely eat up to 12 ounces of seafood, should limit white Cross-contamination risk studies have heavily
(albacore) tuna to 6 ounces per week, and should not eat concentrated on the transmission of Campylobacter
large, predatory fish. Among these vulnerable groups, through poultry, and the great majority have been
there is emerging evidence that consumption beyond 12 conducted in Europe, leaving a knowledge gap for
ounces per week may be safe; however, the U.S. Studies are also needed in the U.S. that
additional benefit/risk modeling is needed taking into concentrate on pathogens and food vehicles other
account the simultaneous presence of multiple than Campylobacter and poultry.
contaminants in a shifting seafood supply. Consumers
need improved access to publicly available user-friendly 4. Improve monitoring and surveillance to better
benefit/risk information to make informed seafood understand the epidemiology of home-based
choices. foodborne illness outbreaks.
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Florida. J Food Prot. 2007;70(5):1230-7.
Yucel Sengun I, Karapinar M. Effectiveness of
U.S. Department of Agriculture. Nationwide Federal household natural sanitizers in the elimination of
Plant Raw Ground Beef Microbiological Survey, Salmonella typhimurium on rocket (Eruca sativa
August 1993--March 1994. Washington, DC: U.S. Miller) and spring onion (Allium cepa L.). Int J Food
Department of Agriculture; 1996. Microbiol. 2005;98(3):319-23.
Table D8.1. Original and final research questions for food safety techniques and consumer behaviors in the home
To what extent do consumers follow proper Question 4. SEPARATE: What techniques for
techniques/behaviors and procedures for food storage preventing cross-contamination are associated with
and food preparation and handling? favorable food safety outcomes?
Question 5. COOK AND CHILL: To what extent do
U.S. consumers follow adequate temperature control
during food preparation and storage at home?
What in-home techniques for food storage and food See Questions 4 and 5.
preparation and handling are associated with
favorable food safety outcomes, such as reduced
pathogen loads and subsequent risk of home-based
foodborne illnesses?
To what extent do consumers follow proper Question 1. CLEAN: What techniques for hand
techniques/behaviors and procedures for hand sanitation are associated with favorable food safety
washing? outcomes and to what extent do U.S. consumers follow
them?
What in-home techniques for hand washing are See Question 1.
associated with favorable food safety outcomes, such
as reduced pathogen loads and subsequent risk of
home-based foodborne illnesses?
To what extent do consumers follow proper Question 3. CLEAN: To what extent do U.S.
techniques/behaviors and procedures for consumers clean their refrigerators?
washing/cleaning utensils, equipment, and surfaces See Question 4.
used in food preparation, serving, cooking, and
eating?
What in-home techniques, for washing/cleaning See Questions 3 and 4.
utensils, equipment, and surfaces used in food
preparation, serving, cooking, eating, are associated
with favorable food safety outcomes, such as reduced
pathogen loads and subsequent risk of home-based
foodborne illnesses?
To what extent do consumers follow proper Question 2. CLEAN: What techniques for washing
techniques/behaviors and procedures for fresh produce are associated with favorable food safety
washing/cleaning foods (such as fruits, vegetables, outcomes and to what extent do U.S. consumers follow
meat, poultry, seafood, eggs) at home? Which food them?
washing/cleaning technique(s) are most commonly See Question 4.
used by consumers?
What in-home techniques for washing/cleaning foods See Questions 2 and 4.
such as fruits, vegetables, meat, poultry, seafood,
eggs are associated with favorable food safety
outcomes, such as reduced pathogen loads (and
reduced chemical contaminant load related to fruits
and vegetables) and subsequent risk of home-based
foodborne illnesses?
To what extent do consumers follow proper Question 6. AVOID RISKY FOODS: To what extent
techniques/behaviors and procedures for consumption do U.S. consumers eat raw or undercooked animal
of undercooked or raw foods? foods?
Question 7. To what extent do specific subpopulations
practice unsafe food safety behaviors?
(Question 7 was within the criteria for all questions, and
was made into a question of its own.)
If soap and water are not available, use alcohol-based gel to clean hands. When using an alcohol-based hand
sanitizer:
• Apply product to the palm of one hand.
• Rub hands together.
• Rub the product over all surfaces of hands and fingers until hands are dry.
Source: Adapted from http://www.cdc.gov/cleanhands/. Accessed April 19, 2010.
When preparing any fresh produce, begin with clean hands. Wash your hands for 20 seconds with warm water
and soap before and after preparation.
Cut away any damaged or bruised areas on fresh fruits and vegetables before preparing and/or eating.
Produce that looks rotten should be discarded.
All produce should be thoroughly washed before eating. This includes produce grown conventionally or
organically at home, or produce that is purchased from a grocery store or farmer’s market. Wash fruits and
vegetables under potable running water just before eating, cutting, or cooking.
Even if you plan to peel the produce before eating, it is still important to wash it first.
Washing fruits and vegetables with soap or detergent or using commercial produce washes is not recommended.
Scrub firm produce, such as melons and cucumbers, with a clean produce brush.
Drying produce with a clean cloth towel or paper towel may further reduce bacteria that may be present.
Many precut, bagged, or packaged produce items like lettuce are pre-washed and ready to eat. If the package
indicates that the contents have been pre-washed and ready to eat, you can use the product without further
washing.
If you do choose to wash a product marked “pre-washed” and “ready-to-eat,” be sure to use safe handling
practices to avoid any cross-contamination. Wash your hands for 20 seconds with warm water and soap before
and after handling the product and wash the produce under running water just before preparing or eating.
Source: Adapted from http://www.fda.gov/downloads/Food/ResourcesForYou/Consumers/UCM174142.pdf.
Accessed April 19, 2010.
Wipe up spills immediately—clean surfaces thoroughly with hot, soapy water; then rinse.
Once a week, throw out perishable foods that should no longer be eaten. A general rule of thumb for
refrigerator storage for cooked leftovers is 4 days; raw poultry and ground meats, 1 to 2 days.
The exterior of the refrigerator may be cleaned with a soft cloth and mild liquid dishwashing detergent as well
as cleansers and polishes that are made for appliance use.
Source: Adapted from http://www.fsis.usda.gov/Fact_Sheets/Refrigeration_&_Food_Safety/index.asp#11.
Accessed April 19, 2010.
When Shopping:
Separate raw meat, poultry, and seafood from other foods in your grocery shopping cart. Place these foods in
plastic bags to prevent their juices from dripping onto other foods. Raw juices often contain harmful bacteria.
It is also best to separate these foods from other foods at checkout and in your grocery bags.
When Refrigerating Food:
Place raw meat, poultry, and seafood in containers or sealed plastic bags to prevent their juices from dripping
onto other foods. When not possible, store raw animal foods below ready-to-eat foods and separate different
types of raw animal foods, such as meat, poultry, and seafood from each other so that they do not cross-
contaminate each other.
Store eggs in their original carton and refrigerate as soon as possible.
When Preparing Food:
Washing raw poultry, beef, pork, lamb, or veal before cooking it is not recommended. Bacteria in raw meat
and poultry juices can be spread to other foods, utensils, and surfaces.
Wash hands and surfaces often. Harmful bacteria can spread throughout the kitchen and get onto cutting
boards, utensils, and countertops. To prevent this:
• Wash hands with soap and warm water for 20 seconds before and after handling food, and after using the
bathroom, changing diapers, handling pets, or anytime hands become contaminated.
• Use hot, soapy water and paper towels or clean cloths to wipe up kitchen surfaces or spills. Wash cloths
often in the hot cycle of your washing machine.
• Wash cutting boards, dishes, and countertops with hot, soapy water after preparing each food item and
before you go on to the next item.
• A solution of 1 tablespoon of unscented, liquid chlorine bleach per gallon of water may be used to sanitize
surfaces and utensils.
Cutting Boards:
Always use a clean cutting board.
If possible, use one cutting board for fresh produce and a separate one for raw meat, poultry, and seafood.
Once cutting boards become excessively worn or develop hard-to-clean grooves, you should replace them.
Marinating Food:
Always marinate food in the refrigerator, not on the counter.
Sauce that is used to marinate raw meat, poultry, or seafood should not be used on cooked foods, unless it is
boiled just before using.
When Serving Food:
Always use a clean plate.
Never place cooked food back on the same plate or cutting board that previously held raw food.
Source: Adapted from http://origin-
www.fsis.usda.gov/Fact_Sheets/Does_Washing_Food_Promote_Food_Safety/index.asp and http://origin-
www.fsis.usda.gov/Fact_Sheets/Be_Smart_Keep_Foods_Apart/index.asp. Accessed April 19, 2010.
To be safe, meat, poultry, and egga and seafoodb products must be cooked to a safe minimum internal
temperature to destroy any harmful microorganisms that may be in the food.
A food thermometer should also be used to ensure that cooked food is held at safe temperatures until served.
Cold foods should be held at 40°F or below. Hot foods should be kept hot at 140°F or above.a
Most available food thermometers will give an accurate reading within 2 to 4°F. The reading will only be
correct, however, if the thermometer is placed in the proper location in the food. a
In general, the food thermometer should be placed in the thickest part of the food, away from bone, fat, or
gristle.a
When the food being cooked is irregularly shaped, such as with a beef roast, check the temperature in several
places. Egg dishes and dishes containing ground meat and poultry should be checked in several places.a
When measuring the temperature of a thin food, such as a hamburger patty, pork chop, or chicken breast, a
thermistor or thermocouple food thermometer should be used, if possible. a
However, if using an “instant-read” dial bimetallic-coil food thermometer, the probe must be inserted in the side
of the food so the entire sensing area (usually 2 to 3 inches) is positioned through the center of the food.a
To avoid burning fingers, it may be helpful to remove the food from the heat source (if cooking on a grill or in a
frying pan) and insert the food thermometer sideways after placing the item on a clean spatula or plate.a
Food thermometers should be washed with hot soapy water. Most thermometers should not be immersed in
water.a
Adapted from a http://origin-www.fsis.usda.gov/Fact_Sheets/Kitchen_Thermometers/index.asp. Accessed April 19,
2010.
b
http://www.fda.gov/Food/ResourcesForYou/HealthEducators/ucm082294.htm. Accessed April 26, 2010.
Read food labels to make sure that the word “pasteurized” is on the label of milk or milk products and, if unsure,
ask a grocery store employee whether a milk or milk product contains pasteurized milk. Such foods made from
unpasteurized milk could contain harmful bacteria.
Choose versions of these types of food made only with pasteurized milk:
Milk
Cream
Yogurt
Pudding
Ice cream and frozen yogurt
Cottage, cream, and ricotta cheeses
Processed cheeses
Soft cheeses such as Brie, Camembert, blue-veined cheeses, and Mexican-style soft cheeses such as Queso
Fresco, Panela, Asadero, and Queso Blanco
Source: Adapted from http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm079516.htm. Accessed April
20, 2010.
SECTION 1: ENERGY BALANCE AND increased risk of overweight and obesity. The evidence
WEIGHT MANAGEMENT is stronger for adolescents. There is inconsistent
evidence that adults who skip breakfast are at increased
risk for overweight and obesity. Limited and
Question 1: What Effects Do the Food inconsistent evidence suggests that snacking is
Environment and Dietary Behaviors Have associated with increased body weight. Evidence is
on Body Weight? insufficient to determine whether frequency of eating
has an effect on overweight and obesity in children and
Conclusion adults.
Conclusion Implications
Strong and consistent evidence demonstrates a large Efforts are warranted to increase dietary intake of heme-
reduction in the incidence of neural tube defects iron-rich foods and of enhancers of iron absorption by
(NTDs) in the U.S. and Canada following mandatory these special populations.
folic acid fortification. A limited body of evidence
suggests stroke mortality has declined in the U.S. and
Canadian populations following mandatory folic acid Question 6: Are Older Adults Consuming
fortification. A limited body of evidence suggests that Sufficient Vitamin B12?
mandatory folic acid fortification has increased the
incidence of colorectal cancer (CRC) in the U.S. and
Conclusion
Canada.
Recent evaluation of NHANES data shows that
Implications
individuals older than age 50 years are consuming
adequate intakes of vitamin B12, including B12 found
Folic acid fortification in the U.S. and Canada appears
naturally in foods and crystalline B12 consumed in
to be successful in the primary health objective of
fortified foods. Nonetheless, a substantial proportion of
reducing the incidence of NTDs. Although some
individuals older than age 50 years may have reduced
negative consequences appear to have occurred (i.e.,
Implications
Question 7: Can a Daily
Multivitamin/Mineral Supplement Prevent Americans are encouraged to eat nutrient-dense forms
Chronic Disease? of foods for breakfast while staying within energy needs
to facilitate achieving nutrient recommendations.
Conclusion Likewise nutrient-dense forms of foods are suggested
for any snacks, if energy allowance permits this
For the general, healthy population, there is no evidence behavior without incurring weight gain.
to support a recommendation for the use of
multivitamin/mineral supplements in the primary
prevention of chronic disease. Limited evidence SECTION 3: FATTY ACIDS AND
suggests that supplements containing combinations of CHOLESTEROL
certain nutrients are beneficial in reversing chronic
disease when used by special populations; in contrast,
certain nutrient supplements appear to be harmful in Question 1: What Is the Effect of Saturated
other subgroups. Fat Intake on Increased Risk of
Cardiovascular Disease or Type 2
Implications Diabetes, Including Effects on
Intermediate Markers Such as Serum Lipid
Although intake of a variety of multivitamin/mineral and Lipoprotein Levels?
supplements increases blood levels of many nutrients,
notably in individuals with suboptimal nutrient status Conclusion
before supplementation (Maraini, 2009), long-term
effects on primary prevention of several chronic Strong evidence indicates that intake of dietary
diseases has not been demonstrated. In this context, saturated fatty acids (SFA) is positively associated with
obtaining essential micronutrients from foods when intermediate markers and end point health outcomes for
possible is the optimal approach and reliance on two distinct metabolic pathways: (1) increased serum
multivitamin/mineral supplements is discouraged. At total and low-density lipoprotein (LDL) cholesterol and
present, Americans are encouraged to meet overall increased risk of cardiovascular disease (CVD) and (2)
nutrient requirements within energy levels that balance increased markers of insulin resistance and increased
daily energy intake with expenditure. This can be risk of T2D. Conversely, decreased SFA intake
accomplished through a variety of food intake patterns improves measures of both CVD and T2D risk. The
that include nutrient-dense forms of foods. evidence shows that 5 percent energy decrease in SFA,
replaced by monounsaturated fatty acids (MUFA) or
polyunsaturated fatty acids (PUFA), decreases risk of
Implications
Conclusion
SECTION 4: PROTEIN
There is moderate evidence that consumption of
unsalted peanuts and tree nuts, specifically walnuts, Question 1: What Is the Relationship
almonds, and pistachios, in the context of a nutritionally Between the Intake of Animal Protein
adequate diet and when total calorie intake is held Products and Selected Health Outcomes?
constant, has a favorable impact on cardiovascular
disease risk factors, particularly serum lipid levels. Conclusion
Implications
Question 5: In Adults, What Are the
Associations Between Intake of Sugar- The replacement of sugar-sweetened foods and
sweetened Beverages and Energy Intake beverages with sugar-free products should theoretically
reduce body weight. Yet many questions remain, as
and Body Weight?
epidemiologic studies show a positive link with use of
nonnutritive sweeteners and BMI. Additionally,
Conclusions whether use of low calorie sweeteners is linked to
higher intake of other calories in the diet remains a
Limited evidence shows that intake of sugar-sweetened debated question.
beverages is linked to higher energy intake in adults. A
In 2005, the DGAC recommended a daily sodium Question 3: What Amount of Water Is
intake of less than 2300 milligrams for the general adult Recommended for Health?
population and stated that hypertensive individuals,
Blacks, and middle-aged and older adults would benefit Conclusion
from reducing their sodium intake even further.
Because these latter groups together now comprise Based on an extensive review of evidence, an IOM
nearly 70 percent of U.S. adults, the goal should be panel in 2004 concluded that the combination of thirst
1500 milligrams per day for the general population. and usual drinking behavior, especially the consumption
Given the current U.S. marketplace and the resulting of fluids with meals, is sufficient to maintain normal
excessively high sodium intake, it will be challenging to hydration. However, because water needs vary
achieve the lower level. In addition, time is required to considerably and because there is no evidence of
adjust taste perception in the general population. Thus, chronic dehydration in the general population, a
the reduction from 2300 milligrams to 1500 milligrams minimum intake of water cannot be set.
per day should occur gradually over time. A recent
Institute of Medicine (IOM) report has provided a Implications
roadmap to achieve gradual reductions in sodium
intake. Because early stages of blood pressure-related In order to prevent dehydration, water must be
atherosclerotic disease begin during childhood, both consumed daily. Healthy individuals who have routine
children and adults should reduce their sodium intake. access to fluids and who are not exposed to heat stress
Individuals should also increase their consumption of consume adequate water to meet their needs. Purposeful
dietary potassium because increased potassium intakes drinking is warranted for individuals who are exposed
helps to attenuate the effects of sodium on blood to heat stress or who perform sustained vigorous
pressure. physical activity. Although uncommon, heat waves are
one setting of extreme heat stress that increases the risk
of morbidity and mortality from dehydration, especially
420 2010 Dietary Guidelines Advisory Committee Report
in older-aged persons. In view of the ongoing obesity and long-term cognitive function and should be
epidemic, individuals are encouraged to drink water and avoided.
other fluids with few or no calories.
Conclusion
Implications
The terms in this Glossary appear in multiple sex and age. The percentile indicates the relative
sections of the Report and are essential to position of the child’s BMI among children of the same
understanding the major themes and concepts sex and age.
discussed throughout. Terms specific to individual
sections are defined there. Definitions are taken Calorie—Unit of energy that is required to sustain the
from a variety of sources, including 2010 DGAC body’s various functions, including metabolic processes
chapters, the 2005 DGAC Report, 2005 Dietary and physical activity. Carbohydrate, fat, protein, and
Guidelines for Americans, Institute of Medicine alcohol provide all of the energy supplied by foods and
reports, USDA and HHS regulatory definitions, and beverages. Calories referred to in terms of dietary intake
published sources in the scientific literature. and expenditure are kilocalories, but are referred to as
calories in this Report.
Added sugars—Sugars, syrups, and other caloric
sweeteners that are added to foods during processing, Carbohydrates—One of the three classes of
preparation, or consumed separately. Added sugars do macronutrients that include sugars, starches, and fibers:
not include naturally occurring sugars such as those in
milk or fruits. Names for added sugars include: brown • Sugars—A simple carbohydrate composed of one
sugar, corn sweetener, corn syrup, dextrose, fructose, unit (a monosaccharide, such as glucose and
fruit juice concentrates, glucose, high-fructose corn fructose) or two joined units (a disaccharide, such
syrup, honey, invert sugar, lactose, maltose, malt syrup, as lactose and sucrose). Sugars include white and
molasses, raw sugar, turbinado sugar, trebalose, and brown sugar, fruit sugar, corn syrup, molasses, and
sucrose. honey.
• Starches—Many glucose units linked together.
Body mass index (BMI)—A measure of weight in Examples of foods containing starch include
kilograms (kg) relative to height in meters (m) squared. vegetables, dry beans and peas, and grains (e.g.,
BMI is considered a reasonably reliable indicator of brown rice, oats, wheat, barley, corn).
total body fat, which is related to the risk of disease and • Fiber—Nondigestible carbohydrates and lignin that
death. BMI status categories include underweight, are intrinsic and intact in plants. Fiber consists of
healthy weight, overweight, and obese. Overweight and dietary fiber, the fiber naturally occurring in foods,
obese describe ranges of weight that are greater than and functional fiber— isolated, nondigestible
what is considered healthy for a given height, while carbohydrates that have beneficial physiological
underweight describes a weight that is lower than what effects in humans.
is considered healthy. Because children and adolescents
are growing, their BMI is plotted on growth charts for
Underweight Less than the 5th percentile Less than 18.5 kg/m2
Healthy weight 5th percentile to less than the 85th percentile 18.5 to 24.9 kg/m2
Overweight 85th to less than the 95th percentile 25.0 to 29.9 kg/m2
Obese Equal to or greater than the 95th percentile 30 kg/m2 or greater
Portion size—The amount of a food served or Refined grains—Grains and grain products missing the
consumed in one eating occasion. A portion is not a bran, germ, and/or endosperm; any grain product that is
standardized amount, and the amount considered to be a not a whole grain. Many refined grains are low in fiber
portion is subjective and varies. (See Serving size.) but enriched with thiamin, riboflavin, niacin, and iron,
and fortified with folic acid as required by U.S.
Processed food—Any food other than a raw regulations.
agricultural commodity, including any raw agricultural
commodity that has been subject to washing, cleaning, Seafood—All commercially obtained fish, shellfish,
milling, cutting, chopping, heating, pasteurizing, and mollusks, both marine and freshwater.
blanching, cooking, canning, freezing, drying,
dehydrating, mixing, packaging, or other procedures Serving size—A standardized amount of a food, such
that alter the food from its natural state. Processing also as a cup or an ounce, used in providing information
may include the addition of other ingredients to the about the food, such as on the Nutrition Facts label or in
food, such as preservatives, flavors, nutrients, and other dietary guidance, or in making comparisons among
food additives or substances approved for use in food similar foods. The portion size consumed may differ
products, such as salt, sugars, and fats. Processing of from the standard service size. (See Portion size.)
foods, including the addition of ingredients, may
The 2010 Dietary Guidelines Advisory Committee foods, and (3) if more fluid milk and less
(DGAC) identified specific questions that they felt cheese were consumed?
could best be addressed through a food pattern E3.7: Replacing all Non-Whole Grains with Whole
modeling approach, using the USDA Food Patterns and Grains. What is the impact on intake of folate
the modeling process developed to address similar and other nutrients if all recommended grain
requests by the 2005 DGAC. Twelve modeling amounts are selected as whole grains rather
analyses were completed and provided as reports to four than half whole and half nonwhole grains?
DGAC subcommittees. The food pattern modeling E3.8: Cholesterol. What is the impact on food
analyses conducted for the DGAC are listed below. Full choices and overall nutrient adequacy of
reports for each analysis are available online at limiting cholesterol to less than 200 milligrams
www.dietaryguidelines.gov. per day?
E3.9: Reducing Cholesterol-Raising Fatty Acids.
E3.1: Adequacy of the USDA Food Patterns. How What is the impact on food choices and overall
well do the USDA Food Patterns, using nutrient adequacy of limiting cholesterol-raising
updated food intake and nutrient data, meet (CR) fatty acids to less than 7 percent of total
IOM and potential DG 2010 nutrient calories and to less than 5 percent of total
recommendations? calories, with CR fatty acids operationalized as
E3.2: Realigning Vegetable Subgroups. What total saturated fatty acids minus stearic acid?
revisions to the vegetable subgroups may help E3.10: Seafood. What is the impact on nutrient
to highlight vegetables of importance and allow adequacy of increasing seafood in the USDA
recommendations for intake levels that are Food Patterns to (1) 4 ounces per week of
achievable, without compromising the nutrient seafood high in n-3 fatty acids, (2) 8 ounces per
adequacy of the patterns? week of seafood in proportions currently
E3.3: Vegetarian Food Patterns. How well do consumed, and (3) 12 ounces per week of
plant-based or vegetarian food patterns, adapted seafood low in n-3 fatty acids?
from the USDA Food Patterns, meet IOM and E3.11: Sodium. What would the sodium levels of the
potential DG 2010 nutrient recommendations? USDA Food Patterns be (1) using current
E3.4: Starchy Vegetables. How do the nutrients patterns, (2) using “typical choices” patterns,
provided by the starchy vegetable subgroup and (3) using only low sodium and no-salt-
compare with those provided by grains and added foods?
those provided by other vegetable subgroups? E3.12: Potassium. What are the potassium levels in
How would nutrient adequacy of the patterns be the USDA Food Patterns, in comparison to
affected by considering starchy vegetables as a current consumptions and DASH diet levels, in
replacement for some grains rather than as a absolute amounts, adjusted for energy intake,
vegetable subgroup? and as a ratio of sodium to potassium? How
E3.5: “Typical Choices” Food Patterns. What is the would potassium levels of the USDA Food
impact on caloric and nutrient intake if the Pattern change if current levels of coffee and
USDA Food Patterns are followed but typical tea intake were included?
rather than nutrient-dense food choices are
made?
E3.6: Milk Group and Alternatives. What is the
impact on nutrient adequacy (1) if no milk or
milk products were consumed, (2) if calcium
was obtained from nondairy sources or fortified
In early 1977, after years of discussion, scientific Department of Health, Education, and Welfare) selected
review, and debate, the U.S. Senate Select Committee scientists from the two Departments and obtained
on Nutrition and Human Needs, led by Senator George additional expertise from the scientific community
McGovern, recommended Dietary Goals for the throughout the country to address the public’s need for
American people (U.S. Senate Select Committee, authoritative and consistent guidance on diet and health.
1977). The Goals consisted of complementary nutrient-
based and food-based recommendations. The first Goal In February 1980, the two Departments collaboratively
focused on energy balance and recommended that, to issued Nutrition and Your Health: Dietary Guidelines
avoid overweight, Americans should consume only as for Americans, a brochure that, in describing seven
much energy as they expended. Overweight Americans principles for a healthful diet, provided assistance for
should consume less energy and expend more energy. healthy people in making daily food choices
For the nutrient-based Goals, the Senate Committee (USDA/HHS, 1980). These Guidelines were based, in
recommended that Americans: part, on the 1979 Surgeon General’s Report on Health
Promotion and Disease Prevention (DHEW/PHS,
• Increase consumption of complex carbohydrates 1979) and reflected findings from a study on the
and “naturally occurring sugars;”and relationship between dietary practices and health
• Reduce consumption of refined and processed outcomes (ASCN, 1979). Ideas for incorporating a
sugars, total fat, saturated fat, cholesterol, and variety of foods to provide essential nutrients while
sodium. maintaining recommended body weight were a focus.
The brochure also provided guidance on limiting dietary
For the food-based Goals, the Committee recommended components such as fat, saturated fat, cholesterol, and
that Americans: sodium, which were beginning to be considered risk
factors in certain chronic diseases. Both the Dietary
• Increase consumption of fruits, vegetables, and Goals and the first Dietary Guidelines for Americans
whole grains were different from previous dietary guidance in that
• Decrease consumption of: they reflected the emerging scientific evidence and
— refined and processed sugars and foods high in changed the historical focus on nutrient adequacy to
such sugars also identify the impacts of diet on chronic disease.
— foods high in total fat and animal fat, and These documents discussed the concepts of moderation
partially replace saturated fats with as well as nutrient adequacy.
polyunsaturated fats
— eggs, butterfat, and other high-cholesterol foods Even though the recommendations of the 1980 Dietary
— salt and foods high in salt Guidelines for Americans were presented as innocuous
• Choose low-fat and non-fat dairy products instead and straightforward extrapolations from the science
of high-fat dairy products (except for young base, they, too, were met with a fair amount of
children) controversy from a variety of industry and scientific
groups.
The issuance of the Dietary Goals was met with
considerable debate and controversy, as industry groups The debate about the 1980 Dietary Guidelines for
and the scientific community expressed doubt that the Americans led to Congressional report language that
science available at the time supported the specificity of directed the two Departments to convene an advisory
the numbers provided in the Dietary Goals. To support committee that would ensure that outside advice, both
the credibility of the science used by the Committee, the formal and informal, was captured in developing future
U.S. Department of Agriculture and U.S. Department of editions of the Dietary Guidelines. A Dietary
Health and Human Services (then called the Guidelines Advisory Committee composed of scientific
1987 Language in the Conference Report of the 1994 An 11-member Dietary Guidelines Advisory
House Committee on Appropriations indicated Committee was appointed by the Secretaries of
that USDA, in conjunction with HHS, “shall HHS and USDA to review the third edition of
reestablish a Dietary Guidelines Advisory Group the Dietary Guidelines and determine whether
on a periodic basis. This Advisory Group will changes were needed. If so, the Committee was
review the scientific data relevant to nutritional to recommend suggestions and the rationale for
guidance and make recommendations on any revisions.
appropriate changes to the Secretaries of the
Departments of Agriculture and Health and 1995 The report of the Dietary Guidelines Advisory
Human Services” (U.S. House of Committee to the Secretaries of HHS and
Representatives, 1987). USDA was published (HHS/USDA, 1995a).
1989 USDA and HHS established a second Federal 1995 Using the 1995 report of the Dietary Guidelines
advisory committee of nine members, which Advisory Committee as the foundation, HHS
considered whether revisions to the 1985 and USDA jointly released the fourth edition of
Dietary Guidelines were needed and made Nutrition and Your Health: Dietary Guidelines
recommendations for revision in a report to the for Americans (HHS/USDA, 1995b). This
2008 A 13-member Dietary Guidelines Advisory American Society for Clinical Nutrition (ASCN).
Committee was appointed by the Secretaries of Symposium. Report of the Task Force on the evidence
USDA and HHS to review the sixth edition of relating six dietary factors to the nation’s health. Am J
Dietary Guidelines for Americans to determine Clin Nutr. 979;32(Supplement):2621-748.
whether changes were needed and, if so, to
recommend suggestions for revision. Murphy S. Development of the MyPyramid Food
2009 USDA established a Nutrition Evidence Guidance System. J Nutr Educ Behav.
Library (NEL) for use in reviewing the 2006;38(6S):S77-S162.
scientific literature for answering
approximately 130 of the 180 scientific National Academy of Science, National Research
questions posed by the Dietary Guidelines Council (NAS, NRC). Diet and Health: Implications
Advisory Committee. This was the most for Reducing Chronic Disease Risk. Washington (DC):
rigorous and comprehensive approach ever National Academy Press, 1989.
used for reviewing the science in order to
develop nutrition-related recommendations for U.S. Congress. National Nutrition Monitoring and
the public. When a full systematic review of Related Research Act of 1990, Public Law 445, 101st
the evidence was not needed, other methods Cong., 2nd Session., Section 301, 7 USC 5341, October
for answering scientific questions were used. 22, 1990.
These included brief updates to substantial
sources of evidences already completed in the U.S. Department of Agriculture and U.S. Department of
past such as the 2005 DGAC Report and IOM Health and Human Services (USDA/HHS). Nutrition
Reports. Food pattern modeling using and Your Health: Dietary Guidelines for Americans. 1st
USDA’s MyPyramid Food Guidance System edition. Washington (DC): USDA/HHS, 1980. Home
and the review of various data analyses were and Garden Bulletin No. 232.
also used in formulating answers for some of
the questions posed. An elaborate public U.S. Department of Agriculture and U.S. Department of
comments database was developed and Health and Human Services (USDA/HHS). Report of
successfully served to accept comments and the Dietary Guidelines Advisory Committee on the
attachments from the public in one central Dietary Guidelines for Americans, 1985. Washington
location. This database served to encourage (DC): USDA, Human Nutrition Information Service,
public participation and supported a collection 1985a.
of more than 800 public comments related to
the DGAC process. U.S. Department of Agriculture and U.S. Department of
Health and Human Services (USDA/HHS). Nutrition
2010 The Committee submitted its report to the and Your Health: Dietary Guidelines for Americans. 2nd
Secretaries of USDA and HHS. This report edition. Washington (DC): USDA/HHS, 1985b. Home
will serve as the basis for preparing the and Garden Bulletin No. 232.
seventh edition of Dietary Guidelines for
Americans. USDA and HHS will jointly issue U.S. Department of Agriculture and U.S. Department of
the seventh edition of the Dietary Guidelines Health and Human Services (USDA/HHS). Report of
for Americans. This publication will continue the Dietary Guidelines Advisory Committee on the
to serve as the basis of Federal nutrition Dietary Guidelines for Americans, 1990. Washington
policy. Additional consumer communication (DC): USDA, Human Nutrition Information Service,
materials will be developed to provide advice 1990a.
U.S. Department of Agriculture and U.S. Department of U.S. Department of Health and Human Services, Public
Health and Human Services (USDA/HHS). Nutrition Health Service (HHS, PHS). The Surgeon General’s
and Your Health: Dietary Guidelines for Americans. 5th Report on Nutrition and Health. Washington (DC):
edition. Washington (DC): USDA/HHS, 2000b. Home DHHS, PHS, 1988. Publication No. 88-50215.
and Garden Bulletin No. 232.
U.S. Department of Health, Education, and Welfare,
U.S. Department of Health and Human Services and Public Health Service (DHEW, PHS). Healthy People:
U.S. Department of Agriculture (HHS/USDA). Report The Surgeon General’s Report on Health Promotion
of the Dietary Guidelines Advisory Committee on the and Disease Prevention. Washington (DC): DHEW,
Dietary Guidelines for Americans, 1995. Washington PHS, 1979. DHEW Publication No. 79-55071.
(DC): USDA, Agricultural Research Service, 1995a.
U.S. House of Representatives Conference Committee
U.S. Department of Health and Human Services and (U.S. House of Representatives). 100th Cong., 1st sess.,
U.S. Department of Agriculture (HHS/USDA). H. Rep. 498, 1987.
Nutrition and Your Health: Dietary Guidelines for
Americans. 4th edition. Home and Garden Bulletin No. U.S. Senate Agricultural Appropriations Committee
232. Washington (DC): HHS/USDA, 1995b. (U.S. Senate). 96th Cong., 1st sess., S. Rep. 1030, 1980.
U.S. Department of Health and Human Services and U.S. Senate Select Committee on Nutrition and Human
U.S. Department of Agriculture (HHS/USDA). Report Needs. Dietary Goals for the United States. 2nd edition.
of the Dietary Guidelines Advisory Committee on the Washington (DC): U.S. Government Printing Office,
Dietary Guidelines for Americans, 2005. Washington 1977.
(DC): USDA, Agricultural Research Service, 2004.
As a government advisory panel, the Dietary Guidelines “other.” Most of these key topic areas were further
Advisory Committee (DGAC) is required by the categorized into subtopics. For example, under
Federal Advisory Committee Act (FACA) to conduct an carbohydrates, additional category selections included
open process in which the public may participate. The added sugars, fiber, whole grains, glycemic index, and
public does this through submitting written and oral low carbohydrates. This function allowed staff to
comments to the Committee. generate reports on specific issues within topic areas.
The first public comment was submitted to the public Although comments could be submitted continually,
comments database on October 17, 2008. Thereafter, each Federal Register notice announcing an upcoming
the Committee received written comments from the DGAC public meeting included a final date for
public continuously and at a steady pace throughout comment submissions. This ensured timely transmission
their deliberations. Comment submissions increased of comments to the DGAC before the meeting. In
noticeably in response to each call for public comments. general, the ending submission date was set at close of
These calls were released through six Federal Register business 6 calendar days before each DGAC meeting
notices announcing upcoming public DGAC meetings. date. This allowed all comments to be posted and
comment reports to be generated and sent to Committee
Comment submissions were collected through a newly members with sufficient time for comments to be
developed electronic database designed for this purpose reviewed before the meeting. Comments that were
and located at www.dietaryguidelines.gov. The submitted later than the time specified in the Federal
motivation for developing this database was to help Register notice were considered by the Committee for
reduce the burden on the public for submitting the following public meeting date. Public comment
comments, especially cumbersome paper submissions; reports by key topic area were made available to
to provide a central place for storing all comments; to Committee members before each DGAC meeting and
allow continual public access to all comments; and to more frequently during the large time spans between the
allow the DGAC to have full access to comments and third and fourth DGAC meeting and the fourth and fifth
accompanying reports, research, and other support DGAC meeting. Comment submission for the sixth
material. This database is the most efficient, open, and meeting ended 13 days before the May 12, 2010
transparent public comment collection system to date. meeting because the Committee needed additional time
to consider the comments before completing their
Each comment submitted to the database was chapters for their DGAC Report.
categorized within one or more of 14 key topic areas.
This allowed anyone interested in a particular topic to When organizations or individuals submitted comments
efficiently navigate to the selected topic area and view to the electronic database, they were required to
comments assigned to that section without having to complete three fields—organization type, key topic, and
spend time combing through all the comments. A query summary comment. Comments could not exceed 2,000
function on this “filing” system also allowed staff to characters. Other fields were optional. Submitters also
generate topic-specific reports of public comments for were able to upload an attachment for comments that
various time periods. This report feature proved exceeded 2,000 characters or for other support material
valuable for the DGAC members, who could easily the submitter desired to share with the Committee.
access and review comments about a certain key topic Disclaimers were posted in multiple places alerting the
area that pertained to their subcommittee’s work. submitter to heed copyright laws.
The 14 topic areas were: alcoholic beverages, A small team of staff reviewed each comment
carbohydrates, eating patterns, energy balance/physical submission. Comments that were offensive in nature
activity, evidence-based review process, fats, fluids and were not posted. Comments that were inappropriately
electrolytes, food groups, food safety, minerals, nutrient categorized in a key topic area(s) were correctly
density/discretionary calories, protein, vitamins, and categorized. Duplicate submissions that were obvious
Linda V. Van Horn, PhD, RD, LD, Chair Dr. Fukagawa is an expert in nutritional biochemistry
and metabolism. Her expertise spans several areas
Dr. Van Horn is a Professor in the Department of including protein and energy metabolism; oxidants and
Preventive Medicine, and the Associate Dean for antioxidants; and the role of diet in aging and chronic
Faculty Development at the Feinberg School of diseases, such as diabetes mellitus. She has chaired the
Medicine at Northwestern University, Chicago. Dr. Van National Institutes of Health Clinical Research Centers’
Horn received her doctorate from the School of Public Committee and is currently a member of the National
Health at the University of Illinois, Chicago and her Institutes of Health Integrative Physiology of Diabetes
master’s in exercise physiology from the University of and Obesity Study Section.
Pittsburgh. Her undergraduate degree is in dietetics,
from Purdue University, West Lafayette. She also is a Cheryl Achterberg, PhD
registered and licensed dietitian.
Dr. Achterberg is the Dean and Professor of the College
Dr. Van Horn’s expertise extends across many areas of of Education and Human Ecology at The Ohio State
nutrition research, medical nutrition education, and University. She received her doctorate in nutrition from
public health policy relevant to the work of the Dietary Cornell University and her master’s in human
Guidelines Advisory Committee. She is a clinical development from the University of Maine at Orono.
nutrition epidemiologist who has conducted population
level research and clinical trials in the prevention and Dr. Achterberg is an expert in health behavior research.
treatment of cardiovascular disease, obesity, and breast Her studies have evaluated consumer understanding of
cancer. She specializes in research on women and the dietary guidelines as well as the impact of behavior
children and is currently the principal investigator in the on the dietary patterns of varying groups, including low-
Women’s Health Initiative Extension Study and the income, young children, and elderly Americans. She
Dietary Intervention Study in Children follow-up study. has served as a Panel member for the World Health
Her research focuses on the benefits of a fat-modified Organization for setting international guidelines for
diet that is high in fruits, vegetables, and fiber-rich Developing Food Based Dietary Guidance. She has
whole grains as part of a low risk lifestyle to prevent been a resource to the Institute of Medicine as an
cardiovascular disease, obesity and cancer. In addition invited panelist for numerous workshops. She has also
to her comprehensive nutrition expertise, she has worked with the United Nations as an expert in
demonstrated successful leadership through multiple nutrition education and community interventions.
research teams.
Lawrence J. Appel, MD, MPH
Naomi K. Fukagawa, MD, PhD, Vice Chair
Dr. Lawrence Appel is a Professor of Medicine,
Dr. Fukagawa is a Professor of Medicine, the Acting Epidemiology, and International Health (Human
Director of Gerontology, and the Associate Program Nutrition), Division of General Internal Medicine, and
Director for the Clinical Research Center at the Director of the ProHealth Clinical Research Unit at the
University of Vermont and Fletcher Allen Health Care. Johns Hopkins Medical Institutions. Dr. Appel received
She received her medical degree from Northwestern his medical degree from the New York University
University and her doctorate in nutritional biochemistry School of Medicine and his master’s of public health
and metabolism from the Massachusetts Institute of from Johns Hopkins University. He is also a practicing
Technology. She is a board-certified pediatrician, but internist and a certified specialist in hypertension.
has focused her research on age-related issues.