Dietary Guidelines for Americans: Broadening the Evidence Base, Applicability, and Implementation to Advance Public Health

Abstract

By law, the National Nutrition Monitoring and Related Research Act of 1990 directs the publishing of the Dietary Guidelines for Americans (DGAs) by the federal government every 5 years. Since the 1985 edition, the Department of Agriculture (USDA) and the Department of Health and Human Services (DHHS) have jointly appointed a committee of nationally recognized experts (the Dietary Guidelines Advisory Committee) to write a scientific report to help inform the federal government on the body of evidence related to diet, nutrition, and health. Many federal agencies, including those of the DHHS (e.g., the National Institutes of Health, the Centers for Disease Control and Prevention) and the USDA (e.g., the Food and Nutrition Service, the Agricultural Research Service), are instrumental for the DGAs. These agencies establish nutrition standards based on the DGAs and fund programs and research to implement the guidelines. The impact of the DGAs is far reaching since they provide the scientific foundation for public health nutrition. This policy statement calls for establishing an adequate nutrition research base to support the regular DGA updates and to ensure that the DGA development process is transparent, includes multiple stakeholders, and justifies the final decisions made. It also provides recommendations for implementation of the guidelines through effective education, standards, communication, policies, and system and environmental changes and through approaches that recognize and accommodate a range of specific individual characteristics (e.g., socioeconomic circumstances, lifestyle, literacy level).

Relationship to Existing APHA Policy Statements

This policy statement replaces the following archived APHA policy statements:

• APHA Policy Statement 92-2: The Prevention of Diet-Related Chronic Diseases
• APHA Policy Statement 8127: Dietary Guidelines for Americans
• APHA Policy Statement 7919: Revision of the National Food Guide and Preparation of National Dietary Guidelines

In addition, if complements the following existing policy statements:

• APHA Policy Statement 20144: Strengthening the Evidence Base for Inclusion of Children Less Than 2 Years of Age in the Dietary Guidelines for Americans
• APHA Policy Statement 200712: Toward a Healthy Sustainable Food System
• APHA Policy Statement 20171: Supporting Research and Evidence-Based Public Health Practice in State and Local Health Agencies

Problem Statement

First published jointly by the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (DHHS) in 1980, the Dietary Guidelines for Americans (DGAs) continue to be the cornerstone of federal nutrition policy and nutrition education activities, providing food-based recommendations to promote health, prevent diet-related disease, and meet nutrient needs.[1–5] The DGAs provide evidence-based information that professionals, public health agencies, nonprofit organizations, and industry use as the basis for nutrition education messages and consumer materials aimed at both the general public and special audiences.[6]

Optimal development and implementation of the DGAs require adequate investments in research and evaluations that provide a solid evidence base and guarantee transparency and input from multiple stakeholders throughout the development process. The process must also support effective public and private communications and policy, system, and environmental modifications based on the guidelines. Implementation of the DGAs should also safeguard the needs of individuals across the life span according to socioeconomic circumstances, lifestyles, cultural differences, literacy levels, and existing chronic disease conditions. With respect to advancing scientifically sound, community-based dietary guidelines, four specific issues arise that require public health strategies and actions: research, transparency, communication/implementation, and cultural appropriateness.

Research: Nutrition research and evaluations of public health programs and practices often fail to provide sufficient and relevant evidence in terms of regular DGA updates, including the feasibility, costs, and benefits of environmentally sustainable diets as well as best policies and environmental and system changes that promote the guidelines. Additional research is needed to determine the most effective approaches to adapt the DGAs with respect to specific characteristics (e.g., socioeconomic status, lifestyle, cultural differences). An ongoing investment in biochemical and epidemiological research is essential to provide the foundation for the DGAs.

The overall diets of Americans are associated with burdensome and costly health outcomes. Current diet quality among Americans is shown in the total Healthy Eating Index score (based on the DGAs) of 59 (out of 100) for the country as a whole. Children 6 to 17 years of age have the lowest score (53).[7] A comparison of food and dietary intakes in 2003–2004 with those in 2015–2016[8] shows no improvement in fruit and vegetable intake, a slight increase in consumption of whole grains, and a decrease in consumption of refined grains. Most significant are the decreases in percentages of calories from saturated fat and added sugar across all ages. Each step closer to eating a diet that aligns with DGA recommendations can help reduce one’s risk of developing diet-related chronic diseases. Reductions of 100 kcal daily may eliminate approximately 71.2 million cases of overweight/obesity, saving $58 billion annually; long-term sodium intake reductions of 400 mg per day would reduce hypertension, saving $2.3 billion annually; and decreases of 5 g per day of saturated fat intake among those with elevated cholesterol would eliminate 3.9 million cases, saving $2 billion annually. [9]

Stronger research support [10] is a key factor in improving Americans’ diets. Stronger research commitments by local, state, and federal departments of health and agriculture are needed to understand the effects of social determinants, environmental modifications, policies, and behavior change strategies in promoting or inhibiting adoption of DGA recommendations. In addition, community-based nutrition research is required to measure the effectiveness of public health programs that implement the DGAs for all Americans, especially those at risk for poor health outcomes due to social determinants of health. Amassing systematic reviews of this research is also needed. In recent decades, private foundations, academic institutions, and some local, state, and federal government agencies have made significant contributions to research on public health practices that address obesity and chronic disease;[11] since 2011, however, federal nutrition research funds (considered discretionary funding) have declined along with the discretionary budget overall.[12]

As an example, the president’s 2019 budget reduced funds for activities of the Centers for Disease Control and Prevention (CDC) focused on chronic disease prevention and health promotion.[13] Nevertheless, programs have been initiated that might result in healthier diets with consequential decreases in health risks and associated costs. In 2017, for instance, the USDA’s National Institute of Food and Agriculture (NIFA) funded research investigating the potential health benefits derived from increased fruit and vegetable consumption.[14] However, the USDA’s decision to relocate NIFA has reduced the workforce and funding.[15] Despite budget pressure, the CDC has supported research to explore the benefits of consuming nutrient-dense, environmentally sustainable diets (defined as diets with low environmental impacts that contribute to food and nutrition security and to healthy lives for present and future generations) and to engage communities in healthy activities that help manage chronic disease and obesity.[16]

The DGAs must recognize the critical interdependencies among food production, food processing, food consumption, environmental sustainability, and long-term food security. According to the Dietary Guidelines Advisory Committee (DGAC), there is moderate evidence that, in general, “a dietary pattern that is higher in plant-based foods, such as vegetables, fruits, whole grains, legumes, nuts, and seeds, and lower in animal-based foods, such as beef, pork, chicken, dairy, and seafood, is more health-promoting and is associated with less environmental impact (greenhouse gas emissions and energy, land, and water use) than is the current average U.S. diet. A diet that is more environmentally sustainable than the average U.S. diet can be achieved without excluding any food groups.”[17] As reflected in a 2015 DGAC report, the database of scientifically sound and objective research evidence is “rapidly evolving.”[18–21] Further research on how to make sustainability-related dietary guidance more affordable and culturally diverse is important, and global nutrition and health groups should continue to advocate for adding sustainability to the DGA recommendations and implementation.

Transparency: Concerns about transparency, potential bias, and limited stakeholder engagement in the DGA development process led Congress to engage the National Academies of Sciences, Engineering, and Medicine (NASEM) and a panel of individuals with balanced representation and broad experiences and viewpoints in reviewing and making recommendations about the process.[22] Nongovernmental nutrition and health groups will need to closely monitor the implementation of new procedures, as suggested by NASEM and other groups, to limit potential bias and maximize the transparency and engagement of multiple stakeholders.

Communication/implementation: Consumer-facing communication and education regarding the DGA recommendations often fail to adequately translate the guidelines into individual behavior and policy changes. The USDA generally does not communicate DGA recommendations simply, practically, through all appropriate channels, and with suitable compelling messages for underserved communities and those of differing cultures within the United States.[23] Specific educational materials related to policy, system, and environmental changes are needed for tailoring the DGAs into practical guidance appropriate for individuals with varying characteristics and backgrounds.[5,24]

Cultural appropriateness: The public is more likely to adhere to the DGAs when their implementation adequately considers the needs of ethnically diverse groups[25] and limitations associated with socioeconomic circumstances, lifestyles, literacy levels, age, and disabilities in the populations most likely to experience chronic diseases related to poor dietary and physical activity habits.[26] Often, minority populations and those with the highest disease burden are unable to prepare healthy meals because they do not have access to affordable, healthy food or culturally appropriate nutrition education.[27–29] Federal nutrition assistance, such as that provided by the Supplemental Nutrition Assistance Program and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), is often inadequate for recipients to purchase food that meets the DGAs.

The prevalence of overweight and obesity, diabetes, hypertension, untreated dental decay, and premature death is disproportionately high in African American, Hispanic/Latino, and lower-income populations,[30,31] reflecting the impact of social determinants of health. For example, according to the CDC, individuals living below 100% of the poverty line have more than twice the prevalence of diabetes as those living above 400% of the poverty line. In addition, the prevalence of hypertension is 40% among non-Hispanic Blacks, as compared with 28% among non-Hispanic Whites. Black and Hispanic subgroups and those with lower incomes have more untreated dental decay and an increased severity of dental disease. [31]

In all age groups, a relationship exists between the amount of dietary sugar ingested and the development of dental caries.[3] Poor diets facilitate the onset of dental caries, and the eating difficulties that often follow poor oral health may lead to both nutrient deficits and poor overall health.[32] The Academy of Nutrition and Dietetics considers nutrition an “integral part of oral health” and “supports collaboration and integration of oral health with nutrition services, education, and research.”[33] Partnerships could be established to address access to low-sugar foods and drinks in WIC programs, promote consumption of fluoridated water, establish consistent oral health messaging on nutrition guidelines, and support the behavior modifications necessary for both healthy eating and oral health.

Evidence-Based Strategies to Address the Problem

The DGAs are the basis for public health programs and policies at the local, state, and federal levels and must be easy to adopt by the broad nationwide constituency. Public health researchers, program administrators/implementers, and advocates will need to ensure that the foundations of the DGAs are science based by monitoring the development process to minimize bias and conflicts of interest and maximize transparency and public engagement. The DGAs must be implemented into policies, environmental opportunities, and effective communications that change behaviors and the social determinants that impede Americans from full adoption of the DGA dietary patterns.

Research: A robust scientific process of developing and updating the DGAs every 5 years requires well-funded biochemical, epidemiological, and public health nutrition research related to food and dietary patterns that prevent or manage overweight, obesity, and other highly prevalent chronic diseases. The DGA recommendations need to be based on rigorous and objective scientific standards for data and analyses. In addition, they must integrate the most recent biochemical and health-related data in a systematic and consistent manner that helps classify nutrients of public health concern.[6] To ensure the most valid and scientifically sound guidelines, the processes and methodologies used to review the preponderance of science must also follow the latest scientific standards, be rigorous and reproducible, provide solid documentation, and maintain the highest degree of integrity.

The National Nutrition Research Roadmap [10] provides a written strategic plan for public health professionals and groups to identify critical human nutrition research gaps and opportunities and to stimulate support to fill gaps and accelerate innovations. This plan identifies a broad group of federal agencies, including the CDC, the Agency for Healthcare Research and Quality, the National Institutes of Health, the Agricultural Research Service, NIFA, and the Economic Research Service, that provide critical scientific evidence for the development and implementation of the DGAs.

The Economic Research Service [34] provides evidence on the impact of food assistance programs on health and on effective approaches to prevent and reduce obesity. It has recently determined the health impact of addition of whole grains to the WIC food package. Two CDC projects illustrate how effective community-based research has contributed valuable diet surveillance and interventions that will help shape DGA recommendations affecting childhood obesity. The Massachusetts Childhood Obesity Research Demonstration (CORD) targeting low-income children using behavioral and environmental intervention strategies has improved body mass index scores,[35] and Texas CORD community- and clinic-based interventions using education and behavior management have shown positive modifications of dietary behaviors among low-income children.[36]

Transparency: Public engagement and clarity in decision making are a strategy to support and monitor the USDA and DHHS revised process for developing the DGAs, which is intended to minimize bias and conflicts of interest and maximize transparency and public engagement. The USDA and DHHS have proposed a policy [37] that supports developing a robust scientific evidence base for updating the DGAs and implementing a transparent and deliberative DGA development process that engages the public and manages sources of bias and conflicts of interest to ensure that the process meets the intended goals.

Investigators in genomics research have described the benefits of expanding transparency and engagement of multiple stakeholders in formulating sound and trusted health policies.[38] However, some researchers have noted the prerequisite to find the best methods and timing for obtaining and integrating informed stakeholder voices into the policy-making process.[39] Public health professionals from government agencies and nongovernmental organizations will need to be engaged and monitor closely whether the process meets the intended goals of transparency, public engagement, and minimal bias in developing the DGAs and ensuring a rigorous, unbiased scientific base of support for future DGAC work.

Communication/implementation: A third pillar is for public health professionals to ensure that all future DGA publications are accompanied by enhanced implementation strategies and tools for food and nutrition programs, food systems, policies, and practices. The DGAs have been an important tool in informing such policy, system, and environmental approaches as increasing access to supermarkets,[40] implementing DGA-based nutrition interventions for young children,[41] restricting snacks sold in schools,[42] and offering bonus-value produce coupons for low-income consumers.[43] For public health practitioners, the guidelines have provided recommendations for public education and behavior change based on dietary patterns and MyPlate food guidance.[44] Research has shown that DGA-based changes in nutritional standards for WIC food packages have reduced obesity among young children.[45] CDC-funded interventions and community programs designed to motivate Americans to be active and select healthy foods and beverages have resulted in healthier snacks and meals served at preschools, schools, worksites, parks, and faith-based organizations, among other successes.[46]

Cultural appropriateness: Lastly, the public health community has begun to make the DGAs more culturally appropriate [47,48] and feasible for the diverse U.S. population. DGA recommendations should urge adoption of behaviors that are affordable, accessible, and realistic for families[49] and suggest improvements to social determinants of food choices.[50] As described by others, the process of tailoring health promotion and dietary recommendations to cultural groups is complex.[51] However, there are a variety of models for developing community-based and culturally appropriate nutrition recommendations and interventions that the DGAs and public health practitioners can draw upon in making relevant recommendations.[52,53]

Opposing Arguments

One opposing argument is that despite the existence of the DGAs for almost 40 years, the prevalence of overweight and obesity in the United States has grown. So why continue issuing the DGAs?

Obesity in America results from a constellation of factors,[54] but research shows that lower adherence to the DGAs, as measured by lower Healthy Eating Index scores, is associated with overweight and obesity.[55] Research indicates that dietary consumption patterns that follow the Healthy Eating Index are associated with a lower risk for abdominal obesity (e.g., a one-point increase in fruit intake is associated with a decrease in abdominal obesity of 2.6%).[56] Growing health care costs and the recent increases in the number of Americans without health insurance[57] argue for increased investments in evaluation and replication of DGA-based programs and policies that help Americans follow the guidelines. There is some emerging evidence that dietary changes are taking place, particularly in childhood nutrition programs.[45]

A second argument is that, based on the poor health status of many Americans, the scientific basis for the DGAs is flawed and newer research on high-protein, high-fat, and low-carbohydrate diets that lead to weight control and blood sugar reductions should be used.

Diet quality has declined over the past 20 years because Americans have not followed the DGAs; specifically, they have consumed a larger number of calories, have consumed larger proportions of calories from fats and sugars, and have not significantly increased their fruit and vegetable consumption.[58] Progress in nutrition research, as with all scientific endeavors, is an iterative process that continues to question existing truths and to revise dietary advice based on new findings gained through scientific methodology. For example, sound scientific research led to the 2010 update of previous DGA advice to lower total fat, instead advising lowering saturated fat and substituting polyunsaturated fat.[59] The 2015 DGAs dropped the recommendation to lower intake of dietary cholesterol based on recommendations of the American College of Cardiology and the American Heart Association. The DGAs reflect the preponderance of new scientific consensus gathered through public comments, gold standard reviews by the Nutrition Evidence Systematic Review team, and expert input. In addition, the process of making changes to address a multigenerational problem such as obesity is not rapid. Increasing use of system- and policy-level interventions, along with development of better interventions, holds promise to better manage body weight.[60,61]

A final argument is that ample nutrition information exists, and guidelines should be based simply on common sense for most Americans.

The value of the USDA/DHHS guidelines is the scientific standard of evidence on which they are grounded and the positive health outcomes and lowered medical costs associated with DGA-based dietary patterns. For most Americans, dietary intakes have led to an increased prevalence of obesity, type 2 diabetes, cardiovascular disease, hypertension, and other chronic diseases; however, scientific research shows that dietary patterns based on the evidence-based DGAs have led to significant reductions in the risk of all-cause mortality, cardiovascular disease, cancer, and type 2 diabetes (reductions of 22%, 22%, 15%, and 22%, respectively).[62] Lowering the prevalence of chronic diseases through diets lower in calories, sodium, and saturated fat has the potential for reductions in medical and health costs.[9,63]

Action Steps

APHA proposes the following action steps:

• Research: Public health agencies at the local, state, and federal levels should collaborate with academic institutions, foundations, and voluntary health organizations to invest in robust scientific research, data collection, and evaluations that provide evidence for regular updates of the DGAs. Research must address current public health contexts and chronic diseases in diverse populations; include community-based interventions; examine the effectiveness of policy, system, and environmental interventions using the DGAs; and explore underlying socioecological factors limiting acceptance and use of DGA messages.
• Transparency: Public health and nutrition professionals and organizations should closely monitor the DGA development process to ensure scientific rigor, eliminate potential bias, enhance stakeholder engagement, explain ongoing decision making, and provide for continuity of focus in key operational and strategic areas over multiple DGA cycles.
• Communication/implementation: Voluntary health organizations, local and state governments, public health nutrition organizations and professionals, and the private sector should implement DGA-based public education, nutrition standards, and approaches for policies, systems, and the environment that reflect the needs of diverse populations and inform individual eating habits, institutional food services, nutrition labeling, worksite food vendors, and other food-related practices.
• Cultural appropriateness: Federal, state, and private research organizations should conduct quality research and gather evidence to ensure that the DGAs are culturally appropriate and feasible with respect to all socioeconomic circumstances, lifestyles, literacy levels, and existing chronic disease conditions. Previous DGAs have generally focused on one dietary pattern; however, there is now a need for the guidelines to encompass broadened dietary patterns and incorporate the requirements of our diverse population. Strategies addressing the food access challenges and higher chronic disease levels of low-income groups the special requirements of disabled Americans, as well as strategies targeting specific cultural and literacy groups, are needed to reach desired health outcomes.

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