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N EW S A N D V I EW S

DOI: 10.1111/j.1467-3010.2012.01996.x

Challenges in dietary guidance: a US perspective

J. Slavin
Department of Food Science and Nutrition, University of Minnesota, USA

Summary

Good nutrition is essential to human health. But how do we dene good nutrition? Nutritional needs vary greatly through the life cycle so a diet that promotes healthy growth and development for a child may not be optimal for the elderly. Also, humans are adaptable to a wide range of dietary patterns and food intakes and their varying cultural preferences must be considered when making dietary recommendations. This paper describes the history of the development of dietary guidelines in the US and discusses some of the complexities around the development of advice for an optimal diet at a population level. The Dietary Guidelines for Americans have been published every ve years since 1980. The development of the most recent Dietary Guidelines for Americans (2010) involved an evidence-based review process to evaluate the strength of the relationships between food intake and disease outcomes. Unfortunately, many accepted relationships between food patterns and disease outcomes are not strongly based on evidence-based reviews. This creates a challenge for government agencies when developing population guidelines for dietary intake, as well as for future committees charged with agreeing on the basis of an optimal diet for good nutrition.
Keywords: chronic disease, diet, dietary guidance, evidence-based review, nutrition, United
States

The search for the holy grail of diets, what we should and should not eat and in what quantities continues to create debate. Diet wars are typically waged by the low-carbohydrate and low-fat camps. Yet, one must remember that humans are omnivores, with gastrointestinal tracts most similar to pigs. Thus, humans can adapt to a wide range of diets and food intakes. Through the ages, traditional diets mostly reect human access to food supply. Although protein requirements are set based on ideal bodyweight (i.e. 0.8 g/protein/kg bodyweight for adults), the amount of carbohydrate and fat in nutritionally adequate diets varies greatly. For example, traditional Arctic diets contain 80% of energy
Correspondence: Dr. Joanne Slavin, Professor, Department of Food Science and Nutrition, University of Minnesota, 1334 Eckles Ave., St. Paul, MN 55108, USA. E-mail: jslavin@umn.edu

from fat, whereas traditional African diets provide 80% of energy from carbohydrate (Harper 1988). Therefore, the trick perhaps for good nutrition is to consume diets that contain the appropriate amount of energy, alongside an adequate amount of protein and sufcient quantities of essential vitamins, minerals and uids; however, such diets may vary in their carbohydrate and fat content.

Accepted nutrition facts

The relationships between vitamin intake and deciency diseases were rst studied in the early 20th century and our understanding of the essential role that nutrients play in health led to the development of nutrient recommendations to prevent such deciency diseases. The US National Academy of Sciences began issuing Recommended Dietary Allowances (RDAs) in 1941. RDAs are the quantity of nutrients a person needs to consume

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daily to ensure basic good health, proper growth and reproductive success, as well as to prevent nutrient deciency diseases. The current nutrition standards for the US and Canada are the Dietary Reference Intakes (DRIs) (FNB/IOM 2005). Dietary deciency diseases have now been virtually eliminated in developed countries, thanks to improvements in the diversity of the food supply and fortication practices. For example, consumption of fortied foods such as ready-to-eat breakfast cereals and regulation for the enrichment of rened grains with micronutrients in low supply in the average diet has improved micronutrient intakes in many countries. In the US, rened grains have been enriched with thiamin, riboavin, niacin and iron since the 1940s with folic acid added since 1998, whilst in the UK, all bread our has been fortied with iron and calcium, as well as thiamin, riboavin and niacin for over 50 years. Having said that however, the report of the Dietary Guidelines Advisory Committee (DGAC) on the Dietary Guidelines for Americans, 2010, identied suboptimal intakes of dietary bre, potassium, calcium and Vitamin D in the US population. A second universally accepted dietary principle is to maintain an appropriate bodyweight by consuming only enough food to balance the amount of energy expended (i.e. balancing energy in vs. energy out). This has, however, become much more difcult as modern life has removed the need for physical labour in our daily living activities (i.e. we have moved from the hunter-gatherer to the technological era), alongside the introduction of tasty convenient foods that are inexpensive and easily accessible.

(4) reduce cholesterol consumption to 300 mg/day; (5) reduce sugar consumption by 40%; (6) reduce salt consumption to 3 g/day. At the time, the committee suggested that these dietary goals could be met by increasing the consumption of fruit, vegetables, wholegrains, poultry, sh, skimmed milk and vegetable oils, and by decreasing the consumption of whole milk, meat, eggs, butterfat, and foods high in sugar, salt and fat. Unfortunately however, suggested diets to meet these dietary goals were not presented alongside the document. Rather, the overall suggestion was to reduce the average fat content of the diet from greater than 40% of energy from fat to 30% of energy from fat, deemed achievable by simply increasing carbohydrate intake to 60% of energy. Therein, the low-fat/ high-carbohydrate diet was born. It was unclear however, how this could be accomplished in combination with the accompanying goal to reduce sugar consumption (carbohydrate), from all sources, by 40%. The rst Dietary Guidelines for Americans (DGAs) were published in 1980 and have been published every ve years since, with the most recent being in 2010. These have continued to stress the reduction of fat and cholesterol in the diet. The scientic basis for early versions of the DGAs was controversial as scientists outside government were not consulted in their development (Harper 1988). More recent versions of the DGAs have included expert panels and a transparent evidence-based methodology, yet the development of the guidelines continues to be criticised as unreective of the limitations or controversies in the scientic evidence base (Hite et al. 2010). The need to assign specic numbers in the DGAs is driven by the relationship between the DGAs and federal nutrition programs (Watts et al. 2011). For example, in the US, nutrition assistance programs such as school lunches and child/ infant feeding programs are required to base their advice on the most recent scientic knowledge, which are the current DGAs. Thus, new regulations within school lunch that require that all grains are wholegrains are supported by the 2010 DGAs. Recommendations from the 2010 DGAs and myplate.gov to make half your plate fruits and vegetables have also had a large impact on menu planning for government feeding programs.

Origin of the low-fat/high-carbohydrate diet

In the 1950s and later, nutritional interest shifted from the prevention of deciency-related diseases to the role of diet in chronic disease prevention . Accordingly, relationships, for example, between dietary fat and heart disease and bre and colon cancer, were considered. In 1977, the US Senate Select Committee on Nutrition and Human Needs proposed the Dietary Goals for the United States (US Senate Select Committee on Nutrition and Human Needs 1977). These population goals were to: (1) increase carbohydrate intake to account for 5560% of energy intake; (2) reduce fat consumption to 30% of energy; (3) modify the composition of dietary fat to provide equal proportions of saturated, monounsaturated and polyunsaturated fatty acids;

The US Dietary Guidelines (DGAs) and our health

Given that the DGAs were established some time ago begs the questions, Does adherence to the DGAs makes us healthier? and did the switch from a fat/ carbohydrate ratio of 40/50 to 30/60 (less fat, more

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carbohydrate) as dened by the Dietary Goals (1977) improve our health? Unfortunately, long-term human intervention studies investigating the effect of diets adhering to the DGA guidelines simply do not exist. Generally, adherence to DGAs is measured in epidemiological studies by means of a scoring system the healthy eating index (HEI), which quanties adherence to the various dietary guidelines. One such study by McCullough et al. (2000) in a population of over 100 000 US adult men found that the HEI was only weakly negatively associated with risk of major chronic disease. In a subsequent analysis of both the HEI and an alternative healthy eating index (that considered other factors such as type of fat and quality of carbohydrate) among more than 70 000 women from the Nurses Health study and over 40 000 men from the Health Professional Follow-up Study over two years of followup, adherence to both indices was found to be protective against cardiovascular disease and diabetes (Chiuve et al. 2012). The authors therefore suggested that adherence to the 2005 Dietary Guidelines may lower risk of major chronic diseases. However, using a 100-point Diet Quality Index to rate participants diets based on meeting the 2005 DGA key recommendations Zemora et al. (2010) did not nd a relationship between weight gain among young adults from different ethnic groups who participated in the Coronary Artery Risk Development in Young Adults study (19852005). Their ndings did not, therefore, support the hypothesis that a diet consistent with the DGAs benets long-term weight maintenance in young American adults.

How were the most recent US DGAs dened?

Responsibility for the development of DGAs rests with an expert scientic group, the DGAC. In the last DGA review (in 2010), the DGAC consisted of 13 scientists (including the present author) with a broad range of expertise in nutrition, physical activity, food behaviour and nutrition through the life cycle. The DGAC is divided into subcommittees to address specic questions relating to diet and disease risk. In 2010, there were eight subcommittees focusing on different dietary issues: (1) alcohol, (2) carbohydrate, (3) energy balance and weight maintenance, (4) fatty acids and cholesterol, (5) food safety and technology, (6) nutrient adequacy, (7) protein and (8) sodium, potassium and water. Being a member of the 2010 DGAC, the author of this paper served as chair of the carbohydrate and protein subcommittees and also as a member of the energy balance and the nutrient adequacy subcommittees.

In their review, the DGAC and related subcommittees addressed questions regarding the relationship between diet and health outcomes by following an evidence-based review process with a strict hierarchy of evidence, with the strongest evidence being found in randomisedcontrolled trials (RCTs), preferably double blinded. Of course, dietary food studies typically suffer in this arena as it is difcult to carry out blind food treatments (e.g. subjects know they are consuming an apple or apple juice). Such trials can work with nutrients however as nutrients can be added to food or drinks without the knowledge of the participants or investigators (i.e. double blind). Following RCTs, the next strongest studies are prospective cohort studies (PCs), where a group or cohort of subjects is studied over time. Food frequency instruments are often used to collect dietary information before any diagnosis of disease, making these studies more reliable than cross-sectional studies where diet and outcome measures are assessed simultaneously. No case-control studies, animal research or in vitro studies are considered in any of the DGAC reviews. Typically, cross-sectional studies are only included if no stronger prospective studies are available for review. Having gathered all of the scientic literature together (i.e. from RCTs and PCs) the body of evidence for each question (e.g. what is the relationship between dietary bre intake and health outcomes) is then examined in great detail (www.nutritionevidencelibrary.com). Within a systematic, evidence-based review, the conclusions drawn can be deemed as strong, moderate, limited or lacking data to support them. There may also be strong evidence of no relationship. For example, no strong evidence was found to support a relationship between glycaemic index and disease outcomes in the 2010 DGAC review (www.dietaryguidelines.gov). Agreeing on the strength of the relationship is always difcult, as, for each question, different types of studies with a variety of outcomes have been published. For each question addressed in the evidencebased report, the precise search criteria, inclusion and exclusion criteria for all of the studies referred to, including the range of dates searched, is available on the US Department of Agriculture portal (www. nutritionevidencelibary.com). Such transparency in an evidence-based approach minimises bias, therefore adding credibility to the ndings.

Challenges in evaluating diet and disease relationships

As is normal in reviews of this kind, there can be issues relating to contradictory evidence and the DGAC 2010

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report was no exception. In a critique of the DGAC 2010, Hite et al. (2010) suggested that the DGAC Report does not provide sufcient evidence to conclude that increases in intake of wholegrain foods and bre, and decreases in dietary saturated fat, salt and animal protein can lead to positive health outcomes. Moreover, they stated that the lack of supporting evidence limits the value of the proposed recommendations as guidance for consumers or as the basis for public health policy.

green leafy vegetables (Carter et al. 2010). Findings showed no signicant benets on the incidence of type 2 diabetes with increased consumption of vegetables, fruit or fruit and vegetables combined.

Conclusions
The DGAC report is an evidence-based, systematic review written by the DGAC. The DGAs are written by the US government based on the DGAC report. Food guides, such as myplate.gov are also produced by US government staff. The translational process taking the scientic report and turning it into the DGAs has been criticised for not being transparent to the public or even to the members of the DGAC (Hite et al. 2010). A systematic evidence-based review of diet and health outcomes does not, however, yield a blueprint for the perfect diet. Nutrient needs vary greatly over the life cycle, so a relatively high-fat diet, as recommended for infants and toddlers, may not be appropriate for an overweight adult. Generally, a balanced diet contains adequate protein (both in terms of quantity and quality) alongside sufcient amounts of essential vitamins and minerals. However, such diets can be either high or low in carbohydrates and fats, and the choice will reect the cultural norms and traditions of consumers.

Accepted carbohydrate policy

Although the amount of dietary carbohydrate that confers optimal health in humans is unknown, the DRIs recommend adults consume 4565% of their total energy from carbohydrates (DRIs 2005). The acceptable macronutrient distribution range for fat is 2035% and for protein is 1035%. These wide ranges exist because protein recommendations when following a low-calorie diet require up to 35% of calories to come from protein. Also, achievement of the recommended intake of dietary bre requires a certain amount of carbohydrate to be ingested. Carbohydrate is found in a variety of foods and drinks [i.e. present as starch, sugar (intrinsic/extrinsic) or bre]. Fruit and vegetables, wholegrains and milk and milk products are major food sources of carbohydrates. Grains and certain vegetables including corn and potatoes are rich in starch. Fruits contain little or no starch but sugar in the form of fructose. Regular soft drinks, sugar/sweets, sweetened grains and regular fruitades/drinks (i.e. sugar sweetened) comprise 72% of the intake of added sugar in the US (Marriott et al. 2010). Limited data exist to suggest that added sugar intake is linked to any adverse health outcome. Generally, intake of all types of carbohydrates is linked to lower bodyweight in PCs (Gaesser 2007). It is difcult to measure added sugar in epidemiological studies, so intake of sugar-sweetened beverages (SSBs) is the proxy for added sugar intake. In PCs there are few data that support a link between intake of SSBs and higher energy intake or bodyweight in adults. Even carbohydrate foods that are generally accepted as healthy, such as fruits and vegetables, do not have strong scientic support for a positive effect on health outcomes (Slavin & Lloyd 2012). For example, a recent systematic review and meta-analysis of the effects of fruit and vegetable intake on incidence of type 2 diabetes included six studies, four of which provided separate information on the consumption of

Conict of interest
The author was a member of the 2010 Dietary Guidelines Advisory Committee. The views expressed in this paper are those of the author alone. The author reports no conict of interest.

References
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