This week’s note is dedicated to Nina Teicholz. Nina is a science journalist and Executive Director of The Nutrition Coalition, a non-profit organisation. The Nutrition Coalition was founded in 2015 with the primary goal of ensuring that US nutrition policy is based on rigorous scientific evidence. The organisation’s vision is "a healthier America with significant reductions in obesity and other nutrition-related diseases, including Type 2 diabetes, heart disease, fatty liver disease, and hypertension, among others."
Nina has presented testimony to the Canadian Senate, the US Department of Agriculture and the 2020 Dietary Guidelines Advisory Committee (DGAC) and has given presentations around the world about US dietary policy following the publication of her book “Big Fat Surprise”, which was named a "best book" of the year by The Economist, The Wall Street Journal, Forbes, Mother Jones, and Library Journal as well as being a finalist for the Investigative Reporters and Editors annual book award. Professor Tim Noakes credits Nina’s book as being a ray of hope in his darkest hour. In May 2014, Tim had just heard that he was to be charged by the Health Professions Council of South Africa in the now famous “Banting for babies” trial when Nina’s book was published. Nina’s book – written by a vegetarian who had found “butter, meat and cheese belong in a healthy diet” – confirmed Tim’s own research and changing beliefs.
Nina is particularly renowned for her challenge to long-established saturated fat restrictions and, in June 2020, a “State-of-the-Art Review” was published in the Journal of the American College of Cardiology (JACC) supporting her position on the evidence (Ref 1). The review was written by a group of leading nutrition scientists, including a former member of the 2015 DGAC and the Chair of the 2005 DGAC. It was called “Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations.” This review found that government limits on saturated fats are not justified by the science.
While this gave a brief glimmer of hope in June, the publication of the Scientific Report of the 2020 DGAC, barely a month later, has – unless the US Congress somehow intervenes – greatly diminished any aspiration of US Dietary Guidelines being substantially revised, when they are issued at the end of this year. (If you are American and would like to contact Congress to urge action, The Nutrition Coalition has made this easy to do here, Ref 2). The Scientific Report is hugely disappointing for Nina, The Nutrition Coalition, the scientists who were involved in the JACC review and many other researchers around the world who were hoping that the DGAC would finally accept that the demonisation of fat, especially saturated fat, has never been evidence-based. This is more than hugely disappointing for the health of Americans because – for something to change, something must change and there is no sign of change in the proposed 2020 Dietary Guidelines for Americans (DGAs). This is globally disappointing, as nations tend to follow the advice from the US DGAs and the rest of the world has also now been condemned to five more years of carbs are good, fat is bad and saturated fat is worse, while obesity and nutrition-related disease continues unabated.
In 1977, a document was published called “Eating in America. Dietary Goals for the United States” (Ref 3). It was the culmination of the work of the Select Committee on Nutrition and Human Needs, led by Senator George McGovern. The document was 10 pages long. The rationale for the report was given as – "our diets have changed radically within the last 50 years, with great and often very harmful effects on our health." The report continued "Too much fat, too much sugar or salt, can be and are directly linked to heart disease, cancer, obesity and stroke, among other killer disease. In all, six or the ten leading causes of death in the United States have been linked to our diet."
A few food and drink items were singled out: "In 1975 we drank on the average of 295 12oz cans of soda." "In the early 1900s almost 40 percent of our caloric intake came from fruit, vegetable and grain products. Today only a little more than 20 percent of calories come from these sources."
The report set out six basic goals:
“1) Increase carbohydrate consumption to account for 55 to 60 percent of the energy (caloric) intake.
“2) Reduce overall fat consumption from approximately 40 to 30 percent energy intake.
“3) Reduce saturated fat consumption to account for about 10 percent of total energy intake.
“4) Reduce cholesterol consumption to about 300 mg. a day.
“5) Reduce sugar consumption by about 40 percent to account for about 15 percent of total energy intake.
“6) Reduce salt consumption by about 50 to 85 percent to approximately 3 grams a day.”
This brief document was succeeded by the first Dietary Guidelines for Americans (DGAs), which were published in 1980 (Ref 4). This was also a brief document – more like a pamphlet – and it reiterated the same points as the 1977 Dietary Goals document: Avoid too much fat, saturated fat, cholesterol, sugar, and sodium. Eat foods with adequate starch and fiber. It added some new messages: "eat a variety of foods"; "if you drink alcohol, do so in moderation” and "maintain ideal weight."
By law (Public Law 101-445, Title III, 7 U.S.C. 5301 et seq.) the DGAs are published by the Federal government every five years. Since the 1985 edition, the US Departments of Agriculture (USDA) and Health and Human Services (HHS) have fulfilled this requirement “by establishing a Dietary Guidelines Advisory Committee of nationally recognized experts in the field of nutrition and health to review the scientific and medical knowledge current at the time” (p1, Ref 5).
Hence the DGAs have been published every five years and here we are in 2020 with the ninth edition in progress. There is nothing brief about the process or documentation anymore. The committee started work in March 2019. Last week, the “Scientific Report of the 2020 Dietary Guidelines Advisory Committee” was published. It is 835 pages long. This precedes the ‘lay’ report, which will be published later on this year. As a guide, the 2015 Scientific Report was 571 pages long (Ref 6) and the final publication in 2015 was 144 pages long (Ref 7).
The DGAs from 2000 to 2010
The 2000 DGAs were firmly based on the Food Pyramid with the classic base of the pyramid recommending “6-11 daily servings of bread, cereal, rice and pasta.” The 2000 DGAs were the last ones to state: “Aim for a total fat intake of no more than 30 percent of calories, as recommended in previous editions of the Guidelines” (Ref 8).
There were two significant changes in the 2005 DGAs (Ref 9):
1) Acceptable Macronutrient Distribution Ranges (AMDRs).
Acceptable Macronutrient Distribution Ranges were developed by the Institute of Medicine and they first appeared in the 2005 DGAs. The DGAs – from the 2005 issue and ongoing – have used AMDRs for the three macronutrients. For men and women aged 19 or over, the AMDRs have been: protein 10-35%; fat 20-35% and carbohydrate 45-65%.
2) Dietary/eating patterns.
The 2000 DGAs mentioned eating pattern(s) (four times), but in the context of the Food Pyramid. The 2005 DGA report mentioned dietary and/or eating pattern(s) approximately 20 times and this time the DASH diet (Dietary Approaches to Stop Hypertension) was introduced as a recommended eating pattern – in addition to the USDA Food Guide. The DASH Eating Plan was described as “high in vegetables, fruits, low-fat dairy products, whole grains, poultry, fish, beans, and nuts and is low in sweets, sugar-sweetened beverages, and red meats.”
Dietary/eating patterns have become increasingly prominent in the DGAs since 2005. The 2010 DGAs added more recommended eating patterns: “The USDA Food Patterns, their lacto-ovo vegetarian or vegan adaptations, and the DASH Eating Plan are illustrations of varied approaches to healthy eating patterns.”
Amusingly, the 2010 DGAs reported that the “‘Mediterranean diet’ is not one eating pattern” because “a large number of cultures and agricultural patterns exist in countries that border the Mediterranean Sea” and so “No single set of criteria exists for what constitutes a traditional Mediterranean eating pattern” (p44, Ref 10). I say amusingly because of what happened five years later…
The 2015 DGAs
Ostensibly the 2015 DGAs were less prescriptive than the first (1980) DGAs, which specified intakes to the percentage, gram, and milligram. The Executive Summary of the 2015 report presented five guidelines and they were quite vague:
“1) Follow a healthy eating pattern across the lifespan.
“2) Focus on variety, nutrient density, and amount.
“3) Limit calories from added sugars and saturated fats and reduce sodium intake.
“4) Shift to healthier food and beverage choices.
“5) Support healthy eating patterns for all.”
The Scientific Report, published in February 2015, created quite a stir by announcing: “Cholesterol is not a nutrient of concern for overconsumption” (p17, Ref 11). This statement closed a brief paragraph, which stated that the 2015 report would not bring forward previous recommendations to limit dietary cholesterol intake to no more than 300 mg/day (which had prevailed since the 1980 DGAs) “because available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol.”
This was featured in an article in June 2015 by Mozaffarian and Ludwig called “The 2015 US Dietary Guidelines – Ending the 35% Limit on Total Dietary Fat” (Ref 12). They reported the dropping of dietary cholesterol as ‘a nutrient of concern.’ They also claimed that a “far less noticed, but more momentous, change” was the new absence of any limitation on total fat consumption. They quoted passages from the long Scientific Report: “Reducing total fat (replacing total fat with overall carbohydrates) does not lower CVD risk… Dietary advice should put the emphasis on optimizing types of dietary fat and not reducing total fat.”
Mozaffarian’s and Ludwig’s article was somewhat premature since the ‘lay’ report, which was published in December 2015, scaled back on both the cholesterol stance and the position on total fat. With reference to dietary cholesterol, the ‘lay’ report said just because the recommendation to limit dietary cholesterol to 300 mg/day is not in the 2015 report, “does not suggest that dietary cholesterol is no longer important to consider when building healthy eating patterns” (p32). The next passage rationalised that foods that are high in dietary cholesterol are high in saturated fat and so should be avoided for that reason.
As for total fat, the AMDRs, which were introduced in 2005, remained the same for all three macronutrients. The AMDR on fat was maintained at 20-35% indicating that a diet as low as 20% fat was deemed acceptable and anything over 35% wasn’t.
The prima facie ‘vagueness’ of the 2015 DGAs was put straight by the detail of the recommended eating patterns. Two of the three examples in the report are in the table below – the “Healthy Vegetarian” and the “Healthy Mediterranean-Style Eating Patterns” – with intakes specified to the gram, ounce, or cup. The issue over the Mediterranean diet was obviously resolved between 2010 and 2015 with the use of the word “style.”
The 2020 Scientific Report
We don’t yet have the 2020 DGAs, we only have the Scientific Report. And, as you can see from the 2015 Scientific Report and the 2015 final guidelines – things can change. There were many passages in the 835 pages that could have inspired a Monday note in themselves, but I’ve focused on what’s new, what hasn’t changed and what might change.
Page 9 of the 2015 DGAs had a ‘box’ called “Looking Ahead to 2020 – Expanding Guidance.” This reported that traditionally the DGAs had focused on individuals aged 2 and older in the United States, including those who are at increased risk of chronic disease. It continued “As mandated by Congress in the Agricultural Act of 2014, also known as the Farm Bill, the Dietary Guidelines will expand to include infants and toddlers (from birth to age 2), as well as additional guidance for women who are pregnant, beginning with the 2020-2025 edition.”
Sure enough, the inclusion of sections on “birth to age 24 months” and “pregnancy and lactation” are the main new features of the 2020 Scientific Report. The "birth to 24 months" section ended up being about human milk/infant formula for the first year and then a recommended food pattern was developed for toddlers aged 12 to 24 months who are fed neither human milk nor infant formula. "The Pattern allows for a variety of nutrient-rich animal-source foods, including meat, poultry, seafood, eggs, and dairy products, as well as nuts and seeds, fruits, vegetables, and grain products, prepared in ways that are developmentally appropriate for this age."
This also amused me as it is very similar to the south African toddler guidelines that turned out to be so favourable to Professor Noakes at the tweet trial. The south African guidelines were “From 6 months of age give your baby meat, chicken, fish, or egg every day as often as possible. Give your baby dark green leafy vegetables and orange coloured vegetables and fruit every day.” Notice the emphasis on nutrient-rich animal-source foods for toddlers, with grains listed last if at all, and then wonder why this changes once the age of two is reached.
The Executive Summary said that there were two “distinguishing features” of the 2020 Scientific Report: i) The lifespan approach – the new sections on those under two years old and during pregnancy/lactation allows the DGAs to cover Americans from cradle to grave; and ii) the continued focus on dietary patterns: “The 2020 committee has made dietary patterns a centerpiece of its report.”
The continued focus on dietary/eating patterns still included the DASH diet, a vegetarian (and vegan) diet, and the Mediterranean-style diet. The word ‘style’ was often dropped, to leave just a Mediterranean diet. There was a new development in Table D8.1 (p513 of the PDF) with the introduction of a concept called “Dietary pattern components.” The table claimed that dietary patterns associated with lower risk of disease consistently include fruits, vegetables, whole grains/cereals, legumes, nuts, low-fat dairy products, fish and/or seafood, unsaturated vegetable oils, lean meat and poultry and that dietary patterns associated with higher risk of disease consistently include red meat, processed meat and high-fat dairy. The red meat mention was interesting as red meat is only mentioned six times in the whole report (outside references) and two of those mentions were in praise of its iron/nutrient content. The 2020 DGAs might well propose that any dietary pattern that includes the foods considered lower risk and avoids the foods considered higher risk will be deemed healthy.
What hasn’t changed?
The five main principles have not changed since the 2015 DGAs. (These are the five presented above under the sub-heading “The 2015 DGAs”). Each principle was followed with a suggested update for 2020-2025. These were so nebulous, it made me wonder what the committee had been doing since March 2019. E.g. the second principle is “Focus on variety, nutrient density, and amount”. The suggested update was little more than: the committee recommends “Focus on nutritional quality of food choices, portion size and frequency of eating” to be included in the overarching guidelines.
The AMDRs have not changed. They remain protein 10-35%, fat 20-35% and carbohydrate 45-65%.
The DGAC still thinks that food groups are vegetables, fruits, grains, dairy, protein foods and oils. I think that food groups are meat, fish, eggs, dairy, vegetables, fruit, nuts & seeds, legumes (beans, pulses, etc) and grains (Ref 13). The big difference between our food groups is that the DGAC lumps meat, fish, eggs, nuts & seeds and legumes under protein foods. The most nutritious food groups are thus aggregated into one group incorrectly named a food group because protein is a macronutrient and not a food group. This ‘macronutrient’ group is ignorant/ill-advised i) because protein is in everything other than sucrose and oils and ii) because as you can see from the example dietary patterns in the table above, this amalgamation of five food groups is supposed to provide just 3.5-6.5oz (100-185g) per day.
What might change?
Bearing in mind that the final report can differ from the Scientific Report, saturated fat is the one to watch. The ignorance shown in the report is spectacular and particularly frustrating given that saturated fat was one specific topic for which comments were invited, back in March 2018, to inform the 2020 DGAs. I made a submission, which serves as a definitive guide to saturated fat (Ref 14). A couple of comments in the 835-page report summarised the ignorance of the DGAC:
– "No DRI values have been established for saturated fatty acids because, unlike unsaturated fatty acids, there is no biological requirement for their intake." (p164 of the PDF)
– "Humans have no dietary requirements for saturated fat or cholesterol because they synthesize them from other dietary substrates… Thus, the Committee recommends that dietary cholesterol and saturated fat intake be as low as possible within a healthy dietary pattern, and that saturated fat intake be limited to less than of 10 percent of total energy intake, as recommended by the 2015-2020 Dietary Guidelines for Americans." (p593 of the PDF).
At the start of my submission I spelled out the “facts about fat”, which I often present at conferences: 1) Human beings must consume fat; we die without doing so. 2) All food that contains fat contains all three natural fats: saturated; monounsaturated and polyunsaturated. It is impossible to consume unsaturated fat without saturated fat, or vice versa, in natural food. 3) Dairy is the only food group that contains more saturated than unsaturated fat.
To say that there is no requirement for saturated fat is to imply that a diet could exist without saturated fat. Indeed one of the 2020 DGAC members, Jamy Ard, did question saturated fat intake to the extreme: “Why should it not be zero?… since saturated fat is not an essential nutrient.” Dr. Ard, who is a medical director of Nestle, Inc., one of the world’s biggest junk-food manufacturers, was echoed by Linda Van Horn, a long-term saturated-fat foe who has argued against these fats for decades (Ref 15).
My second fact about fat should have specified “All food that contains fat (and sucrose is the only food that doesn’t contain even a trace of fat).” The DGAC – or at least some of the members – appear not to know that every food that they recommend in their dietary patterns – from kale to kidney beans – contains fat and thus contains saturated fat.
I searched the report for references to 7%, as there have been fears that the DGAC may try to restrict saturated fat even further. This did not appear to be recommended in the Scientific Report, but we can be confident that the cap will remain at 10%, if not lower.
The final observation worthy of mention is that, while saturated fat/fats/fatty acids appeared 305 times in the 2020 Scientific Report, the word seafood was mentioned 421 times and the word fish additionally 173 times. Remember from above that red meat was mentioned narratively just four times in the report. While the demonisation of saturated fat continues, there is clearly a diminished incidence of red meat bashing.
The DGAC members seem to be waking up to the importance of fish, but this only serves to expose their ignorance. My submission contained this exact sentence: “And the oily fish (Ref 16), which we are advised to eat, has twice the total fat and one and a half times the saturated fat of that red meat (Ref 17) we are told to avoid.” The final 2020 DGAs publication is likely to be telling us to eat more fish, while eating less saturated fat. It will be definitely be telling us to eat most of our calorie intake in the form of carbohydrate, while eating less sugar – when carbohydrate essentially is combinations of sugar molecules (glucose, fructose and galactose).
As was shared above, by law, the DGAs must be published every five years and this requirement is supposed to be fulfilled by assembling “nationally recognized experts in the field of nutrition and health to review the scientific and medical knowledge current at the time.” What has happened is that a panel has been assembled, the majority of whom have conflicts with the International Life Sciences Institute (ILSI), which was set up by a Coca-Cola executive 40 years ago in the US and operates throughout the world. Thus, just as happens in the UK, American dietary guidelines are effectively being set by the fake food industry (Refs 18 & 19). Maybe the DGAC members are conflicted rather than ignorant, but, either way, America and the other nations following suit deserve better.
* The Scientific Report for the 2020 Dietary Guidelines for Americans has just been published. This is the comprehensive document (835 pages), which precedes the Dietary Guidelines for Americans due out later this year.
* Dietary goals for Americans were first set in 1977, following the work of Senator George McGovern’s select committee. The first Dietary Guidelines for Americans (DGAs) were set in 1980 and it is now ingrained in US law that these will be published every five years. This year is the ninth edition.
* The first DGAs were very prescriptive with amounts recommended to the percent, gram and milligram for carbohydrate, fat, saturated fat, dietary cholesterol, sugar, and salt.
* The next significant changes in the DGAs came in 2005, when the 30% cap on total fat was replaced with the introduction of Acceptable Macronutrient Distribution Ranges (AMDRs). The AMDR for fat was 20-35% and this has not changed since.
* Since 2005, dietary/eating patterns have become increasingly prominent. The DASH diet (Dietary Approaches to Stop Hypertension) was the first dietary pattern to be featured (although the famous Food Pyramid had been used as a guide until this point). Vegetarian and Mediterranean-style dietary patterns have been added since.
*The 2015 Scientific Report appeared to drop dietary cholesterol as a nutrient of concern and to end the limit on total fat. However, the actual 2015 DGAs – published later that year – did not reflect early interpretations. This reminds us that the Scientific Report and the DGAs can differ.
* The new features of the 2020 Scientific Report are i) that the DGAs will cover the age group birth to 24 months for the first time and ii) guidance for pregnant and lactating women will be included.
* Many things have not changed in the 2020 Scientific Report. The AMDRs haven’t changed. The five (vague) principles established in the 2015 DGAs haven’t changed. The focus on dietary patterns, rather than individual nutrients, is set to continue. The 10% limit on saturated fat hasn’t changed although at least one member of the DGA committee wondered why saturated fat intake shouldn’t be zero. I wondered whether this was a result of nutritional ignorance or the fact that the majority of the committee had conflicts with a global fake food organisation.
Ref 1: Astrup et al. Saturated Fats and Health: A Reassessment and Proposal for Food-based Recommendations: JACC State-of -the-Art Review. JACC. June 2020. https://www.sciencedirect.com/science/article/pii/S0735109720356874
Ref 2: https://www.nutritioncoalition.us/take-action/
Ref 3: Carter J.P. Eating in America; Dietary Goals for the United States; Report of the Select Committee on Nutrition and Human Needs US Senate. Cambridge, MA, USA: MIT Press 1977.
Ref 4: U.S. Department of Health and Human Services, Agriculture USDo. Dietary Guidelines for Americans. Washington: U.S. Government printing office, 1980.
Ref 5: Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans. Scientific Report of the 2020 Advisory Committee. In: (HHS) DoHaHS, ed., 2020:835.
Ref 6: Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans. Scientific Report of the 2015 Advisory Committee. In: Department of Health and Human Services (HHS), ed., 2015:571.
Ref 7: U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition.: Available at http://health.gov/dietaryguidelines/2015/guidelines/. 2015.
Ref 8: Department of Health and Human Services (HHS). Dietary Guidelines for Americans. Fifth edition. In: Department of Health and Human Services (HHS), ed., 2000.
Ref 9: Department of Health and Human Services (HHS). Dietary Guidelines for Americans. Sixth edition. In: Department of Health and Human Services (HHS), ed., 2005.
Ref 10: Department of Health and Human Services (HHS). Dietary Guidelines for Americans. Seventh edition. In: Department of Health and Human Services (HHS), ed., 2010.
Ref 11: Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans. Scientific Report of the 2015 Advisory Committee. In: Department of Health and Human Services (HHS), ed., 2015:571.
Ref 12: Dariush Mozaffarian and David S. Ludwig. The 2015 US Dietary Guidelines – Ending the 35% Limit on Total Dietary Fat. JAMA June 2015.
Ref 13: https://www.zoeharcombe.com/2015/05/food-groups/
Ref 14: https://www.zoeharcombe.com/2018/03/the-us-dietary-guidelines/
Ref 15: https://www.nutritioncoalition.us/news/committee-aims-to-lower-caps-on-saturated-fats
Ref 16: United States Department of Agriculture ARS. Fish, mackerel, Atlantic, raw, 2013.
Ref 17: United States Department of Agriculture ARS. Beef, bottom sirloin, tri-tip, separable lean only, trimmed to 0″ fat, choice, raw [URMIS #2244], 2013.
Ref 18: Gareth Iacobucci. Food and soft drink industry has too much influence over US dietary guidelines, report says. BMJ 2020. https://www.bmj.com/content/369/bmj.m1666
Ref 19: https://www.nutritioncoalition.us/news/unbalanced-subcommittee-on-saturated-fat