Dietary Guidelines For Americans

Transcription

1 1980 I ll begin with an overview on dietary advice in the United States, how it evolved and how the current Dietary Guidelines sit in the context of many prior Guidelines There have been many Dietary Guidelines. Every five years a new committee is formed and members are asked whether there have been any important developments since the last iteration. Not surprisingly, every five years Committee members say, Yes there has been important research. That being said, the recommendation that is relevant to milk has been for many years the exact same statement. "Eat a variety of foods." If you dive into this section of each Guideline, one of those foods is milk, and you are supposed to drink it as part of a varied diet. Dietary Guidelines For Americans Jointly developed by HHS / USDA Science-based advice for ages 2+ Evolution of Food Guidance at USDA Promote health Prevent chronic disease Federal nutrition policy / programs Food for Young Children 1916 Vehicle to speak with one voice 1940s The Dietary Guidelines for Americans is the central document in the United States for science-based nutrition advice for people ages 2 and older. The Guidelines are supposed to promote health and prevent chronic disease, but I think the most important contribution is not the health education of individual Americans, but rather its impact on Federal policy and programs. Every day approximately one in five Americans consumes some food that has been provided to him or her by the government in many different ways. So when one changes the Dietary Guidelines, one starts to change the food supply in the country. To me, that is the most important aspect of this work. The Guidelines also allow all of us, in theory, to speak with one voice, provided the recommended diet is science-based and people can agree on the evidence and how to interpret it. 1970s 1950s-1960s Milk: 2 to 3 cups / day 1992 The Dietary Guidelines actually have a distant cousin and that is the Food Pyramid, but please note that they are not the same thing. If you go back, the first food guidance system started in 1916 and every few decades it has been updated. These food guidance systems were created to teach Americans about healthy eating. One of the important points that I learned by looking through these old versions is that the milk recommendations were actually significantly higher in the past. If you look, for instance, in the 1940s, children and adolescents were recommended to have three servings a day. In the 1950s and 1960s teenagers were encouraged to have four servings a day. And in 1992 we had the introduction of the famous Food Pyramid, which actually recommends two to three cups per day. Now, if you drill down and look in late childhood and adolescence, the recommendation is three cups per day. So it is interesting that in the age group where we have had some concerns over the past two days of this conference, the recommendation during 1992 to 2004 was for three servings; and it is only in the other periods of life that two servings were recommended US Dietary Guidelines: Milk and Milk Products Carlos Camargo 1

2 Pyramid. So, again, the Food Pyramid is a separate process from the Guidelines themselves Members of 2005 DGAC Janet King, PhD, RD (Chair) Children s Hospital Oakland Research Institute Oakland, CA Lawrence J. Appel, MD, MPH Johns Hopkins Medical Institutions Yvonne L. Bronner, ScD, RD, LD Morgan State University Benjamin Caballero, MD, PhD Johns Hopkins Bloomberg School of Public Health Carlos A. Camargo, MD, DrPH Harvard University Boston, MA Fergus M. Clydesdale, PhD, University of Massachusetts, Amherst Amherst, MA In 2000 there was another iteration of the U.S. Dietary Guidelines, and I think most people would agree that one of the unfortunate things that happened that year was that instead of saying, eat a variety of foods, the 2000 Guidelines said Let the Pyramid guide your food choices. In other words, that 1992 educational tool, the Food Pyramid, which was created by the U.S. Department of Agriculture for teaching Americans what to eat, became the driver of the Dietary Guidelines instead of vice versa. In 2005 one of the first things that we Committee members agreed upon was that the Dietary Guidelines should drive the Food Pyramid content and not vice versa. Vay Liang W. Go, MD University of California at Los Angeles Los Angeles, CA Penny M. Kris-Etherton, PhD, RD Penn State University University Park, PA Joanne R. Lupton, PhD Texas A&M University College Station, TX Theresa A. Nicklas, DrPH, MPH, LN Baylor College of Medicine Houston, TX Russell R. Pate, PhD University of South Carolina Columbia, SC F. Xavier Pi-Sunyer, MD, MPH Columbia University New York, NY Connie M. Weaver, PhD Purdue University, West Lafayette, IN The members of the 2005 Committee are listed here. The person who I think played the strongest role in terms of milk recommendations was Connie Weaver, who is a popular speaker and prolific writer who focuses on osteoporosis and how milk relates to peak bone mass. And I have to comment, having listened to all the presentations here; this may be one of the first conferences on milk that has had no presentations on bones and bone health. I think that is what makes this conference so extraordinary, our focus here on all the other potential effects of milk. However if you lived in a world of bone health and osteoporosis and fractures, you'd have a very different view of the value of milk and milk products, as Connie does. Process for 2005 Guidelines May 2003 Aug 2003 Dietary Guidelines Advisory Committee Major Topics 1. Aiming to meet nutrient intake recommendations Aug 2004 Jan 2005 Dietary Guidelines for Americans Apr 2005 USDA Food Pyramid 2. Energy Federal Food Policy 3. Discretionary calories 4. Fats 5. Carbohydrates 6. Selected food groups (e.g., fruits & vegetables) 7. Fluid and electrolytes The process involved three phases. The first was formation of the Advisory Committee, which is supposed to review the science. Next came the writing of the actual Dietary Guidelines, which are a summation of that science written by the staff at the Departments of Agriculture (USDA) and Health and Human Services (HHS). At the risk of offending someone, I can tell you as a participant who survived this process that it was wonderful to have Health and Human Services there because the conflicts are quite real and at times quite distressing. In fairness to the USDA, they are in a very awkward spot where they are trying to promote agriculture (which now means the food and beverage industries) at the same time as they are trying to create healthy diet recommendations. We heard repeatedly that, all foods are part of a good diet and that, there are no bad foods and so forth. So it was helpful to have people from HHS there to remind us of the purpose of the entire project to develop science based advice to promote health and prevent chronic disease. Finally, from the official Dietary Guidelines, the USDA then had a second chance to come up with their own spin on the data in creating their instructional tool, the new Food 8. Ethanol 9. Food safety In any case, the whole spectrum of diet was reduced to these nine neat categories or chapters. It s important to recognize that one of these categories, # 6, was what we might call a potpourri chapter for things one can't quite put under protein or under fat, things that don't quite fit anywhere else. This chapter housed fruits and vegetables, whole grains, and milk. Milk, Hormones & Human Health October,

3 9 Key Messages 1. Consume a variety of foods within and among the basic food groups while staying within energy needs 2. Control calorie intake to manage body weight 3. Be physically active every day 4. Choose fats wisely for good health 5. Choose carbohydrates wisely for good health 6. Increase daily intake of fruits and vegetables, whole grains, and reduced-fat milk and milk products 7. Choose and prepare foods with little salt 8. If you drink alcoholic beverages, do so in moderation 9. Keep food safe to eat Here are the 9 Key Messages that emerged from each chapter. As we reviewed the evidence behind each of these different areas, the areas of major controversy were without question, fats, carbohydrates and then this potpourri chapter for selected food groups. more fruits and vegetables. There was nothing controversial about recommending more whole grain. So, really, the controversy for item #6 was about milk. And as I have told Walt (Willett) and others, I was focusing my time primarily on trans fats, sugarsweetened beverages, alcohol and food safety. So this milk recommendation was a less important concern. 1. Nutrient Adequacy Consume a variety of foods within and among the basic food groups, while staying within energy needs. Basic food groups are: Fruits Vegetables Grains Milk, yogurt and cheese Meat, poultry, fish, dry beans, eggs, and nuts Areas of Consensus (6) 1. Consume a variety of foods within and among the basic food groups while staying within energy needs 2. Control calorie intake to manage body weight 3. Be physically active every day Choose and prepare foods with little salt 8. If you drink alcoholic beverages, do so in moderation 9. Keep food safe to eat The conclusions for other areas were pretty straightforward even if it did take a lot of discussion to actually recommend that people should exercise more to keep off weight, and that people should choose and prepare foods with little salt. Areas of Controversy 4. Choose fats wisely for good health When you look at the actual recommendations and how they relate to milk, one of the issues related to nutrient intake and the other to the presence of milk in the selected foods group. Finally, I recall some discussion about fluids and electrolytes, and specifically potassium intake something that I know Walter wants to return to shortly. So this was the basic structure of our work. And then the Committee, broken into subcommittees, reviewed the scientific literature in a systematic way. This aspect of the Committee work was very well done. And here are the recommendations that we gave to the Secretaries of USDA and HHS. For nutrient adequacy, it was the old, eat a variety of foods, and one of those food groups was, of course, milk. 1. Nutrient Adequacy (continued) Nutrient Intake Adults do not consume enough vitamins A, C, and E; calcium; magnesium; potassium; and fiber. Children do not consume enough vitamin E, calcium, magnesium, potassium, and fiber. At the same time, in general, Americans consume too many calories and too much saturated and trans fat, cholesterol, added sugars, and salt. 5. Choose carbohydrates wisely for good health 6. Increase daily intake of fruits and vegetables, whole grains, and reduced-fat milk and milk products 4. Choose fats wisely for good health avoid solid fats 5. Eat more whole grains and less added sugars 6. Increase daily intake of fruits and vegetables But what about those areas of controversy? Here are the actual recommendations and below what I would have preferred, perhaps in There was nothing controversial about recommending And if you look a little more into the nutrient adequacy, the focus was, of course, the low calcium intake of Americans. Approximately 70 percent of the calcium intake for Americans comes from milk and, like it or not, if you look at the calcium intake of adolescents, it is abysmal; it is very low. For example, 70 percent of 9 to 18-year-old boys have less than adequate intake. 92 percent of 9 to 18-year-old girls have less than adequate intake. So in a world where you are trying to increase calcium intake and simultaneously increase potassium and, perhaps Vitamin D; milk looks quite attractive US Dietary Guidelines: Milk and Milk Products Carlos Camargo 3

4 1. Nutrient Adequacy (continued) Special Groups Iron: Folic Acid: pregnant pregnancy For adolescent females and women of childbearing age For women capable of becoming and in the first trimester of Vitamin B12: For those over age 50 Vitamin D: For the elderly, persons with dark skin, and persons exposed to insufficient UVB radiation And Vitamin D was a focus of discussion. Unfortunately, that conversation got cut short because we had to rely on the Institute of Medicine s (IOM) Daily Recommended Intake (DRI) documents, and the Vitamin D report is almost a decade old and probably out-of-date. Accordingly, our hands were tied. A brief word on potassium, our recommendation was to increase consumption of foods with potassium, which I think is sound. However, I remember repeated references, which I found somewhat surprising, that milk was a great source of potassium. Again, Walt will comment on that shortly Dietary Guidelines (Jan 2005) Overall message Eat fewer calories Be much more active Make wiser food choices consumption Fruits & vegetables Whole grains Non-fat or low-fat milk Eat less Salt (less than 2300 mg) Solid fats, including trans fats (as low as possible) Added sugars, especially sugar-sweetened beverages 6. Selected Food Groups Increase daily intakes of fruits and vegetables, whole grains, and reduced-fat milk and milk products. Fruits and Vegetables: At 2000 kcal/d, 9 servings (4-_ cups) Whole Grains: At least 3 servings (3 ounces) per day Milk: At 1600 kcal/day or more, 3 cups of non-fat or low-fat milk (or the equivalent) Well, in the end, here is a summary of the 2005 U.S. Dietary Guidelines in one slide. The messages are very common sense, and, of course as this audience knows, there was a recommendation to increase consumption of -- remember those foods to encourage? milk. Yes, to my later dismay, I realized that milk had become a fruit and vegetable, which I think is somewhat unfortunate. But please don t misconstrue this criticism. There were a lot of good things in those 2005 Guidelines, for instance, specific instruction about eating less salt, specific advice about cutting trans fats, a specific focus on sugarsweetened beverages in relation to obesity, and more. The linkage of sugar-sweetened beverages to obesity was something that had not been done before by a U.S. government agency. The specific recommendation for milk is shown here: at 1600 kcal/day or more, 3 cups of non-fat or low-fat milk (or the equivalent). It later occurred to me that this simple recommendation had magically elevated milk to the level of fruits and vegetables and whole grains, but that s another story. 7. Sodium and Potassium Choose and prepare foods with little salt. Nearly all Americans consume substantially more salt than they need. The general goal for adults is to consume less than 2,300 mg of sodium per day. Many persons will benefit from reducing salt intake even more. At the same time, individuals are encouraged to increase their consumption of foods rich in potassium. Potassium lowers blood pressure and blunts the effects of salt on blood pressure. Increase potassium to at least 4,700 mg daily. At this point, in early 2005, the USDA got their chance to review and revise these messages as they prepared the materials for educating the public, the new Food Pyramid. And I am not sure how happy the average USDA person was, but I do know that a lot of other people in the food and beverage industries were very unhappy. And so when the new Pyramid emerged about four months later, I must tell you, it was a profound disappointment. I think all of you would agree that this graphic, with a little skinny person climbing stairs next to a rainbow, well, it conveys very little information. And this was the result of more than $2 million of research. What a disappointment. Nevertheless, the actual Milk, Hormones & Human Health October,

5 Dietary Guidelines persist and I m pleased to report that they are changing the American food supply in many ways, for instance, the school lunch program. Today there will be almost 30 million kids having a federally funded school lunch and their diet is changing for the better as a result of the recommendations by our group. If you go to the My Pyramid website, which has been provided by the USDA, there is a little more information about actual food products. I am not sure what you are supposed to learn quickly from this site; but here it is, milk, with the recommendation of three cups. Summary To surprise of many, the 2005 Dietary Guidelines adopted most of the DGAC advice Focus on CALORIES More realistic times for PHYSICAL ACTIVITY MORE fruits & vegetables, whole grains LESS solid fats, sugar-sweetened beverages In summary, and to the surprise of many, the 2005 Dietary Guidelines adopted most of the Advisory Committee s advice. Many of the recommendations were significant improvements from the 2000 Guidelines. With regard to milk, and looking at the transition from the 2000 to the 2005 Guidelines, for the adolescent group that is of perhaps greatest concern, there actually was no change; both Guidelines recommended three cups. For the rest, in other words, the younger and the older groups, the milk recommendation went from two to three servings. My take on it, at the time, was that there were other battles to fight, and so this 1- cup increase went through without much concern on my part. As you ve seen from the data presented over the past days, it's not exactly clear, at least in my mind, that there is a major health hazard. We need continued research on the effects of milk on health to resolve lingering doubts US Dietary Guidelines: Milk and Milk Products Carlos Camargo 5