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Departments: Wouldn’t You Like to Know

Updates from the Dietary Guidelines for Americans

Bushman, Barbara A. Ph.D., FACSM, ACSM-CEP, ACSM-EP, ACSM-CPT

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ACSM's Health & Fitness Journal: 11/12 2021 - Volume 25 - Issue 6 - p 5-10
doi: 10.1249/FIT.0000000000000711
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Q: What should fitness professionals know about the current Dietary Guidelines for Americans?

A: The Dietary Guidelines for Americans (DGA) is written for health professionals and policy makers (1) and focuses on health promotion and disease prevention (2). Given this aim, the guidelines do not include clinical guidance on specific chronic disease treatment; these situations require adaptation of the dietary guidelines by qualified health professionals working with individual patients (3). For background on DGA, see Box 1.

BOX 1. Background of the DGA

The first DGA was released in 1980, a collaboration between the U.S. Department of Agriculture (USDA) and the Department of Health and Human Services (USDHHS), with encouragement to maintain recommended body weight while consuming a variety of foods to provide essential nutrients (2). The focus went beyond previous guidance on adequate consumption of nutrients to also consider how diet can affect chronic diseases (2). Because of some concerns related to the scientific support for the recommendations, the USDA and the USDHHS were directed by Congress to seek outside scientific experts, thus the establishment of the Dietary Guidelines Advisory Committee, which issued a 19-page scientific report used to develop the 1985 DGA (2). An advisory committee has been responsible for reviewing the scientific evidence ever since, and the report has grown in length from that first 19-page document to 835 pages with online appendices and full systematic reviews for the report used for the most current DGA (1). This underscores the scientific basis in place with each new DGA. Starting with the 1995 edition, the DGA is now mandated by statute to be released at least every 5 years (2).

The ninth edition (DGA9) is the first set of DGA that provides guidance throughout the entire life span from birth through older adulthood; each life stage includes a chapter, including new chapters for infants and toddlers and pregnant or lactating women (3). DGA9 highlights this comprehensive premise with the following statement: “Just about everyone, no matter their health status, can benefit from shifting food and beverage choices to better support healthy dietary patterns” (3). The term “dietary pattern” reflects one’s complete dietary intake, food and beverages, over the course of time. Dietary patterns are a focus, given that foods and nutrients are consumed in various combinations over the course of a day or week, rather than in isolation (3). The DGA is not prescriptive of a particular diet but rather is “a customizable framework of core elements in which individuals make tailored and affordable choices that meet their personal, cultural, and traditional preferences” (3).

CURRENT STATUS

The Healthy Eating Index (HEI) is a tool developed in 1995 that is used to evaluate how closely Americans are following the DGA (4). The most current HEI examined 13 components from different food items compared with recommendations found in the previous (2015–2020) DGA. The range of potential scores is 0 to 100, with 100 reflecting full alignment between foods consumed and the key dietary recommendations (4). The total HEI score was 59 out of 100, suggesting that the average American diet does not match dietary recommendations. As can be seen in the infographic in Figure 1, scores have fluctuated somewhat over time and differ based on age (5). There is much room for improvement as no age-group is close to the maximum score of 100 points. The DGA9, as with previous editions, focuses on well-documented relationships between food and health — for achieving and maintaining good health as well as for chronic disease risk reduction (3).

Figure 1
Figure 1:
Health Eating Index scores showing trends over time and by age-group (graphics from: www.dietaryguidelines.gov/resources/downloadable-graphics#infographics).

GUIDELINES, RECOMMENDATIONS, AND KEY PRINCIPLES

There are four overarching guidelines: 1) follow a healthy dietary pattern at every stage of life; 2) customize and enjoy nutrient-dense foods and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations; 3) focus on meeting food group needs with nutrient-dense foods and beverages, and stay within caloric limits; and 4) limit foods and beverages higher in added sugars, saturated fat, sodium, and limit alcohol consumption (3). The concept of “nutrient-dense” choices reflects selections that “provide vitamins, minerals, and other health-promoting components and have little added sugars, saturated fat, and sodium” (3). As noted in the third guideline, the core elements of a healthy dietary pattern include all types of vegetables (dark green; red and orange; beans, peas, and lentils; and starchy), fruits (especially whole fruit), grains (whole grains for at least half of grains), dairy (fat-free or low-fat milk yogurt, cheese with alternatives of lactose-free products, and fortified soy beverages and yogurt), protein foods (lean meats, poultry, eggs; seafood; beans, peas, and lentils; nuts, seeds, soy products), and oils (vegetable oils and foods containing oils such as seafood and nuts) (3). Specific recommendations related to limitations in the fourth guideline are noted in Box 2 (3).

BOX 2. Limitations on added sugars, saturated fat, sodium, and alcoholic beverages

Some limitations are recommended (3):

  • Added sugars — less than 10% of calories per day starting at age 2 years. Avoid foods and beverages with added sugars for those younger than age 2 years.
  • Saturated fat — less than 10% of calories per day starting at age 2 years.
  • Sodium — less than 2,300 milligrams per day — and even less for children younger than age 14 years.
  • Alcoholic beverages — adults of legal drinking age can choose not to drink, or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed. Drinking less is better for health than drinking more. There are some adults who should not drink alcohol, such as women who are pregnant.

Key dietary principles are provided in the DGA9 to help individuals in the process of meeting the guidelines and recommendations. One principle is that food and beverages should be the primary sources to meet nutritional requirements, although when not possible to meet nutrient needs from these items, fortified foods and nutritional supplements may be included (3). A second principle is choosing a variety of options from each food group as this provides flexibility within the overall diet and can be helpful in meeting nutrient needs (3). Foods in all forms — fresh, canned, dried, frozen, and 100% juices — can contribute to a healthy dietary pattern (3). A third principle is to pay attention to portion size. Portion size is “the amount of food or beverage served or consumed in one eating occasion” (3). The Nutrition Facts label can be helpful in the selection of appropriate portions as serving sizes are noted along with the calories per serving (see Figure 2 for the new label) (6). Consuming more or less than a serving size will either raise or lower the caloric intake for that item (3). Attention in this area can be helpful in assisting an individual to stay within caloric limits.

Figure 2
Figure 2:
Nutrion Facts label (graphic from: https://www.fda.gov/food/new-nutrition-facts-label/whats-new-nutrition-facts-label).

Some nutrients and dietary components are not being consumed in adequate amounts, given the lack of nutrient density in many diets (3). In particular, the following are considered as public health concerns for the general U.S. population: calcium, potassium, dietary fiber, and vitamin D (3). These components are included on the nutrition facts label given the concern with underconsumption in the typical U.S. diet (6).

IS PHYSICAL ACTIVITY MENTIONED IN THE DGA9?

Healthy lifestyle choices focus on both nutrition and physical activity. Thus, physical activity is included within the DGA9. Specifically, the importance of daily physical activity for children and adolescents is described: at least 3 hours of a variety of activity for preschool-aged children and at least 60 minutes of moderate to vigorous activity for school-aged youth (3). Similarly, benefits of regular physical activity for adults are highlighted: moving more while sitting less, attaining at least 150 to 300 minutes per week of moderate intensity aerobic activity, and engaging in muscle strengthening activity on at least 2 days/week (3). Physical activity recommendations during pregnancy and postpartum as well as for older adults also are highlighted (3). Given the DGA is focused on dietary aspects, the reader is directed to the Physical Activity Guidelines for Americans, along with the consumer resources of “Move Your Way” (see https://health.gov/our-work/physical-activity) available from the U.S. Department of Health and Human Services for more detailed information on physical activity recommendations (7).

Beyond the summary information on physical activity guidelines for various groups, the DGA9 (Appendix 2, see pages 140-141 in the DGA9 document, https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf) also includes tables with estimated daily caloric needs for males and females from ages 2 to 76 years and above based on activity level (3). The activity levels include sedentary (“includes only the physical activity of independent living”); moderately active (“includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 mph, in addition to the activities of independent living”); and active (“includes physical activity equivalent to walking more than 3 miles per day at 3 to 4 mph, in addition to the activities of independent living”) (3). An understanding of these activity definitions is needed to avoid misinterpretation. For those engaging in more activity than reflected in the “active” category, caloric requirements may be greater, or much greater for those engaging in high levels of training. This can create a challenge to consume sufficient calories for bodily function as well as high levels of activity/exercise. For more background, see this Wouldn’t You Like to Know article focused on caloric requirements for those with higher activity levels (8).

WHAT CONSUMER FOCUSED RESOURCES ARE AVAILABLE?

The DGA is developed for professionals rather than the consumer audience (3). As noted in the introductory message from the U.S. Department of Agriculture and U.S. Department of Health and Human Services Secretaries, “With the release of the Dietary Guidelines for Americans, 2020–2025, we have an important call to action for you as health professionals and policymakers. We are asking you to help the public ‘make every bite count with the Dietary Guidelines for Americans.’ Help people make food and beverage choices that are rich in nutrition — individual choices that can become a healthy routine over time, choices they can enjoy in good health for many years to come” (3). The call to action “making every bite count” is built within the DGA9 (see Figure 3) (5).

Figure 3
Figure 3:
Make every bite count with the Dietary Guidelines (graphic from: https://www.dietaryguidelines.gov/resources/downloadable-graphics#infographics).

Translation of the content is an important aspect to make the DGA actionable for the public. According to the 2021 Food and Health Survey, more Americans are familiar with the DGA than in the past (9). In 2021, 46% indicated knowing “at least a fair amount” compared with 2010 when only 23% expressed this level of knowledge (9). Of those who knew about the DGA, 57% indicate this knowledge helps them make smarter food choices and 55% find help in understanding food group intake targets (9). Although this is an encouraging trend, there are still many individuals who remain unaware of the guidance provided. Materials are available to help spread the message.

The “Start Simple with MyPlate Today” handout (found at https://www.dietaryguidelines.gov/sites/default/files/2021-03/DGA_2020-2025_StartSimple_withMyPlate_English_color.pdf) is a consumer brochure that summarizes the DGA9 in an action-oriented fashion (5). The “MyPlate” web site is a comprehensive resource (https://www.myplate.gov/), including the opportunity to personalize the DGA with the “MyPlate Plan” (10). Other MyPlate resources include videos, downloadable graphics (see example in Figure 4), and infographics (see example in Figure 5 that includes cues to be active as well as focusing on dietary choices) (10).

Figure 4
Figure 4:
MyPlate graphic (graphic from: https://myplate-prod.azureedge.net/sites/default/files/2020-12/myplate_white_0.jpg).
Figure 5
Figure 5:
Example of infographic (graphic from: https://myplate-prod.azureedge.net/sites/default/files/2020-12/Resolutions%20Into%20Solutions%20%282016%29.pdf).

Professional toolkits are available on the MyPlate web site along with information on “Start Simple with MyPlate” app and much more (10). Note that this resource web page for professionals is divided into sections for various groups, including registered dietitian nutritionists, communicators, and educators.

As a note of caution, fitness professionals must be aware of their scope of practice regarding nutrition and dietary matters. Within the American College of Sports Medicine Job Task Analysis for the Certified Personal Trainer, one of the job tasks identified is to educate clients using scientifically sound resources. This task specifically lists “knowledge of Dietary Guidelines for Americans” as a requirement for Personal Trainers (11). Another job task in the area of legal and professional responsibilities for Certified Personal Trainers includes “Collaborate with health care providers and organizations to create a network of providers who can assist in maximizing the benefits and minimizing the risk of an exercise program,” and this includes knowledge of the scope of practice for Certified Personal Trainers and identification of individuals requiring referral — one of the examples for referral is dietary counseling (11).

Excellent insights on the topic of scope of practice are provided in “Drawing the Line: Understanding the Scope of Practice Among Registered Dietitian Nutritionists and Exercise Professionals” (12). As noted in this ACSM blog, “Exercise professionals do not provide ‘individualized nutritional advice’ but only ‘general, non-medical nutrition education’ to clients. An exercise professional can use nutrition information and guidelines published by governmental organizations such as the United States Department of Agriculture (USDA). They also may reinforce individual recommendations provided by an RDN/CSSD [Registered Dietitian Nutritionist/Certified Specialist in Sports Dietetics]” (13). Thus, knowledge of the DGA is key for fitness professionals, while remaining within one’s appropriate scope of practice when working with individual clients/patients and referring as required for individualized nutritional guidance.

CONCLUSION

The DGA9 focuses on overall patterns of eating, the combination of foods and beverages consumed over time. Making healthy choices, focused on nutrient-dense foods and beverages, within caloric limits is encouraged throughout the life span. DGA9 is directed toward policy makers and nutrition and health professionals; consumer-oriented materials and resources are promoted with MyPlate. MyPlate is one way the DGA9 is translated into action to assist individuals with making healthy dietary choices. Fitness professionals can benefit from an understanding of the DGA9 and the resources and tools available from MyPlate, while remaining aware of appropriate scope of practice.

References

1. U.S. Department of Agriculture and U.S. Department of Health and Human Services Web site [Internet]. Evolution of the Dietary Guidelines for Americans Process and Products: 1980 to Present. Alexandria (VA): USDA; [cited 2021 May 11]. Available from: https://www.dietaryguidelines.gov/media/799.
2. U.S. Department of Agriculture and U.S. Department of Health and Human Services Web site [Internet]. History of the Dietary Guidelines. Alexandria (VA): USDA; [cited 2021 May 11]. Available from: https://www.dietaryguidelines.gov/about-dietary-guidelines/history-dietary-guidelines.
3. U.S. Department of Agriculture and U.S. Department of Health and Human Services Web site [Internet]. Dietary Guidelines for Americans, 2020–2025. 9th ed. Alexandria (VA): USDA; December 2020; [cited 2021 May 11]. Available from: DietaryGuidelines.gov.
4. U.S. Food and Nutrition Service Web site [Internet]. Health Eating Index. Alexandria (VA): USDA FNS; 2020 July 21; [cited 2021 May 25]. Available from: https://www.fns.usda.gov/healthy-eating-index-hei.
5. U.S. Department of Agriculture and U.S. Department of Health and Human Services Web site [Internet]. Resources. Alexandria (VA): USDA; [cited 2021 June 10]. Available from: https://www.dietaryguidelines.gov/resources.
6. U.S. Food and Drug Administration Web site [Internet]. What’s New with the Nutrition Facts Label? Silver Spring (MD): FDA; [cited 2021 June 10]. Available from: https://www.fda.gov/food/new-nutrition-facts-label/whats-new-nutrition-facts-label.
7. U.S. Department of Health and Human Services [Internet]. Physical Activity Guidelines for Americans. 2nd ed. Washington (DC): U.S. Department of Health and Human Services; 2018. [cited 2021 June 10]. Available from: https://health.gov/our-work/physical-activity/current-guidelines.
8. Bushman BA. Caloric requirements for young competitive female athletes. ACSMs Health Fit J. 2012;16(5):4–8. Available from: https://journals.lww.com/acsm-healthfitness/Fulltext/2012/09000/Calorie_Requirements_for_Young_Competitive_Female.4.aspx.
9. International Food Information Council [Internet]. Food and Health Survey 2021. Washington (DC): International Food Information Council; 2021 May 19; [cited 2021 June 8]. Available from: https://foodinsight.org/wp-content/uploads/2021/05/IFIC-2021-Food-and-Health-Survey.May-2021-1.pdf.
10. U.S. Department of Agriculture Web site [Internet]. MyPlate. Alexandria (VA): USDA; [cited 2021 June 10]. Available from: https://www.myplate.gov/.
11. American College of Sports Medicine Web site [Internet]. Exam Content Outlines. Indianapolis (IN): ACSM; [cited 2021 June 10]. Available from: https://www.acsm.org/get-stay-certified/get-certified/prepare-for-exams/exam-content-outlines.
12. Kruskall LJ, Manore MM, Eickhoff-Shemek JM, Ehrman JK. Drawing the line: understanding the scope of practice among registered dietitian nutritionists and exercise professionals. ACSMs Health Fit J. 2017;21(1):23–32. Available from: https://journals.lww.com/acsm-healthfitness/fulltext/2017/01000/drawing_the_line__understanding_the_scope_of.8.aspx.
13. Kruskall LJ. Nutrition and the Exercise Professional’s Scope of Practice. Indianapolis (IN): ACSM; 2019 Sept 9; [cited 2021 June 10] Available from: https://www.acsm.org/blog-detail/acsm-certified-blog/2019/09/09/nutrition-scope-of-practice.
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