Spring/Summer 2003

Vol. 11, Issue 1

Convergence in Guidelines for Prevention of Chronic Diseases Dictates Lifestyle Change for Americans
by J.A. Grisso, M.D., M.Sc., Senior Program Officer, and J. Michael McGinnis, M.D., Senior Vice President and Director, Health Group, The Robert Wood Johnson Foundation, Princeton, NJ

The comprehensive and far-reaching World Health Organization/Food and Agriculture Organization (WHO/FAO) report "Diet, Nutrition, and the Prevention of Chronic Diseases" is particularly timely for a U.S. population facing an unprecedented obesity epidemic. It offers the prospect of collaborative WHO-FAO policies and programs to foster global initiatives that promote changes in agricultural production, food production and marketing, and economic development to elicit dietary behavior important to better health.

The urgency for change is compelling. Sixty-one percent of U.S. adults are overweight, and the prevalence of obesity in the country (31 percent) nearly doubled from 1980 to 1999. In children, overweight levels have tripled among adolescents and more than doubled among younger children since the 1970s, placing U.S. youths at increased risk in later years for heart disease, hypertension, diabetes mellitus and various cancers. The shift to micronutrient-sparse/energy-dense diets high in fat and simple carbohydrates, coupled with increasingly sedentary lifestyles at work and home, are key contributors to the problems and issues addressed in the report.

Dietary Guidance and Policy in the United States
Three organizations are central to the development and administration of dietary guidance and policy in the United States: the U.S. Department of Agriculture (USDA), the U.S. Department of Health and Human Services (DHHS) and the nongovernmental Food and Nutrition Board (FNB) of the National Academy of Science's Institute of Medicine. The "Dietary Guidelines for Americans" are the official U.S. dietary guidance developed jointly by USDA and DHHS by law. These guidelines, which include a graphic representation called the "Food Guide Pyramid," are updated every five years, and are based in part on "Dietary Reference Intakes" (DRIs) developed periodically by the FNB.

Comparison of WHO/FAO and U.S. Recommendations
The WHO/FAO recommendations and the Dietary Guidelines (as well as the DRIs) are generally similar with respect to fats, cholesterol, protein, carbohydrates (including grains, fruits, vegetables, free sugars and fiber), sodium chloride and daily physical activity. (See chart.) While the WHO/FAO report tends to present recommendations as percentages of energy intake and the U.S. guidelines as daily servings of fruits, vegetables and whole grains, their conclusions, both regarding carbohydrates and other nutrients, are comparable.

The WHO/FAO report also includes separate recommendations for preventing obesity, diabetes, cardiovascular diseases, cancer, dental diseases and osteoporosis. While the Dietary Guidelines do not present an extensive scientific review, such reviews are produced or commissioned as part of the process of developing the guidelines.

COMPARISON OF WHO/FAO AND U.S. RECOMMENDATIONS FOR DAILY DIETARY INTAKE AND PHYSICAL ACTIVITY
	WHO/FAO Recommendations	Dietary Guidelines for Americans	FNB Dietary Reference Intakes
Total fats	15-30% ^a	<or= 30%^b	25-35%
Saturated fatty acids (SFAs)	< 10%	< 10%	As low as possible
Polyunsaturated fatty acids (PUFAs)^c	6-10%
n-6 PUFAs	5-8%	5-10%
Trans fatty acids	< 1%		As low as possible
Cholesterol	<or= 300 mg	<or= 300 mg
Protein	10-15%	4 servings (~ 10-15%)^b	10-35%
Carbohydrates	55-75% (% total energy minus protein & fat)	6-11 servings Bread, Cereal, etc., group^b	45-65%
Total dietary fiber	> 25g from foods^d	> 25g	38g & 25g for men & women<= 50 yrs
Free sugars	< 10%^e	12 tsps^f or < 10%	< 25%
Sodium chloride	5 to 6g (iodized)	5 to 6g
Fruits and vegetables	At least 400g	5-9 servings (~120g each)
Physical activity of moderate intensity	At least 30, pref. 60, min.^g	At least 30 min.	At least 60 minutes
^a Percentages mean total daily energy consumed. ^b Also note recommendation: 2-3 servings each from Meat, Poultry, Fish, Dry Beans, Eggs and Nuts Group, and from Milk, Yogurt and Cheese Group. ^c n-3 PUFAs1-2%; Monounsaturated fatty acids Total fat minus (SFAs + PUFAs + trans fats). ^d Preferably from whole-grain cereals, fruits and vegetables. ^e All added monosaccharides and disaccharides, plus sugars naturally present in honey, syrups and fruit juices. ^f For a 2200 calorie diet only; less for fewer calorie diets. ^g Recommended duration varies with focus: cardiovascular risk reduction or weight reduction.

The Challenge to U.S. Policy-Makers, Food Marketers and Consumers
Both the WHO/FAO report and the Dietary Guidelines emphasize lifestyles that are active, as well as diets that feature fruits, vegetables and whole grains; are lower in free or added sugars, salt and fats (especially saturated fats); and maintain body weights within desirable ranges. For Americans, however, neither the WHO/FAO recommendations nor the Dietary Guidelines adequately address portion sizes and increased consumption of nutrient-empty, calorie-dense foods.

Over the last 20 years, more Americans are eating away from home, consuming more energy per meal and more snacks, and increasing total energy intake. Not surprisingly, these trends have led to an alarming rise in overweight levels and obesity. Despite policies for labeling of food products and prepared meals, improvement in American dietary patterns is hindered by the absence of effective incentives to motivate consumers to eat smaller portions and to substantially reduce their reliance on "nutrient-lite/calorie-dense" foods.

Similarly, the emphasis on fruits, vegetables and carbohydrates needs to be clarified for U.S. consumers to ensure that these recommendations are not misinterpreted and taken as a suggestion to consume more sweetened, refined food products. This, coupled with evolving insights into dietary fat components and uncertainties about appropriate protein targets, suggests that the Food Guide Pyramid needs to be redesigned to bring the graphic representation more in line with the recommendations.

Finally, improving the specificity and utility of food guidance and nutrition programs in the United States requires better baseline and trend data on nutrient intakes and food consumption from efforts in nutrition monitoring and nutrition research. Until we can discern more accurately what people are eating, where and why, our capacity to develop guidance and incentives that yield better dietary patterns will be limited.

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