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From Medscape Internal Medicine > Staying Well With Fryhofer, MD

2010 Dietary Guidelines -- Take-Home Points

A. Fryhofer, MD, FRCP

2010 Dietary Guidelines for Americans: Background

The Total Diet

Beyond the Food Groups

Summary: Making the Guidelines About You

References

2010 Dietary Guidelines for Americans: Background

This issue of Staying Well focuses on eating well, the cornerstone of staying

well. The timing of this topic is no coincidence. It corresponds to the release

of the 2010 Dietary Guidelines for Americans,[1] the holy grail of dietary

advice for Americans age 2 and older. The guidelines, a joint effort of the

Department of Agriculture (USDA) and Department of Health and Human Services

(HHS), were first published in 1980 and are updated every 5 years. The final

recommendations were unveiled on January 31, 2011, at a press conference led by

heads of the sponsoring government departments, Agriculture Secretary Tom

Vilsack and HHS Secretary Kathleen Sebelius. The recommendations are the basis

of federal nutrition policies, including food assistance programs.

Under Siege by Obesity and Chronic Disease

These evidenced-based guidelines come at a time when Americans are under siege

from an epidemic of obesity. America is fat. We eat too much, and too much of

the wrong things. Obesity rates over the past 30 years have doubled for adults

and tripled for kids. Currently, two thirds of all US adults and one third of

children are overweight or obese. More than one third of all US adults (34%) and

nearly one fifth of children (17%) are obese.

As our population has grown in girth, so have the numbers of people with chronic

diseases. Cancer affects nearly 1 in 2 men and women at some time during their

lives.

Certain cancers, including breast, endometrium, colon, kidney, mouth, pharynx,

larynx, and esophagus, have dietary risk factors. Nearly 24 million American

adults, 11% of the US population, already have diabetes. More than 81 million

people already have heart disease; that's 37% of the US population. Nearly 75

million Americans have hypertension; that's 34% of our population. In addition,

the 78 million Americans with pre-diabetes and more than 75 million with

pre-hypertension are also headed down this dangerous path. We need a new dietary

roadmap.

Politically Phrased

Although the The New York Times [2] deemed this set of guidelines " the bluntest

nutrition advice to date, " the messages are gently expressed and politically

phrased, which is not unexpected considering the powerful food lobby. Although

the wording is often too subtle for my liking considering the obesity epidemic's

physical and fiscal toll, the explanations are solid. Please excuse me if I am a

little more direct in my interpretation as I discuss the report. It's a

reflection of how I deal with patients.

The Total Diet

The latest mantra is the " Total Diet " (coined by the Dietary Guidelines Advisory

Committee), one that is nutrient dense, energy balanced, and portion controlled.

The guidelines emphasize vegetables, fruits, and high fiber whole grains. It is

a more plant-based diet with vegetables (including cooked dry beans and peas),

more fruits, whole grains, nuts, and seeds. The guidelines have chapters on

which foods to reduce and which foods to increase. More seafood is recommended.

Moderation is the motto when it comes to lean meats, poultry, and eggs. Low-fat

and fat-free dairy products are best. Cut down on solid fats and added sugars

because they offer fewer nutrients and guarantee more calories. Watch your salt

intake. And exercise: we don't get enough; we need to do more.

What to Reduce

Salt is number 1. The guidelines hit hard on sodium. Our current average daily

salt intake is about 3400 mg sodium. The new guidelines call for a drastic

reduction to under 2300 mg sodium daily, the amount of sodium in 1 tsp of salt.

Nearly half of us, including everyone 51 and older, need to further reduce

intake to 1500 mg daily, which is three fourths a teaspoon of salt. That is also

the desirable maximum for blacks of any age, and anyone with high blood

pressure, diabetes, or chronic kidney disease.

This means less reaching for the shaker and less shaking when you grab it. Also

check labels on prepared foods. However, even making these changes may not

ensure that we can reduce salt to recommended levels. Previous studies have

shown that the vast majority of sodium (75%) comes from processed and restaurant

foods.[3-5] The food industry must get on board with salt reduction efforts if

we are to be successful in this endeavor.

Fat warnings. Stay clear of trans-fats and anything that's partially

hydrogenated. Also avoid saturated fats, including coconut, palm, and palm

kernel oils. Use soft instead of stick margarines, and, in cooking, use

vegetable oils instead of butter. Monounsaturated and polyunsaturated oils are

best, including safflower, canola, and olive oils. There's a handy chart in the

guidelines[1] that profiles the types of fats in an array of different oils.

Cholesterol. For dietary cholesterol, the guidelines say no more than 300 mg

total per day.[1] Cutting dietary cholesterol to less than 200 mg daily can be

beneficial for people at high risk for heart disease.

Sugary drinks and alcohol. When it comes to fluids, go with water instead of

sugary drinks. Sodas, energy drinks, and sports drinks are to blame for 36% of

added sugars in our diet.

Consume alcohol only in moderation defined as a max of 1 drink a day for women,

and 2 drinks a day for men. One drink is 12 ounces of beer, 5 ounces of wine, or

1 1/2 ounces of 80 proof distilled spirits. Alcohol trends, definitions of

levels of consumption, and risky drinking are discussed. In the chapter on

weight management, the guidelines remind us that alcohol also has calories: 7

" empty " calories per gram.

What to Increase

Fruits and vegetables. More of some things is a good thing. Eat more fruits and

vegetables and the guidelines were clear on what that means. Fill half your

plate with fruits and vegetables, and make your plate colorful with a variety of

dark green, red, and orange vegetables, including beans and peas. Here's why.

They are low in calories, rich in the nutrients we often lack (folate,

magnesium, dietary fiber, and vitamins A, C, and K), and they may help prevent

chronic diseases. Eating fruits and veggies is linked to lower risks for heart

attack, stroke, and certain cancers.

More whole grains. This is not new. An emphasis on whole grains was also

discussed in the 2005 version of the guidelines. The message is to make sure at

least half the grains you consume are whole grains (as opposed to refined

grains).

Whole grains mean the entire seed, kernel (germ, bran, and endosperm) and all.

The minimal goal for most people is 3 ounces of whole grains per day. Refined

means the grains have been milled, meaning the bran and germ have been

separated, a process that strips away valuable nutrients like iron and B

vitamins, like thiamine, riboflavin, niacin, and folic acid. If you consume

refined grains (and it is hard not to), make sure they are " enriched, " which

means extra iron and B vitamins have been added.

The guidelines contain a lot of practical tips that can come in handy at the

grocery store when checking food labels and ingredients. Buzz words for whole

grains include buckwheat, bulgur, millet, oatmeal, quinoa, rolled oats, brown or

wild rice, whole grain barley, whole rye, whole wheat. The guidelines also

dispel a myth about bran: Bran is not whole grain (but it is a good source of

dietary fiber.)

However, even with the best intentions, it is hard to figure out what you are

getting. Labels can be misleading. The guidelines say " Multi-grain,

stone-ground, 100% wheat, cracked wheat, seven grain, and bran are not usually

100% whole grain products and may not contain any whole grains. " That's where

checking the " % Daily Value " on labels can help. Pick products that contain

10-19% daily value of fiber, which means " good " source of dietary fiber, or 20%

daily value or more, which means excellent source of dietary fiber.

Neglected nutrients. Choose foods with more potassium, dietary fiber, calcium,

and vitamin D. A potassium-rich diet helps lower blood pressure, and also staves

off kidney stones and bone loss.

Adequate daily fiber intake is 25 g per day for women and 38 g per day for men.

Most of us average only 15 g of fiber in a day.

Appendices 12-15 in the guidelines[1] have useful charts listing the nutrient

content of selected food sources for potassium, fiber, calcium, and vitamin D,

respectively. Interestingly, the vitamin D chart is in micrograms (mcg) not the

more familiar International Units (IUs). No worries: the footnote says 1 mcg of

vitamin D is 40 IU. The RDA is 600 IU for most children and adults, 800 IU for

adults over 70. Thus, vitamin D intake should be less than 100 mcg or 4000 IU

daily, to avoid adverse effects.

Protein: A Bright Spot for Carnivores, but Seafood Rules

The guidelines stopped short of recommending less red meat. However, they do

stress getting protein from a variety of sources, like soy, unsalted nuts, and

seeds.

More seafood in place of meat and poultry is preferred. Animal-based proteins

are high in saturated fat and are considered " solid fats " according to the

guidelines. On the other hand, seafood, nuts, and seeds contain healthier mono-

unsaturated and poly-unsaturated fats that the guidelines consider " oils. "

Seafood. Seafood recommendations for pregnant women were also modified and

clarified: Women who are pregnant or breast-feeding should eat 8-12 ounces of

seafood a week. Mercury content concerns necessitate no more that 6 ounces of

white albacore tuna a week for women who are pregnant or nursing and NO tile

fish, NO shark, NO swordfish, and NO king mackerel. Appendix 11 in the

guidelines[1] has a nice chart showing omega-3 fatty acid and mercury content

for selected seafood.

Plant-based protein: know your beans and peas. There are peas and there are

peas. Some have protein. Some do not. Beans and peas, including kidney beans,

pinto beans, black beans, garbanzo beans (also known as chickpeas), lima beans,

black-eyed peas, split peas, and lentils are protein foods. In addition to

protein, they are great sources of iron, zinc, fiber, potassium, and folate. On

the other hand, green peas and string beans are not protein sources. Green peas

are starchy vegetables. String beans are in the same group as lettuce, onion,

celery, and cabbage.

Supplements for Some

Although the basic premise of the guidelines is that nutrient needs should be

attainable through nutrient-rich foods, the guidelines do give a thumbs up for

supplements for specific groups: folic acid 400 mcg for women of child-bearing

potential, extra folic acid and iron for pregnant women, and vitamin B12

supplements for those over 50 who don't absorb it well.

Beyond the Food Groups

Eating Behaviors

The new guidelines are more comprehensive and go beyond food groups and number

of servings. The new guidelines address not only food choices, but also eating

behaviors: when you eat, where you eat, how often you eat, and how much you eat.

Behaviors like eating breakfast, snacking, portion control, and eating fast

foods all matter.

Food Safety

The basic food handling safety principles (Clean, Separate, Cook, and Chill) are

discussed to raise awareness of and stave off foodborne illness, which affects

more than 76 million people in the United States each year, including causing

325,000 hospitalizations and 5000 deaths. There is even a chart in the

guidelines[1] showing safe minimal cooking temperatures for meat, seafood, and

poultry.

Access to Healthy Choices

All the careful planning and good intentions in the world are useless if people

don't have access to healthy food choices. Concerns about " food deserts " --

neighborhoods in which there is not access to fresh fruits and vegetables --

were voiced at the press conference, along with a call to action. Pilot programs

to help remedy access problems, including buyer discounts, green cards for

buying fresh produce, and also mobile fresh produce delivery -- much like the

milkman used to do -- to areas without neighborhood full-service grocery stores

are supposedly in the works.

mary: Making the Guidelines About You

Finally, the new guidelines promote individualization of the recommendations and

integrating the recommendation into a pattern that works for you, one that meets

nutritional needs without exceeding energy needs. The document downloaded is 112

pages, but it's an easy read. The first two thirds are didactic chapters with

handy boxed highlights that are easy to skim. The remaining 30 pages consist of

appendices, some that can be easily copied and given to patients. They are now

available online at:

http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/PolicyDoc\

..pdf. So check it out and encourage your patients to take a look, too.