ADSA comments on the 2015-2020 Dietary Guidelines for Americans

The South African food-based dietary guidelines are developed and informed by all available and latest scientific evidence relevant to nutrition and eating patterns, according to Catherine Pereira, Public Relations Portfolio holder on the Association for Dietetics in South Africa's (ADSA) Executive Committee.

She highlighted three points:

The South African dietary guidelines are specifically tailored to meet the needs of the South African population.
The South African dietary guidelines were updated in 2013 already, and will be updated again when it is deemed necessary.
The South African dietary guidelines are not solely informed by the American guidelines (but rather are informed by all available evidence) and do not follow the same time frame of being updated as the American guidelines.

Two South African nutrition experts provided that comments on the updated Dietary Guidelines for Americans.

Comments provided by Prof Edelweiss Wentzel-Viljoen from the North-West University

The 2015-2020 Dietary Guidelines for Americans were released on the 7^th of January 2016 after the Dietary Guidelines Advisory Committee compiled the Scientific Report in February 2015. The guidelines are to be used by professionals, the general public, media, food industry and government to help individuals (2yrs and older) and families to consume a healthy diet. The guidelines are also used in the developing of public health policies and programmes and nutrition education programmes.

The guidelines are evidence-based by integrating scientific research, food pattern modelling and analysis of current intake of the US population. They also take into account the change in the disease pattern of the American population. The guidelines reflect the large body of evidence that healthy eating patterns and regular physical activity are associated with positive health outcomes:

• Strong evidence: healthy eating patterns are associated with reduced risk of cardiovascular disease;
• Moderate evidence: healthy eating patterns associated with reduced risk of type 2 diabetes mellitus, certain types of cancer, overweight and obesity;
• Emerging evidence suggests that a relationship may exist between healthy eating patterns and some neurocognitive disorders and congenital anomalies

The guidelines are the following:

• Follow a healthy eating pattern across the lifespan: this guideline includes choosing an appropriate energy intake to achieve and maintain a healthy body weight
• Focus on variety, nutrient density and amount
• Limit energy from added sugars and saturated fats and reduce sodium intake
• Shift to healthier food and beverage choices: focus on choosing nutrient-dense foods and beverages
• Support healthy eating patterns for all: from home to school to work to communities

Key recommendations

• Follow a healthy eating pattern that accounts for all foods and beverages within an appropriate energy level
• A healthy eating pattern includes:

-        A variety of vegetables from all of the subgroups – dark green, red and orange, legumes (beans and peas), starchy, and other
-        Fruits, especially whole fruits
-        Grains, at least half of which are whole grains
-        Fat-free or low-fat dairy, including milk, yoghurt, cheese and/or fortified soy beverages
-        A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas) and nuts, seeds, and soy products
-        Oils

• A healthy eating pattern limits:

-          Saturated fats and trans fats, added sugars, and sodium
-          Consume less than 10% of energy per day from added sugars
-          Consume less than 10% of energy per day from saturated fats
-          Consume less than 2300mg per day of sodium
-          If alcohol is consumed, it should be consumed in moderation (1 drink/day for women and up to 2 drinks/day for men)

An important underlying premise of the Guidelines is that the nutritional needs should be from foods – including fresh, canned, dried and frozen foods.

The Dietary Guidelines also include a section on different healthy eating patterns including guidance on portions and quantities:

• Healthy U.S style eating pattern
• Healthy Mediterranean style eating pattern
• Healthy Vegetarian eating pattern

Take home messages:

• Eat a variety of foods within an energy balance to reach and maintain a healthy body weight and focus on nutrient-dense foods
• Eat more vegetables with a focus on colourful and variety of vegetables
• Eat enough fruit especially whole fruits and less fruit juice
• Eat enough whole grains and less refined grains; stay away for any added sugar food or beverage
• Focus on fat free or low-fat dairy products
• Lower intake of meats and focus on lean meats and poultry (associated with reduced risk of cardiovascular disease in adults); stay away from processed meats/poultry
• Eat 240g (two medium portions) of fish per week (=250mg/day of EPA and DHA), eat a variety of seafoods
• Use canola, olive, peanut, sunflower and soybean oil; stay away from coconut, palm kernel and palm oil – oil should be liquid at room temperature
• Can drink 3 – 5 cups coffee per day (=400mg/d of caffeine)
• Limit salt intake

The South African Food Based Dietary Guidelines (2013) (SAFBDGs) were updated at the end of 2012 and are also based on scientific evidence and the South African disease profile, food pattern and dietary intake, and incorporate any changes in these since the 2003 FBDGs were developed. The recommendations are:

• Enjoy a variety of foods
• Be active
• Make starchy foods part of most meals
• Eat plenty of vegetables and fruit every day
• Eat dry beans, split peas, lentils and soya regularly
• Have milk, maas or yoghurt every day
• Fish, chicken, lean meat or eggs can be eaten daily
• Drink lots of clean, safe water
• Use fats sparingly. Choose vegetable oils, rather than hard fats
• Use sugar and foods and drinks high in sugar sparingly
• Use salt and food high in salt sparingly

The SAFBDGs are in line with the 2015-2020 Dietary guidelines for Americans. Both focus on foods rather than nutrients and both emphasize a variety of foods, eat more vegetables and limit the intake of added sugar and salt and stay away from the wrong type of fat. Not one makes any recommendation regarding cholesterol intake per se and does not limit the intake of foods high in cholesterol.

The SAFBDGs also place emphasis on the intake of clean safe water, since our food intake studies show that we, in general, do not drink enough water. The biggest difference is that the SAFBDGs include more whole grains than the American guidelines (which recommend that at least half of grains should be whole). The staple foods of the majority of South Africans are maize meal porridge and bread, both of which are fortified with vitamins and minerals, and thus justify the inclusion of enough starchy foods on a daily basis to meet energy requirements.

The SAFBDGs do not say anything about trans fats, the reason being that South Africa has legislation in place that prevents food industry to use trans fatty acids in any food product. The salt reduction regulations coming into effect in June 2016 will also assist South Africans to reduce their salt intake.

The National Department of Health, Directorate: Nutrition developed a Food Guide based on the SAFBDGs to assist health professionals and the public to follow a healthy eating pattern. A figure displaying the food guide is provided below. The proportion of the circles serves as a guide to show the foods that should be eaten in larger amounts compared to those eaten sparingly.

Comments provided and extracts from the original document by Prof Marjanne Senekal from the University of Cape Town

Summary: In general, the guidelines are very similar to the previous American guidelines, with the most prominent change the move to a focus on eating patterns rather than foods and nutrients as such. Furthermore, the evidence base for the recommendations has been built out and strengthened.

It would have been good to see a stronger focus on the need to change to more plant-based protein choices, as the evidence strongly emphasizes this concept.

Background

In the United States of America, the Dietary Guidelines are required under the 1990 National Nutrition Monitoring and Related Research Act, which states that every 5 years, the U.S. Departments of Health and Human Services (HHS) and of Agriculture (USDA) must jointly publish a report containing nutritional and dietary information and guidelines for the general public. Previous editions of the Dietary Guidelines focused primarily on individual dietary components such as food groups and nutrients.

However, people do not eat food groups and nutrients in isolation but rather in combination, and the totality of the diet forms an overall eating pattern. The components of the eating pattern can have interactive and potentially cumulative effects on health.

A large body of evidence now shows that healthy eating patterns and regular physical activity can help people achieve and maintain good health and reduce the risk of chronic disease throughout all stages of the lifespan. As a result the 2015-2020 Dietary Guidelines for Americans were developed to reflect this evidence through its recommendations.

Strong evidence shows that healthy eating patterns are associated with a reduced risk of cardiovascular disease (CVD). Moderate evidence indicates that healthy eating patterns also are associated with a reduced risk of type 2 diabetes, certain types of cancers (such as colorectal and postmenopausal breast cancers), overweight, and obesity.

In depth investigation of the most recent literature strongly supports this new approach. These advancements have provided a greater understanding of, and focus on, the importance of healthy eating patterns as a whole, and how foods and beverages act synergistically to affect health.

The role of especially fruits, vegetables and whole grains are emphasized as part of these patterns, with fat-free or low-fat dairy, seafood, legumes, and nuts most probably also contributing to health eating patterns. Lower intakes of meats, including processed meats; processed poultry; sugar-sweetened foods, particularly beverages; and refined grains have often been identified as characteristics of healthy eating patterns.

Process for the development of the guidelines

One of the strengths of the new American guidelines is that a rigorous process was followed in the development of the guidelines.

• An external Dietary Guidelines Advisory Committee (Advisory Committee) was appointed to ensure sound external scientific advice to inform policy decisions. Nominations from the public were also sought for candidates to serve on the 2015 Advisory Committee. The 15 members of the 2015 Advisory Committee are prestigious researchers in the fields of nutrition, health, and medicine. Their role was to provide advice and recommendations to the Federal Government on the current state of scientific evidence on nutrition and health. Per Federal Advisory Committee Act rules, Advisory Committee members were thoroughly vetted for conflicts of interest before they were appointed to their positions and were required to submit a financial disclosure form annually.
• The 2015 Advisory Committee used four state-of-the-art approaches to review and analyze the available evidence: original systematic reviews; existing systematic reviews, meta-analyses, and reports by Federal agencies or leading scientific organizations; data analyses; and food pattern modeling analyses. This multifaceted approach allowed the Advisory Committee to ask and answer scientific questions about the relationship of diet and health to systematically, objectively, and transparently synthesize research findings and to limit bias in its evaluation of the totality of the evidence for the topics it reviewed. The public was invited to submit written comments to the Advisory Committee throughout the entirety of its work as well as oral comments at a public meeting.
• The Advisory Committee’s work culminated in the Scientific Report of the 2015 Dietary Guidelines Advisory Committee, which was submitted to the Secretaries of HHS and of USDA and made available for public and agency comment in February 2015.
• In the second stage, the policy document Dietary Guidelines was developed, applying several process steps to promote scientific rigor. Similar to previous editions, this 8th edition builds upon the preceding edition, with the scientific justification for revisions informed by the Advisory Committee’s report and consideration of public and Federal agency comments.
• Federal experts validate the rigor of the policy document in multiple ways - they provide comments regarding the applicability and rigor of the report for consideration in translating the science into policy. These policy writers include nutrition scientists, policy experts, and communications specialists. Consultation with other Federal experts occurs throughout the policy development process.
• Extensive review and clearance of the policy document also occurs by Federal experts within the agencies of both Departments. The Federal clearance of the policy document culminates with review and approval by the Secretaries of HHS and of USDA.

The guidelines

Although the overall approach has changed from focusing on individual foods and nutrients to integration of these into a pattern of consumption, the components emphasised as part of the pattern speak to the emphases that were contained in the 2010 guidelines. In brief, healthy eating patterns include (daily recommendations based on 2000kcal/8400kJ diet:

• A variety of vegetables from all of the subgroups—dark green, red and orange, legumes (beans and peas), starchy, and other: 2½ cup-equivalents (note: starchy vegetables mentioned specifically, not so in previous guidelines)
• Fruits, especially whole fruits (at least 50%): 2 cup-equivalents per day. Whole fruits include fresh, canned, frozen, and dried forms. (Note: very specific guidelines for use of fruit juice have been added)

Note: the fruits and vegetables are not mentioned as one group as was typically done in the past

• Grains, at least half of which are whole grains: 6 ounce (e.g. 1 med slice bread) equivalents per day). This group includes grains as single foods (e.g., rice, oatmeal, and popcorn), as well as products that include grains as an ingredient (e.g., breads, cereals, crackers, and pasta). (Note: points re whole vs refined grains are emphasized).
• Fat-free or low-fat dairy, including milk, yogurt, cheese, and/or fortified soy beverages: 2 cup-equivalents per day for children ages 2 to 3 years, 2½ cup-equivalents per day for children ages 4 to 8 years, and 3 cup-equivalents per day for adolescents ages 9 to 18 years and for adults. (Note: Soy beverages fortified with calcium, vitamin A, and vitamin D, are included as part of the dairy group because they are similar to milk based on nutrient composition and in their use in meals. Other products sold as “milks” but made from plants e.g., almond, rice, coconut, and hemp “milks” may contain calcium, but they are not included as part of the dairy group because their overall nutritional content is not similar to dairy milk and soymilk).
• A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products: 165g-equivalents of protein foods per day. (Note: For balance and flexibility within the food group, weekly recommendations for the subgroups: seafood; meats, poultry, and eggs; and nuts, seeds, and soy products have been included).
• Oils are part of healthy eating patterns, but because they are a concentrated source of energy, the amount consumed should be within energy recommendations: 27 g (about 5 teaspoons) per day (2000Kcal diet). Oils are fats that contain a high percentage of monounsaturated and polyunsaturated fats and are liquid at room temperature. Although they are not a food group, oils are emphasized as part of healthy eating patterns because they are the major source of essential fatty acids and vitamin E. The fat in some tropical plants, such as coconut oil, palm kernel oil, and palm oil, are not included in the oils category because they do not resemble other oils in their composition. Specifically, they contain a higher percentage of saturated fats than other oils

Note: The following guidelines are in line with previous guidelines, thus no change in the restriction of added sugar, staturated and trans fats.

• Added sugars: less than 10% of calories per day. Added sugars include syrups and other caloric sweeteners. (Note: This recommendation is a target to help the public achieve a healthy eating pattern, which means meeting nutrient and food group needs through nutrient-dense food and beverage choices and staying within energy limits; replacing added sugars with high-intensity sweeteners may reduce calorie intake in the short-term, yet questions remain about their effectiveness as a long-term weight management strategy.
• Saturated fats: limit to less than 10% of energy per day by replacing them with unsaturated fats and while keeping total dietary fats within the age-appropriate energy requirement. (Note: The human body uses some saturated fats for physiological and structural functions, but it makes more than enough to meet those needs. Individuals 2 years and older therefore have no dietary requirement for saturated fats. Saturated fats in the diet should be replaced with polyunsaturated and mono-unsaturated fats to reduce risk of CVD events and CVD-related deaths).
• Trans fat intake should be as low as possible by limiting foods that contain synthetic sources of trans fats, such as partially hydrogenated oils in margarines, and by limiting other solid fats.
• Cholesterol intake though the diet is not essential as the body synthesizes sufficient of this compound to fulfil the  physiological and structural functions thereof but makes more than enough for these purposes. The USDA Food Patterns are limited in saturated fats, and because of the commonality of food sources of saturated fats and dietary cholesterol, the Patterns are also low in dietary cholesterol. (Note: Strong evidence from mostly prospective cohort studies but also randomized controlled trials has shown that eating patterns that include lower intake of dietary cholesterol are associated with reduced risk of CVD, and moderate evidence indicates that these eating patterns are associated with reduced risk of obesity.)
• Sodium intake is limited in Healthy eating patterns limit sodium to less than the age specific upper tolerable level (UL). Sodium is an essential nutrient and is needed by the body in relatively small quantities, provided that substantial sweating does not occur.

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