ABCs of Dietary Guidelines 2000 for Clinicians

Johanna Dwyer, DSc, RD j Alice H. Lichtenstein, DSc

School of Nutrition Science and Policy and Jean Mayer USDA Human Nutrition Research
Center on Aging at Tufts University, Boston, Massachusetts

j ABSTRACT gins in the 1970s, when it had become increasingly

The Dietary Guidelines for Americans are the ABCs for apparent that nutritional advice that focused simply
good health. They urge that all Americans Aim for fit- on getting enough food to eat was not sufficient to
ness, Build a healthy base, and Choose sensibly. Action
make Americans healthy. Too much food, as well as
steps include the following: Aim for fitness: Aim for a
healthy weight. Be physically active everyday. Build a imbalances between the types and amounts of food
healthy base: Let the food pyramid guide your food and the nutrients they contained, was creating
choices. Choose a variety of grains daily, especially health problems, including increased risks of several
whole grains. Choose a variety of fruits and vegetables diet-related chronic, degenerative diseases. Pressure
daily. Keep food safe to eat. Choose sensibly: Choose mounted for more authoritative advice on healthy
a diet that is low in saturated fat and cholesterol and
moderate in total fat. Choose beverages and foods to
eating that dealt with these issues.
moderate your intake of sugars. Choose and prepare By this time, Congress and many leading health
foods with less salt. If you drink alcoholic beverages, do experts had become increasingly convinced that
so in moderation. Nutr Clin Care. 2000;3:359–370 j national planning required closer synchronization
between agricultural and health policies involving
KEY WORDS: dietary guidelines, nutrition policy
nutrition, especially in those areas involving risks
The Dietary Guidelines for Americans, 20001 repre- for chronic degenerative diseases linked to diet. It
sent the best current thinking about what Ameri- was also noted that authoritative and comprehen-
cans should eat to stay healthy. This article reviews sive dietary guidance to reduce risks of chronic, de-
why these guidelines exist, how they are formu- generative diseases was not available. These con-
lated, and the rationale for this latest revision. We cerns gave rise to a document addressing both issues,
then note some key changes that will affect your entitled Dietary Goals for the United States, which
patients, as well as practical steps you can take in emerged from hearings of the Senate Select Commit-
everyday practice to help your patients lead fuller, tee on Nutrition and Human Needs held in the mid
healthier lives through good nutrition. 1970s. This was a start, but it was evident that a
more careful review of the scientific evidence was
needed before national nutrition goals or guide-
WHY DIETARY GUIDELINES EXIST lines for individuals could be formulated in a sound
The most recent dietary guidelines can best be un- manner.
derstood within the context of their history. It be-
Reprint requests to Johanna Dwyer, DSc, RD, New England Medical
HOW THE GUIDELINES WERE DEVELOPED
Center, Box 783, 750 Washington Street, Boston, MA 02111. E-mail:
[email protected] During the Carter administration, the Department
of Health, Education and Welfare built on these
© 2000 Tufts University, 1096-6781/00/$15.00/0 Nutrition in Clinical Care,
early efforts by convening a working group to re-
Volume 3, Number 6, 2000 359–370 view evidence for associations between certain nu-
360 j DWYER AND LICHTENSTEIN Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6

trients and chronic degenerative disease risks. These updated report that would provide evidence-based
findings were published in the peer-reviewed litera- recommendations for any proposed revisions.
ture. Later on, the Secretaries of Health, Education The draft report, which consisted of suggestions
and Welfare and the US Department of Agriculture, for revision of the consumer guidance booklet and
the cabinet departments with the most direct re- documentation of the rationale for each change, was
sponsibilities in the area of nutrition, appointed an submitted for consideration to the 2 cabinet secretar-
expert committee. The committee was asked to ies (Agriculture and Health and Human Services) in
use the findings of the conference to craft a docu- December of 1999 and posted in the Federal Regis-
ment consumers could use for modifying their indi- ter for public comment. The comments were re-
vidual diets. The document also was envisioned as viewed and the document revised as deemed neces-
being potentially useful to policymakers as a guide sary by the cabinet secretaries. The final document
for planning nutrition policy. The first set of dietary was issued at the National Nutrition Summit held in
guidelines was issued in 1980. By federal mandate, Washington, DC, in May 2000. The Dietary Guide-
these guidelines are revised every 5 years to keep lines are now being disseminated to the public and
the recommendations in step with current science. to government decision makers. The process of har-
In 1998, the Secretaries of Agriculture and Health monizing the report with other federally-issued food
and Human Services appointed an Advisory Commit- guidance material, such as the Nutrient Label and
tee to review the 1995 Dietary Guidelines for Ameri- the Food Guide Pyramid, has begun.
cans, to determine if a revision was needed and, if
so, to provide recommendations for possible revi-
sions. The Dietary Guidelines Advisory Committee
THE YEAR 2000 DIETARY GUIDELINES
consisted of American biomedical scientists with
special expertise in nutrition (Table 1). Table 2 allows a comparison of the 2000 guide-
After a review of the data, the Advisory Commit- lines—the latest step in this evolutionary process—
tee determined that the 1995 report did need revi- with those of previous years. As the science has
sion. The process included an exhaustive literature changed over the past two decades, the substance
review and 4 public meetings to hear testimony, of the guidelines has changed considerably. Their
gather evidence, and discuss recent research find- tone has also changed; the current guidelines have
ings. A public comment period was open during fewer “don’ts” and more “do’s” than their forebears.
the entire review process. Consumer focus groups The fundamental message of the 2000 guidelines
were commissioned to determine how members of is that eating well and regular exercise are essential
the general public interpreted the current (1995) for maintaining good health—and that doing so can
guidelines. The committee then set about to inte- be enjoyable. These messages are summarized in
grate all the accumulated material to develop an the guidelines’ “ABCs for good health”—Aim for fit-

Table 1. Dietary Guidelines 2000 Advisory Committe

Chair Cutberto Garza, MD, PhD, Cornell University, Ithaca, New York
Vice Chair Suzanne Murphy, PhD, RD, University of Hawaii, Honolulu, Hawaii
Members • Richard Deckelbaum, MD, College of Physicians and Surgeons of Columbia University, New York, New York
• Johanna Dwyer, DSc, RD, Tufts University and New England Medical Center, Boston, Massachusetts
• Scott Grundy, MD, PhD, The University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
• Rachel Johnson, PhD, MPH, RD, The University of Vermont, Burlington, Vermont
• Shiriki Kumanyika, PhD, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
• Alice H. Lichtenstein, DSc, Tufts University, Boston, Massachusetts
• Meir Stampfer, MD, DrPH, Harvard University, Boston, Massachusetts
• Lesley Fels Tinker, PhD, RD, Fred Hutchinson Cancer Research Center, Seattle, Washington
• Roland Weinsier, MD, DrPH, University of Alabama at Birmingham, Birmingham, Alabama
 Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6
Table 2. Changes in the Dietary Guidelines for Americans, 1980–2000
Topic 1980 1985 1990 1995* 2000*

Food selection Eat a variety of foods Eat a variety of foods Eat a variety of foods Eat a variety of foods Let the Food Pyramid guide
your food choices
Food Safety Keep foods safe to eat
Weight Maintain ideal weight Maintain desirable weight Maintain healthy weight Balance the food you Aim for a healthy weight
eat with physical
activity; maintain or
improve your weight
Physical Activity [see above] Be physically active daily
Fat Avoid consuming Avoid consuming too Choose a diet low in fat, Choose a diet low in fat, Choose a diet low in fat,
too much fat, much fat, saturated fat, saturated fat, and saturated fat, and saturated fat, and
saturated fat, and cholesterol cholesterol cholesterol cholesterol, and
and cholesterol moderate in total fat
Grains, fiber Eat foods with Eat foods with adequate Choose a diet with plenty Choose a diet with plenty Choose a variety of grain
adequate starch and fiber of vegetables, fruits, of grain products, fruits, products daily, especially
starch and fiber and grain products and vegetables whole grains
Fruits and vegetables [see above] [see above] Choose a variety of fruits
and vegetables daily

Dietary Guidelines for Clinicians

Sugar Avoid consuming Avoid consuming too Use sugars only in Choose a diet moderate Choose beverages and
too much sugar much sugar moderation in sugars foods to limit moderate
your intake of sugars
Sodium/salt Avoid consuming Avoid consuming too Use salt and sodium Choose a diet moderate Choose and prepare
too much sodium much sodium only in moderation in salt and sodium foods with less salt
Alcohol If you drink alcohol, If you drink alcoholic If you drink alcoholic If you drink alcoholic If you drink alcoholic
do so in beverages, do so beverages, do so beverages, do so beverages, do so
moderation in moderation in moderation in moderation in moderation

*Not in prioritized order.

Source: International Food Information Council.

j 361
362 j DWYER AND LICHTENSTEIN Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6

Figure 1. ABC’s for Good Health.

Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6 Dietary Guidelines for Clinicians j 363

ness, Build a healthy base, and Choose sensibly. vised to lose weight, especially if other risk factors
(Figure 1) or a high waist circumference are present; people
with BMIs under 25 but with high waist circumfer-
ences should be advised to watch their weights.
New in the 2000 guidelines is the goal for every
AIM FOR FITNESS
individual to achieve a healthy weight, not some
Aim for a Healthy Weight impossible-to-reach ideal. The healthy BMI range
applies to adults of all ages. Most patients have un-
Rationale
realistically low weight goals that may need modifi-
There is extensive evidence that excess weight is
cation. Remind patients that small losses, even as lit-
related to increased mortality risk. Overweight is
tle as 10 to 15 pounds, will make a big difference in
also associated with morbidity. These risks start to
health risks, and that even a small loss will improve
rise at more moderate degrees of overweight than
appearance and feelings of wellbeing. Encourage
were previously thought. Even the loss of modest
patients to pick an achievable weight goal they can
amounts of weight, 10 to 20 pounds, or about 10%
work toward achieving over the next 6 months.
to 20% of body weight, can have very striking health
For patients who don’t feel they can lose weight,
benefits. The evidence for clinical guidelines on treat-
the first goal should be to help them to stop gain-
ing obesity has been summarized recently and is con-
ing. Discuss a plan to help them avoid further gains.
sistent with these messages.2
Once weight gain has stopped, you can help them
lose weight gradually. Overweight people with eat-
ing disorders and children who are overweight
Key Points
need special attention.
Every patient needs to have his or her weight eval-
All overweight patients need suggestions to help
uated to determine if he or she is in the healthy
them get started. The Food Guide Pyramid is a good
range. Then he or she should strive to attain or
guide for building a healthy pattern of meals and
maintain a healthy weight.
snacks. Stress sensible portion sizes using the Food
Guide Pyramid portions as a starter—these portion
sizes are much smaller than most people typically
Steps to Take
eat. Remind your patients that high-fat, high-calorie
Calculate your patient’s BMI and measure waist cir-
foods and alcoholic beverages are easy to consume
cumference. Multiply weight in pounds by 705. Di-
in excess, so these need special attention. At the
vide by height in inches. Then divide by height in
same time, remind patients of the importance of
inches again to get the BMI. Be sure also to assess
reading labels: low-fat doesn’t always mean low in
other factors that increase disease risks with over-
calories. Finally, stress a physically active life-style
weight. These include a family or personal history
that involves moving the body at least 30 minutes a
of heart disease, middle age (males older than 45
day at moderate activity levels.
years or postmenopausal females), smoking, seden-
tary lifestyle, high blood pressure, abnormal blood
cholesterol (high LDL-cholesterol, low HDL-choles-
Be Physically Active Each Day
terol, and/or high triglycerides), and diabetes. The
presence of any of these additional factors increases Rationale
the urgency of managing weight or avoiding further A sedentary lifestyle increases risks of many chronic
gains. Weight gain (gain of 1 BMI unit or 5 to 10 diseases, even for individuals whose weights are at
pounds) is also a sign for action to manage weight. appropriate levels. Regular physical activity not only
Next, discuss a healthy weight goal that falls increases physical fitness but has positive effects on
within the healthy range for the patient. For non- bone health, endurance and muscle strength, well-
pregnant adults, this healthy range is a BMI from being, and helps control weight. A recent report of
18.5 to 25, with a waist circumference of no more the Surgeon General, entitled Physical Activity and
than 35 inches for women or 40 inches for men. In- Health, provides further support for the importance
dividuals with BMIs greater than 25 should be ad- of these measures.3
364 j DWYER AND LICHTENSTEIN Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6

Key Points physical activity diary for the week before his or
Adults should aim for 30 minutes of moderate phys- her next visit, and go over it together to develop
ical activity most days a week. There are even more further suggestions.
health benefits from increasing the amount of time A goal for progressing in a more physically ac-
spent in physical activity, particularly vigorous phys- tive life is to try to walk 2 miles in 30 minutes. Peo-
ical activity, strength and resistance training, and ple who are trying to lose weight or maintain weight
activities that increase flexibility. Physical activity loss may need even more physical activity than this.
should be a regular part of daily life for everyone, re- Patients can increase the health benefits of physical
gardless of age. activity by spending more time in vigorous physical
activities.
Steps to Take
Your highest priority should be patients who are
extremely sedentary, because such patients run very BUILD A HEALTHY BASE
high risks of health problems as a result of their ha-
Let the Pyramid Guide your Food Choices
bitual inactivity. People who walk less than 15 min-
utes a day are extremely sedentary. Many older peo- Rationale
ple are very inactive and individuals with chronic Provide the dietary context in which to assemble
diseases may feel that physical activity is unsafe for specific guidance on food-based recommendations.
them; they will need special help.
First, make sure the patient’s medical impediments Key Points
or related risks (eg, heart disease, diabetes, hyperten- Regardless of a patient’s specific eating pattern, a
sion, or obesity) are taken into account. Then discuss good way to provide general advice on construct-
why physical activity is important and suggest a safe ing a healthy eating plan is to start with the 3 groups
and workable physical-activity plan. For individuals of food at the base of the Food Guide Pyramid (Figure
who are very inactive, walking clubs or other struc- 2)—grains, fruits, and vegetables. Within this general
tured activities may be useful and even as little as 15 framework, people can make choices that will ac-
minutes a day of walking is a good start. commodate their cultural, religious, or personal pref-
Gradually increase the exercise recommendation erences. Eating upward from the bottom of the pyra-
once the patient becomes more active. Ask your pa- mid will provide a nutrient-dense foundation for an
tient to increase his or her daily physical activity by eating pattern that is moderate in saturated fat,
15 minutes; this might include a brisk walk, addi- cholesterol, salt, and sugars. In epidemiologic stud-
tional work involving moving objects, or sports such ies, dietary patterns high in grains, fruits, and vege-
as dancing, biking, or swimming. tables are associated with decreased incidence of
Urge patients who are already active to increase common chronic diseases.
or maintain their physical activity. Make sure they
include not only aerobic physical activity that speeds Steps to Take
the heart rate and breathing and contributes to car- Urge patients to consume foods from the different
diovascular fitness, but also strength building and categories within the Food Guide Pyramid. Empha-
flexibility. size a broad range of grain products, fruits, and veg-
Check to see if your patient is doing any strength etables.
or resistance training; if not, suggest some simple Remember that there are many different health-
steps such as lifting small weights. Discuss ways ful eating patterns. People who are unwilling, or un-
the patient can set a good example for spouses, sig- able, to consume foods from one of the food groups
nificant others, and children by being active. Most should be encouraged to choose alternatives. For ex-
patients find it easiest to choose structured physi- ample, if a patient does not, or cannot, consume milk
cal activities that fit into their daily routines. Sug- and milk products, he or she should choose alternate
gest low-cost, structured exercise programs avail- sources of dietary calcium (ie, soy-based beverages
able in your community for those who like group with added calcium, tofu made with calcium sulfate,
activities, or a sound self-help book for those who breakfast cereals with added calcium, canned fish
like to do things solo. Ask your patient to keep a with bones, fruit juice with added calcium, and dark-
Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6 Dietary Guidelines for Clinicians j 365

Figure 2. Food Guide Pyramid: a guide to daily

food choices.

green leafy vegetables). Guidance for such accom- years have especially high needs for calcium. How-
modations can be found in the Dietary Guidelines ever, dairy products and other sources of calcium
document. should be low fat or fat free to keep saturated fat
Explain that many individual foods can make intakes low. Additional and/or alternative sources
multiple contributions to helping patients reach of calcium should be encouraged (see above).
the recommended number of daily servings in a va- Other nutrients of concern to specific groups of
riety of food groups in the Food Guide Pyramid. individuals include iron in young children, teenage
For example, a chicken sandwich may include serv- girls, and women of childbearing age; folate in women
ings of bread, meat, and vegetables (eg, lettuce). of childbearing age; and vitamin D and B12 in older
Often, serving sizes for commonly consumed foods adults. Most of these needs can be met through diet.
are larger than that defined as a “serving size” within However, women who could become pregnant may
the Food Guide Pyramid. It is important to emphasize need folate supplements or folate-fortified foods. Simi-
that in order to stay in energy balance, your patients larly, older adults and people with little exposure to
need to moderate both number of servings and serv- sunlight may need supplementary vitamin D; people
ing size. Too much of anything, even “healthy” foods, who seldom eat dairy products or other rich sources
can result in weight gain. of calcium need calcium-fortified foods or supple-
Typical serving sizes, USDA Pyramid serving sizes, ments; and people who eat no animal foods or who
serving sizes as defined on food labels, and serving are over 50 years old, may require Vitamin B12 sup-
sizes of common foods served in restaurants are of- plements. However, nobody should depend on
ten different. For example, on the label, one serving supplements to meet basic nutritional needs. Stress
of pasta is defined as 1 cup. But on the Food Guide foods first.
Pyramid, one serving of pasta is defined as just 1/2
cup—far less than most people eat at a single meal.
Table 3 lists Food Guide Pyramid serving sizes for a Choose a Variety of Grains Daily, Especially
number of foods from each food group. Whole Grains
The consumer document has specific, practical Rationale
advice on food sources of nutrients that are fre- Grain products form the foundation of the diet, be-
quently low in the diet. Individuals in certain vul- cause they provide vitamins, minerals, carbohydrates
nerable groups should consult this advice. For ex- (starch and dietary fiber), and other substances that
ample, adolescents and adults over the age of 50 are important for good health.
366 j DWYER AND LICHTENSTEIN Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6

Table 3. What Counts As a Serving? grains because consumption of such products typi-
Bread, cereal, rice and pasta group cally is low, and increasing it may confer special
(grains group)—whole grain and refined health benefits. In additional to whole wheat, you can
1 slice of bread encourage consumption of a wide variety of whole-
About 1 cup of ready-to-eat cereal grain products, including brown rice, bulgur (cracked
1/2 cup of cooked cereal, rice, or pasta wheat), graham flour, oatmeal or whole oats, popcorn
Vegetable group or other whole corn products, pearl barley, and whole
1 cup of raw leafy vegetables rye. Ingredient labels on packaged foods can help pa-
1/2 cup of other vegetables—cooked or raw tients select products made with whole grains. Those
3/4 cup of vegetable juice that list whole wheat or whole grain first, or as the
Fruit group sole grain ingredient, are high in whole grains. The
1 medium apple, banana, orange, pear Nutrient Facts panel can help patients compare
1/2 cup of chopped, cooked, or canned fruit the relative amounts of fiber per serving of common
3/4 cup of fruit juice foods.
Milk, yogurt, and cheese group (milk group)*
1 cup of milk† or yogurt†
1 1/2 oz. of natural cheese† (such as Cheddar) Choose a Variety of Fruits and
†
2 oz. of processed cheese (such as American) Vegetables Daily
Meat, poultry, fish, dry beans, eggs, and Rationale
nuts group (meat and beans group)
A diet high in fruits and vegetables may protect
2–3 oz. of cooked lean meat, poultry, or fish
against chronic disease, promote healthy bowel func-
1/2 cup of cooked dry beans†† or 1/2 cup of tofu counts as
1 oz. of lean meat
tion, and provide essential vitamins and minerals, fi-
2 1/2 oz. soyburger or 1 egg counts as 1 oz. of lean meat
ber, and other substances that are important for good
2 tablespoons of peanut butter or 1/3 cup of nuts counts as
health.
1 oz. of meat
Key Points
Note: Many of the serving sizes given above are smaller than those on
the Nutrition Facts Label. For example, 1 serving of cooked cereal, rice,
Each category of fruits and vegetables is rich in dif-
or pasta is 1 cup for the Label but only 1/2 cup for the Pyramid. ferent nutrients, but none is rich in all nutrients.
*This includes lactose-free and lactose-reduced milk products. One
cup of soy-based beverage with added calcium is an option for those
For example, citrus fruits are a good source of vita-
who prefer a non-dairy source of calcium. min C, while winter squash is a good source of vita-
†
Choose fat-free or reduced-fat diary products most often.
††
min A (carotenoids). Therefore, it is best to eat a
Dry beans, peas, and lentils can be counted as servings in either the
meat and beans group or the vegetable group. As a vegetable, 1/2 range of fruits and vegetables.
cup of cooked, dry beans counts as 1 serving. As a meat substitute,
1 cup of cooked, dry beans counts as 1 serving (2 oz. of meat).
Source: Dietary Guidelines for Americans, 2000. Steps to Take
Fruits and vegetables aren’t good for you only when
fresh; fresh, frozen, dried, or canned fruits and veg-
Key Points etables, as well as juice, are healthful also. How-
Grain products tend to be low in fat, unless fat is ever, it is important to note that juice lacks the fi-
added during the processing. Therefore, they are ber normally present in the other forms of fruits
not calorie dense. Whole-grain products, as well as and vegetables and often is high in calories. When
fruits and vegetables, are especially rich in dietary buying prepared vegetable and fruit items, the Nu-
fiber and, possibly, in other protective substances. trient Facts panel and ingredient statement on food
Federal regulations ensure that refined-grain prod- labels can help patients determine whether the prod-
ucts are enriched with added thiamin, riboflavin, uct is high in added sugar, fat, or salt. Since many
niacin, and iron, and, more recently, fortified with Americans’ fruit and vegetable intakes are low, pa-
folic acid. tients should be encouraged to try new ways of eat-
ing these foods (eg, incorporated into food mixtures
Steps to Take such as meat loaf or soup, or as toppings on pizza).
Encourage the use of a variety of grain products, Tell patients to make it a habit to include fruits and
both whole grain and fortified. Emphasize whole vegetables with meals and to use them as snacks.
Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6 Dietary Guidelines for Clinicians j 367

The goal is at least 2 servings of fruit and 3 servings fish, and shellfish. They also should be especially care-
of vegetables per day. The more colorful fruits and ful when eating out to make sure that foods are thor-
vegetables frequently are the most nutrient dense, oughly cooked and served piping hot. All patients
and, thus, deserve special attention. need to remember to play it safe; if they have doubts
when shopping or eating out, they should choose
something else.
Keep Food Safe to Eat
Rationale
CHOOSE SENSIBLY
Food-borne disease is a major source of preventable
illness. Although food-safety problems often arise far- Choose a Diet that Is Low in Saturated Fat and
ther back in the food chain, recent evidence shows Cholesterol and Moderate in Total Fat
that food preparation and storage practices at home,
Rationale
as well as lack of precautions when eating out, also
Fats are important sources of energy and essential
contribute to risks of food-borne illness.
fatty acids. They are critical for the absorption of
fat-soluble vitamins (vitamins A [carotenoids], D, E
Key Points
and K). Saturated fat intake has been steadily declin-
People need to keep foods safe to eat at home and
ing in the US, but it is still higher than currently rec-
when eating out. Table 4 provides a home food-
ommended (,10% of energy from saturates, ,30%
safety checklist. Some people are at special risk,
of energy from all sources of fat). In some individu-
and they need to take extra precautions.
als, very low-fat diets (,20% of energy from fats)
may result in increased blood triglycerides and de-
Steps to Take
creased HDL-cholesterol levels. This is why the cur-
Focus first on your patients who are at highest risk
rent Dietary Guidelines shifted the emphasis from
of food-borne illness. These include pregnant women,
low-total-fat diets to low-saturated-fat and low-cho-
older persons, and those with weakened immune sys-
lesterol diets.
tems, such as those undergoing chemotherapy and in-
dividuals who are HIV positive. Urge these patients to
Key Points
do a safety check on the way their food is handled at
It is the type of fat (ie, saturated fat) and choles-
home—especially perishable foods such as eggs,
terol, rather than the total amount of fat, that is
meats, poultry, fish, shellfish, milk products, and
most closely related to the risk of developing car-
fresh fruits and vegetables. The Dietary Guidelines
diovascular disease. “Fat-free” or “low-fat” does not
consumer booklet provides some specific points to
necessarily indicate products that are more nutri-
check. Suggest that high-risk patients buy and
tious or, for that matter, lower in calories than their
use food thermometers to make sure that foods are
full-fat counterparts. Exceptions are low-fat and fat-
cooked to safe temperatures. People at high risk also
free dairy and meat products, where the reduction
should avoid unpasteurized juices and milk products,
in fat is primarily in saturated fat, and where other
raw sprouts, undercooked or raw meat, poultry, eggs,
caloric sources (ie, sugars) are not added.

Table 4. Home Food-Safety Checklist Steps to Take

Clean: Wash hands and surfaces often when preparing food Make sure your patient understands that not all fats
Separate: Separate raw, cooked, and ready-to-eat foods are the same—foods high in saturated fats, trans
while shopping, preparing, or storing
fats, and cholesterol increase blood cholesterol lev-
Cook: Cook foods to safe temperatures
els. Saturated fats and cholesterol are found prima-
Chill: Refrigerate perishable foods promptly
rily in fats of animal origin (meat and dairy prod-
Follow the label: Food labels have instructions that can help
ucts), and saturated fats are also present in tropical
keep foods safe
oils (coconut, palm, and palm kernel oils). Dietary
Serve safely: Keep hot foods hot and cold foods cold when
serving cholesterol is found only in foods of animal origin,
If in doubt, throw it out especially eggs. Trans fatty acids are found in low
levels in meat and dairy products and at variable
368 j DWYER AND LICHTENSTEIN Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6

levels in hydrogenated fats or products made from Choose Beverages and Foods to Moderate
them (such as vegetable shortening and some stick your Intake of Sugars
margarines, which are high in trans fats). Commer-
cially fried foods and baked products account for Rationale
most trans fatty acids consumed in the United Sugars occur naturally in a wide variety of foods, in-
States. cluding milk, fruits, some vegetables, breads, cere-
Unsaturated, fat-rich foods (high monounsaturated als, and grains. Foods high in added sugars, like soft
or polyunsaturated fat) decrease blood cholesterol drinks, are high in calories and may contribute to
levels, especially polyunsaturates. Unsaturated fats are weight gain or lower consumption of more nutri-
found mainly in vegetable oils (except tropical oils) tious foods.
and products made from these oils, such as full-fat
salad dressings. Oils high in monounsaturated fatty ac-
ids include canola and olive oils; oils high in polyun- Key Points
saturated fatty acids are soybean and corn oils. Consumption of foods containing sugars and
Fish, canola, and soybean oil also contain omega starches may contribute to tooth decay. The bacte-
n-3 fatty acids. Data suggest that n-3 fatty acids may ria in the mouth use the sugars and starches to pro-
be cardio-protective. Foods and fats relatively high duce acid that can cause tooth decay. A critical
in n-3 fatty acids are also low in saturated fatty ac- variable in this process is the amount of time the
ids. Patients should make grains, fruits, and vegeta- sugar or starch is retained in the mouth.
bles the foundation of their diet to avoid foods high The body does not distinguish between naturally
in saturated fat and cholesterol. They can accom- occuring and added sugars. In the United States, the
plish this by following the Pyramid Guide and read- major source of added sugars is soft drinks. Candies,
ing the Nutrient Facts panels and ingredient labels cakes, cookies, and fruit drinks are the other major
of the foods they purchase. Table 5 provides some contributors of added sugars. The sugars in milk, fruit,
useful additional advice. and fortified cereals tend to be associated with higher

Table 5. Food Choices for Heart Health1

Fats and oils
Choose vegetable oils rather than solid fats (meat and dairy fats, shortening)
If you need fewer calories, decrease the amount of fat you use in cooking and at the table
Meat, poultry, fish, shellfish, eggs, beans, and nuts
Choose 2 to 3 servings of fish, shellfish, lean poultry, other lean meats, beans, or nuts daily
Trim fat from meat and take skin off poultry
Choose dry beans, peas, or lentils often
Limit your intake of high-fat processed meats such as bacon, sausages, salami, bologna, and other cold cuts. Try the lower-fat
varieties (check the Nutrition Facts label)
Limit your intake of liver and other organ meats
Use egg yolks and whole eggs in moderation. Use egg whites and egg substitutes freely when cooking since they contain no
cholesterol and little, or no, fat
Dairy products
Choose fat-free or low-fat milk, fat-free or low-fat yogurt, and low-fat cheese most often. Try switching from whole to fat-free or
low-fat milk. This decreases saturated fat and calories but keeps all other nutrients the same
Prepared foods
Check the Nutrition Facts label to see how much saturated fat and cholesterol are in a serving
Choose foods lower in saturated fat and cholesterol
When eating out
Choose fish or lean meats as suggested above. Limit ground meat and fatty processed meats, marbled steaks, and cheese
Limit your intake of foods with creamy sauces, and add little or no butter to your food
Choose fruits as desserts most often
Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6 Dietary Guidelines for Clinicians j 369

amounts of other nutrients than the sugars in these Steps to Take

other foods. Urge patients who still salt their foods to cut down
on how much they use and to use herbs, spices,
Steps to Take and fruits to flavor their foods instead. Salt is found
Urge patients to choose foods and drinks sensibly mainly in processed and prepared foods, so eating
to limit their intake of sugars. This can be accom- less of these can help reduce salt in the diet. Many
plished by getting the majority of calories from grains prepared foods are now available in reduced-or low-
(especially whole grains), fruits and vegetables, low- salt versions and are the preferable choices. In addi-
fat and fat-free dairy products, and lean meats or tion to the front of the food package, the Nutrition
meat substitutes. Foods and drinks high in added sug- Facts label on processed foods can help to identify
ars, such as soft drinks and sweets, should not be foods that are lower in sodium.
substituted for foods that are high in other nutrients One of the major sources of sodium in most Ameri-
as well (ie, milk, fruit). Patients of all ages should be can diets is restaurant food or fast foods. Some restau-
familiar with oral hygiene techniques to maintain rants now have identified “healthier” selections that
healthy gums and teeth (ie, minimize between-meal are low in sodium and saturated fat; these menu items
snacks containing sugars and starches, swish after are good choices. The DASH (Dietary Approaches to
eating, brush at least twice per day, discuss dental hy- Stop Hypertension) diet, which is high in fruit and
giene with dentist). Patients should be made aware vegetables and low in fat, has been shown to have
of the synonyms for added sugar used on food labels. positive effects on blood pressure lowering, espe-
These include: brown sugar, corn sweetener, corn cially when it includes lowered sodium intakes.4–6
syrup, dextrose, fructose, fruit juice concentrate, glu-
cose, high-fructose corn syrup, honey, invert sugar,
lactose, maltose, malt syrup, molasses, raw sugar, su- If You Drink Alcoholic Beverages, Do So in
crose, syrup, and table sugar. Moderation
Rationale
Alcohol can be considered both a food—in that it
Choose and Prepare Foods with Less Salt provides food energy and few other nutrients—and
Rationale a drug that can have powerful effects, particularly
Salt intake is associated with high blood pressure in some individuals.
and with calcium excretion in the urine.
Key Points
Key Points “Moderation” in alcohol intake is defined as no more
There is good evidence that some people are salt than 1 drink per day for women and 2 for men; the
sensitive—that is, their blood pressure increases differences in tolerance are mainly due to sex differ-
with increased salt intake. Unfortunately, there is ences in body size and water (lean muscle mass).
no simple laboratory test that can identify truly salt-
sensitive individuals. However, since consuming less
salt is good for everyone, in addition to having spe- Steps to Take
cial benefits for some, it is a good idea for everyone Some patients should not drink at all, and they
to consume less salt. (For hypertensive individuals should be advised accordingly. Patients who should
who are overweight, weight reduction can also help, not drink fall in two categories. First are patients
but many individuals who are hypertensive are not with certain easily identifiable characteristics. These
overweight.) persons include children, adolescents, individuals
Since most Americans already get more sodium who cannot restrict their drinking to moderate lev-
than they need, it is healthier to learn to eat foods els, and women who may become pregnant or who
with more of their natural flavor, without adding are pregnant. Older persons have a reduced toler-
salt. However, much of the salt we eat comes hid- ance for alcohol since their lean muscle mass is
den in prepared foods. Therefore, it is also critical lower, and they should be counseled to be moder-
to choose and prepare foods that are low in salt. ate in their drinking. A second category of patients
370 j DWYER AND LICHTENSTEIN Nutr Clin Care, Nov/Dec 2000–Vol 3, No. 6

who need to take special care with alcohol are necessarily reflect the views of the US Department of
those taking certain prescription drugs or over-the- Agriculture.
counter medications that interact with alcohol.
Check to make sure that these patients recognize
that they are at risk, and do a quick review of the REFERENCES
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This article was funded in part by a contract between 8. Dietary Guidelines Advisory Committee 2000. Re-
the US Department of Agriculture and Tufts Univer- port of the Dietary Guidelines Advisory Committee on
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ings, conclusions, or recommendations expressed in MD: US Department of Agriculture, Agricultural Research
this publication are those of the authors and do not Service; 2000.