Guidelines for Healthy Eating
Unfolding Case
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Aurea Espada
Aurea is 30 years old and has battled ulcerative colitis for more than 10 years. Medication helps keep her in remission, but when she is stressed or eats too much fiber, she has diarrhea, which is sometimes bloody. To keep her gut calm, she avoids fruits, vegetables, and whole grains. She worries that her diet lacks healthy foods and that she is at greater risk of chronic disease because of it.
Check Your Knowledge
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Learning Objectives
Upon completion of this chapter, you will be able to
1 Describe the four sets of standards that compose the Dietary Reference Intakes.
2 Explain what the Recommended Dietary Allowances represent.
3 Summarize the 2015-2020 Dietary Guidelines for Americans.
4 Give examples of nutrient-dense foods.
5 Describe how the Healthy U.S.-Style Eating Pattern differs from a typical American eating pattern.
6 Describe how the Healthy U.S.-Style Eating Pattern differs from the Healthy Mediterranean-Style Eating Pattern and the Healthy Vegetarian Eating Pattern.
7 Compare nutrition recommendations from the American Heart Association, the American Cancer Society, and the American Institute for Cancer Research.
Who determines how much of each nutrient people need and how much is too much? What is the right combination and proportion of foods that must be consumed in order to be healthy? This chapter covers nutrient needs and how they translate into food and eating patterns. Topics include the Dietary Guidelines for Americans and its companion tool MyPlate, a comparison of guidelines issued by leading health agencies, and a sampling of guidelines and graphics from other countries.
DIETARY REFERENCE INTAKES
Dietary Reference Intakes (DRIs) a set of four nutrient-based reference values used to plan and evaluate diets.
Recommended Dietary Allowances (RDAs) the average daily dietary intake level sufficient to meet the nutrient requirement of 97% to 98% of healthy individuals in a particular life stage and gender group.
In the early 1990s, Canadian scientists and the Food and Nutrition Board of the Institute of Medicine embarked on a comprehensive, multiyear project to update and expand nutrient intake recommendations. Based on the results of thousands of research studies, nutrition experts produced a series of in-depth reports featuring a new set of references called Dietary Reference Intakes (DRIs) that estimate nutrient needs for healthy people. The reports are summarized in Dietary Reference Intakes: The Essential Guide to Nutrient Requirements (Institute of Medicine, 2006). Recommendations are made for vitamins, minerals, carbohydrates, protein, fat, cholesterol, fiber, electrolytes, and water. The DRIs is a group name for four separate reference sets:
Recommended Dietary Allowances (RDAs)
Estimated Average Requirement
Adequate Intake
Tolerable Upper Intake Level
Each of these reference values has a specific purpose and represents a different level of intake (Fig. 8.1). Nutrients have either an RDA or an Adequate Intake; not all nutrients have an established Tolerable Upper Intake Level (Table 8.1). Each reference value is viewed as an average daily intake over time, at least 1 week for most nutrients. Summary tables of the DRIs appear in Appendices 1, 2, and 3. Additional reference values include Acceptable Macronutrient Distribution Ranges and an Estimated Energy Requirement.
DRIs are used by scientists and nutritionists who work in research or academic settings and by dietitians who plan menus for specific populations, such as elderly, schools, prisons, hospitals, nursing homes, and military feeding programs. They are also used to assess the adequacy of an individual’s intake by comparing estimated intake with estimated requirements. Keep in mind that
obtaining a reliable estimate of a person’s actual intake is difficult due to reporting errors, flaws in estimating portion sizes, and day-to-day variation in food intake. Unless a person has participated in a nutrient requirement study, it is impossible to quantify exact nutrient requirements for an individual. Because consumers eat food and not nutrients, the DRIs are not suited to teaching people how to make healthy choices.
obtaining a reliable estimate of a person’s actual intake is difficult due to reporting errors, flaws in estimating portion sizes, and day-to-day variation in food intake. Unless a person has participated in a nutrient requirement study, it is impossible to quantify exact nutrient requirements for an individual. Because consumers eat food and not nutrients, the DRIs are not suited to teaching people how to make healthy choices.
 Figure 8.1 ▶ Representation of DRI along a continuum of intake. |
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Recommended Dietary Allowances
The RDAs represent the average daily recommended intake to meet the nutrient requirements of 97% to 98% of healthy individuals by life stage and gender. The recommendations are based on specific criteria indicators for estimating requirements, such as plasma and serum nutrient concentrations, and are set high enough to account for daily variations in intake. When estimating the nutritional needs of people with health disorders, health professionals use the RDAs as a starting point and adjust the values according to the individual’s need.
Unfolding Case
Think of Aurea. During periods of exacerbation, her nutrient needs increase related to impaired nutrient absorption secondary to inflammation and diarrhea. The RDA and other DRI references are intended for healthy people only and thus may not reflect Aurea’s actual needs during periods of exacerbation. Unfortunately, evidence-based diet recommendations do not exist for patients with inflammatory bowel disease other than to follow a healthy and varied diet. How can she achieve that goal given her food intolerances? Would she benefit from a multivitamin and mineral supplement? What nutrients and nonnutrient substances are not found in multivitamin and mineral supplements that are also important for health?
Estimated Average Requirement
Estimated Average Requirement (EAR) values are used to determine RDA values; they are not used as a stand-alone reference. The EAR is the amount of a nutrient that is estimated to meet the requirement of half of healthy people in a lifestyle or gender group. “Average” actually means median. By definition, the EAR exceeds the requirements of half of the group and falls below the requirements of the other half. The EAR is not based solely on the prevention of nutrient deficiencies but includes consideration for reducing the risk of chronic disease and takes into account the bioavailability of the nutrient—that is, how its absorption is affected by other food components.
Estimated Average Requirement (EAR) the nutrient intake estimated to meet the requirement of half of the healthy individuals in a particular life stage and gender group.
Adequate Intake
An Adequate Intake (AI) is set when an RDA cannot be determined due to lack of sufficient data on requirements. It is a recommended average daily intake level thought to meet or exceed the needs of virtually all members of a life stage or gender group based on observed or experimentally determined estimates of nutrient intake by groups of healthy people. The primary purpose of the AI is as a goal for the nutrient intake of individuals. This is similar to the use of the RDA except that the RDA is expected to meet the needs of almost all healthy people, while in the case of an AI, it is not known what percentage of people are covered.
Adequate Intake (AI) an intake level thought to meet or exceed the requirement of almost all members of a life stage and gender group. An AI is set when there are insufficient data to define an RDA.
Tolerable Upper Intake Level
The Tolerable Upper Intake Level (UL) is the highest level of average daily nutrient intake that is likely to pose no risk of adverse health effects to almost all individuals in the general population. It is not intended to be a recommended level of intake; there is no benefit in consuming amounts greater than the RDA or AI.
Tolerable Upper Intake Level (UL) the highest average daily intake level of a nutrient likely to pose no danger to most individuals in the group.
Acceptable Macronutrient Distribution Ranges
The Acceptable Macronutrient Distribution Ranges (AMDRs) are broad ranges for each energy nutrient, expressed as a percentage of total calories consumed. These ranges are associated with reduced risk of chronic disease and are such that an AI of all nutrients can be obtained. Over time, intakes above or below this range may increase the risk of chronic disease or deficiency, respectively. The AMDRs for adults are as follows:
Acceptable Macronutrient Distribution Ranges (AMDRs) an intake range as a percentage of total calories for energy nutrients.
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Estimated Energy Requirements
Similar to the EAR, the Estimated Energy Requirements (EERs) are defined as the dietary energy intake predicted to maintain energy balance in healthy, normal-weight individuals of a defined age, gender, weight, height, and level of physical activity consistent with good health. Exceeding the EER may produce weight gain. See Chapter 7 for more on determining energy needs.
Estimated Energy Requirements (EERs) level of calorie intake estimated to maintain weight in normal-weight individuals based on age, gender, height, weight, and activity.
FROM NUTRIENTS TO FOOD: HEALTHY EATING
Healthy eating guidelines translate the science of nutrient needs into evidence-based recommendations for eating patterns to meet those needs. A healthy eating pattern not only provides adequate amounts of all essential nutrients but also helps people attain and maintain healthy body weight, promotes overall health, and reduces the risk of chronic disease. Prominent characteristics of healthy eating patterns are the following:
Variety—in the color of fruits and vegetables, the selections within each group, and methods of cooking
Balance—all food groups are included in reasonable proportions
Moderation—limited amounts of saturated fat, added sugars, and sodium; moderate amounts of alcohol and coffee if adults so choose
Individually appropriate—calorically, culturally, personally, and economically
No foods are prohibited
Dietary Guidelines for Americans
The Dietary Guidelines for Americans (DGA), published jointly every 5 years since 1980 by the U.S. Department of Health and Human Services (USDHHS) and the U.S. Department of Agriculture (USDA), are a report containing nutritional and dietary information and guidelines for the general public. It serves as the federal policy on nutrition, dictating how education, communication, and food assistance programs are conducted by the government. They are evidence-based recommendations designed for professionals to help people ages 2 years and older consume a healthy, nutritionally adequate diet.
As the science of nutrition has evolved, so have the DGA; the 2015-2020 version focuses on healthy eating patterns as a whole rather than individual components such as food groups and nutrients. This shift in focus is in recognition of the interactive and potentially cumulative effects food components can have on health (USDHHS & USDA, 2015). A focus on eating patterns is supported by results of studies that examine the relationship between eating patterns, health, and risk of disease. The 2015-2020 DGA contain five overarching guidelines that encourage healthy eating patterns that are proposed as a framework rather than a rigid requirement. Key recommendations are included to help Americans implement the guidelines in their entirety. Americans are urged to make gradual changes in their eating patterns by shifting their food choices to higher quality selections. The guidelines and recommendations are featured in Box 8.1.
To illustrate how the guidelines and recommendations translate into types and amounts of food, the DGA feature three styles of different healthy eating patterns. Within each style, there are 12 different calorie levels, ranging from 1000 to 3200 calories in 200-calorie increments. This wide range of calorie levels is intended to meet the needs of individuals across the lifespan. Each style lists recommended amounts of food within each food group for each calorie level. Table 8.2 compares each of the styles at 1600- and 2000-calorie levels. The styles are summarized in the following sections.
Healthy U.S.-Style Eating Pattern
This pattern is based on the types and proportions of foods Americans typically consume but in nutrient-dense forms and appropriate amounts. The most notable difference from the typical
American pattern is the reduction of meat and poultry. Although this style is designed to meet the nutritional needs of almost all healthy people, the amounts of vitamin D, vitamin E, potassium, and choline are marginal or less than the RDA or AI for many or all age and gender groups. Of these nutrients, low intakes of potassium and vitamin D are of most concern.
American pattern is the reduction of meat and poultry. Although this style is designed to meet the nutritional needs of almost all healthy people, the amounts of vitamin D, vitamin E, potassium, and choline are marginal or less than the RDA or AI for many or all age and gender groups. Of these nutrients, low intakes of potassium and vitamin D are of most concern.
BOX 8.1 2015-2020 Dietary Guidelines for Americans
The Guidelines
Follow a healthy eating pattern across the lifespan. All food and beverage choices matter. Choose a healthy eating pattern at an appropriate calorie level to help achieve and maintain a healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease.
Focus on variety, nutrient density, and amount. To meet nutrient needs within calorie limits, choose a variety of nutrient-dense foods across and within all food groups in recommended amounts.
Limit calories from added sugars and saturated fats and reduce sodium intake. Consume an eating pattern low in added sugars, saturated fats, and sodium. Cut back on foods and beverages higher in these components to amounts that fit within healthy eating patterns.
Shift to healthier food and beverage choices. Choose nutrient-dense foods and beverages across and within all food groups in place of less healthy choices. Consider cultural and personal preferences to make these shifts easier to accomplish and maintain.
Support healthy eating patterns for all. Everyone has a role in helping to create and support healthy eating patterns in multiple settings nationwide, from home to school to work to communities.
Key Recommendations
Consume a healthy eating pattern that accounts for all foods and beverages within an appropriate calorie 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
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