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OCR for page 84
4
Interpretation and Application of the
Recommendations in the
Diet and Health Report
EFFECTIVE IMPLEMENTATION of dietary recommendations re-
quires, at a minimum, that they be interpreted in a consistent
manner and have broad applicability. In this chapter, the committee
interprets the recommendations in the Food and Nutrition Board's
Diet and Health report (NRC, 1989a) and describes how implementors
in all sectors of society can use them to teach consumers how to
improve their diets. However, this discussion is designed to be applicable
to most sets of dietary recommendations and guidelines prepared by
various expert bodies.
INTERPRETATION OF THE DIET AND HEALTH
RECOMMENDATIONS
The Diet and Health recommendations pertain to every healthy North
American from age 2. Quantitative target levels in the recommenda-
tions were based on expert judgment as to whether these levels are
likely to be attained by the population. The Committee on Diet and
Health believed its recommendations could be achieved without drastic
changes in usual dietary patterns and without undue risk of nutrient
deficiencies. This committee agrees with that view. People with
medical problems and those on special diets should seek professional
advice on the applicability of the recommendations to them. Infants
and children under age 2 have special dietary needs that are not
covered by dietary recommendations; expert advice on their nutritional
needs can be obtained from pediatricians or nutritionists who work
with these groups.
84
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INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
85
A person's entire dietary pattern, rather than individual meals or
snacks, should be planned to meet the recommendations. The Committee
on Diet and Health did not specify the period during which one's
dietary pattern should meet these goals (e.g., over the course of a day
or a week) but implied that routine eating patterns should be compatible
with them. The extensive data base from which they were derived
indicates that the risk of several chronic diseases is likely to be re-
duced among populations whose routine dietary patterns are similar
to those advocated by that committee. To move toward such an
eating pattern, this committee believes that consumers should plan
their daily diet to achieve it, but that flexibility should predominate
over rigid self-discipline. For example, people should not be alarmed
if their diets on any given day do not fully or precisely meet the
recommendations. In general, menu planning is simplified when it is
focused on a day, several days, or a week rather than single meals as
time frames during which the recommendations should be met.
The Diet and Health recommendations were presented in a logical
sequence that also reflected a general order of importance. Highest
priority is given to reducing fat intake, since the scientific evidence
linking dietary fats and other lipids to health is strongest and the
likely impact from dietary change on public health is the greatest.
Lower priority was given to recommendations on other dietary com-
ponents because they are derived from weaker evidence or because
their public health impact is not likely to be as strong. The Committee
on Diet and Health emphasized, however, that maximum benefits to
health are likely to be achieved by basing meal patterns on all nine
recommendations and the Recommended Dietary Allowances (RDAs)
(NRC, 1989b).
Thus, efforts to implement dietary recommendations should focus
primarily on encouraging and teaching people to limit their consumption
of total fat, saturated fat, and cholesterol. As people modify their
diets to meet this most important recommendation, they should find
little difficulty in meeting the next two recommendations to increase
intake of carbohydrates and to limit protein intake. The best way to
reduce fat intake is to eat more low-fat foods, such as grains, vegetables,
legumes, and fruits (thereby eating more carbohydrates) and, if desired,
moderate portions of meat, poultry, and fish (thereby limiting protein
intake). Nutrient adequacy, the focus of several other recommenda-
tions, is likely to be achieved by the judicious selection of a plant-
enriched diet containing some lean meats and low-fat dairy products.
The Committee on Diet and Health emphasized that, depending on
need, the calories lost by reducing dietary fat intake should be made
up by consuming carbohydrate-rich plant foods such as cereals, fruits,
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86
IMPROVING AMERICA'S DIET AND HEALTH
and vegetables rather than high-protein foods. Most people in the
United States consume more than enough protein, as is discussed
later in this chapter.
The Diet and Health recommendations can be followed by people
who consume almost any culturally, ethnically, or regionally specific
cuisine, since they encourage the use of a wide variety of foods. They
are especially suitable for many ethnic cuisines (e.g., Chinese and
Indian) that tend to be lower in total fat, saturated fat, and choles-
terol and higher in plant foods and complex carbohydrates than tra-
ditional Western cuisines. Nevertheless, such cuisines may need to
be modified (e.g., less sodium-rich soy sauce in Chinese cooking).
Lack of access to a wide variety of nutritionally desirable foods is
a formidable barrier to eating well, especially for people on limited
incomes who must shop in stores with limited choices. It may not be
possible, for example, for such people to drink low-fat or skim milk
if local food stores charge premium prices for them or stock only
whole milk. Dietary recommendations can be followed by those on
limited incomes if they shop carefully at stores with an adequate
selection of foods and reasonable prices. In selecting meat, poultry,
and fish, less expensive cuts should be chosen; legumes (dried beans
and peas) should be used in place of these foods as necessary or
desired. Grain products are relatively inexpensive, as are many fresh
vegetables and fruits in season or frozen or canned produce. Low-fat
and skim milk and low- or nonfat dairy products often cost less than
whole milk and products made from it.
The Committee on Diet and Health advocated the consumption of
a wide variety of foods; it did not prohibit specific foods or food
products, since the nutritional composition of the total diet is of most
importance. Nevertheless, consumers will need to limit their consump-
tion of oils, fats, egg yolks, and salt as well as fried and other fatty
foods. For example, it would not be possible to limit cholesterol
intake to less than 300 mg/day without limiting egg yolks to an
average of one or less daily.
The RDAs provide sex- and age-specific guidelines on the levels of
intake of essential nutrients judged to be adequate to meet the needs
of most healthy people. Although they are set high enough to exceed
the nutrient requirements of most people, it is difficult to determine
the needs of any individual. Therefore, it is prudent to recommend
that consumers eat diets that provide nutrients at approximate RDA
levels. Consumers are likely to meet the Diet and Health recommendations
and the RDAs if they consume adequate calories, select a variety of
foods from the major food groups (emphasizing those low in fat, salt,
and sugars), and limit their intake of alcoholic beverages.
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INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
MEETING THE RECOMMENDATIONS
87
The general strategies described in this section for implementing
dietary recommendations at the points of food purchase, preparation,
and consumption are not meant to be comprehensive nor specific to
any individual. Individuals' food choices differ on the basis of dietary
preferences and dislikes, nutrient and energy needs, and many other
factors (see Chapter 3~. For example, an active college athlete with high
caloric needs can eat more food than a sedentary roommate of the same
sex and similar age and height who is restricting calories to reduce
weight. If both roommates were to eat diets that meet the recommenda-
tions and contain the same percentage of calories from fat, carbohydrate,
and protein, the higher-calorie diet of the athlete would contain a greater
total amount of these macronutrients. In contrast, recommendations for
cholesterol and sodium intake, which are given in absolute amounts,
are the same for both. Because the athlete consumes more food than the
dieter, the athlete will need to pay careful attention to limit intake of
foods that are high in these nutrients.
The emphasis on consuming certain foods and limiting others is
based on common dietary practices in the United States as shown by
food consumption surveys. People who already consume diets that
meet some or all of the Diet and Health recommendations should be
encouraged to continue their healthful eating habits and make specific
modifications as appropriate.
Implementors have important roles to play in helping people to
apply the principles of dietary recommendations when they shop for
food, prepare meals, and eat outside the home. In addition, implementors
should encourage people to take political and other actions that will
lead to health-promoting food choices becoming more widely available
and being perceived as desirable choices (see Chapter 8~.
Table 4-1 presents a general guide for meeting dietary recommen-
dations. Consumers can use this guide along with other information
in this chapter and a variety of publications from the U.S. Department
of Agriculture (USDA) and the U.S. Department of Health and Human
Services (DHHS) (see, for example, NCI/NHLBI, 1988, and USDA,
1989) to eat in ways that meet dietary recommendations as well as
the RDAs.
Food Selection
Wise food shoppers select a variety of foods from all the major
food groups, emphasizing those within each group that are low or
relatively low in fat, salt, and simple sugars. By planning menus in
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88
IMPROVING AMERICA'S DIET AND HEALTH
TABLE 4-1 Guide to Meet Dietary Recommendations
Food Group
Recommended Number of Servings
Grains and legumes
Vegetables and fruits
Dairy products
Meat, poultry, fish, and alternates
(eggs, legumes, nuts, and seeds)
Other foods
(fats, sweets, and alcohol)
At least six servings per day; consume grains in
their whole form as often as possible. A serving
is equivalent to one slice of bread or one small
roll; 0.5 bun, bagel, or muffin; 0.5 cup of cooked
cereal, rice, or pasta; 1 oz of ready-to-eat cereal;
or 0.5 cup of cooked legumes.
At least five servings per day, with an emphasis
on a variety of green and yellow vegetables (e.g.,
broccoli, kale, sweet potatoes, and carrots) and
citrus fruits (e.g., oranges and grapefruits). A
serving is equivalent to 0.5 cup of fresh or cooked
vegetables or fruits, 1 medium fresh fruit or
vegetable, 1 cup of leafy raw vegetables, 6 oz of
juice, or 0.25 cup of dried fruit.
Two servings per day for children, three to four
servings per day from ages 11 to 25 and for
pregnant and lactating women, and two to three
servings per day from age 25. A serving is
equivalent to 8 oz (1 cup) of milk or yogurt, 1.5
oz of natural cheese, and 2 oz of processed cheese.
Two servings per day. A serving is equivalent
to approximately 3 oz (cooked weight) (4 oz raw)
of lean meat, fish, or poultry. Count 1 egg, 0.5
cup of cooked legumes, or 2 tablespoons of pea-
nut butter as 1 oz of meat. Limit egg yolks to
no more than three to four per week; there are
no limits on egg whites.
Limit use of foods that are high in oil, fat, or
simple sugars; limit use of these items in food
preparation. For those who drink alcoholic bev-
erages, limit consumption to less than 1 oz of
pure alcohol per day.
aThis guide has been constructed from the following sources: DHHS, 1990; NRC,
1989a,b; and USDA, 1989. Modest differences exist among these sources in the way
foods are grouped (e.g., in the placement clef legumes) and in the recommended num-
ber of servings from each group (e.g., should there be a minimum recommended
number of servings for both vegetables and fruits?). Nevertheless, they are very simi-
lar in the general type of eating pattern recommended.
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INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
89
advance and preparing a list of needed items before shopping for
food, consumers may decrease impulse buying (particularly of foods
with high levels of dietary components that should be limited) and
stay within their food budgets. Shoppers should be encouraged to
read nutrition labels to help them choose health-promoting products.
Food Preparation
The nutritional quality of foods can be affected by preparation methods.
For example, the potential reduction in fat intake achieved by skinning
a chicken breast may be more than offset if a high-fat sauce is served.
The fat content of the latter could be greater than that in an equivalent
amount of top round steak that is carefully trimmed and then broiled.
As a general rule, frying of foods is discouraged; low- or no-fat alterna-
tives include steaming, broiling, roasting, baking, boiling, stewing,
microwaving, and stir-frying (if little oil is used).
Time-constrained cooks may find it easier to prepare quick yet
nutritious meals with the help of appliances such as the microwave
oven, pressure cooker, crackpot (slow cooker), blender, and food
processor. Time can also be saved by purchasing presliced fruits,
vegetables, and meats, which are increasingly available in supermarkets,
but at extra cost. Cooks should be encouraged to use recipes that call
for no or only small amounts of fatty, salty, or sugary items as essential
ingredients or flavor enhancers.
Eating Outside the Home
People have limited control over the preparation of foods when
they eat out, but they can select the types and the amounts of foods
to be consumed. Full-service restaurants usually provide the largest
selection of menu items prepared in a variety of ways compared with
the expanding but still limited menus in fast-service food establishments.
People should be encouraged to choose restaurants that honor spe-
cial requests and to inform the waitstaff how they want their meals
to be prepared and served. Implementors should also provide con-
sumers with tips for eating out, such as the following: if serving sizes
of the entrees seem too large, ask for half or petite portions, choose
an appetizer as a main dish, or share the entree; order fish, poultry,
or meat broiled without fat, and poultry without skin; ask that salad
dressings and sauces be served on the side; ask about the availability
of foods that may not be on the menu such as skim milk or fresh
fruit; and balance any high-fat or high-salt items with foods that are
lower in these components.
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9o
IMPROVING AMERICA 'S DIET AND HEALTH
The limited menus of fast-service food establishments where an
estimated 20% of the U.S. population eats on a typical day (Massa-
chusetts Medical Society Committee on Nutrition, 1989) make it difficult
for people to select meals at these places that are low in fat and salt,
since so many products are fried and seasoned. Consumers should
be encouraged to order small sandwiches (such as single hamburgers
rather than special, larger ones with special sauces), select prepared
vegetable salads or items from the salad bar if available and use low-
calorie dressings, and ask for low-fat or skim milk, fruit juice, or
water as beverage options.
Many resources are available to help consumers put dietary rec-
ommendations into practice by improving their skills in selecting and
preparing foods. They include cookbooks and books on diet and
health; booklets and pamphlets issued by the federal government
(particularly the Human Nutrition Information Service of the USDA),
the Cooperative Extension Service (CES), voluntary health agencies,
and several food retailers; community nutrition education classes
sponsored by local high schools, colleges, and universities or by CES;
and cooking classes. Professional nutritionists and dietitians are often
knowledgeable about these resources and can be contacted by the
public at local hospitals or health departments. These health-care
professionals are trained to help individuals who need special assis-
tance to improve or fine-tune their dietary patterns or to overcome
personal difficulties in meeting dietary recommendations.
This committee recommends that additional resources be prepared.
These include a comprehensive manual to assist consumers in incor-
porating the principles of dietary recommendations into their eating
patterns and a food skills, nutrition, and health curriculum to teach
children such concepts from an early age (see Chapter 8~.
ACHIEVING SPECIFIC DIET AND HEALTH
RECOMMENDATIONS
¢1) Reduce total fat intake to 30% or less of calories. Reduce saturated
fatty acid intake to less than 10% of calories and the intake of cholesterol to
less than 300 mg daily.
According to the Committee on Diet and Health, a large and con-
vincing body of evidence from studies on humans and laboratory
animals shows that diets low in saturated fatty acids (saturated fat)
and cholesterol are associated with low risks and rates of atheroscle-
rotic cardiovascular diseases. High-fat diets are also linked to a high
incidence of some types of cancers (especially of the colon, prostate,
and breast) and probably obesity. That committee noted that there is
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INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
91
TABLE 4-2 Total Fat, Saturated Fat, and Cholesterol Intake in the
Average U.S. Diet Compared to the Diet and Health Recommendations
Total Fat, Saturated Fat,
% of total % of total Cholesterol,
Intake kcal kcal mg
Diet and Health <30.0 <10.0 <300
recommendation for
people from age 2 year0,b
Men (19 to 50 years old)C 36.4 13.2 435
Women (19 to 50
years old)C 36.7 13.4 272
Children (1 to 5 years old)C 34.9 14.0 233
a From NRC (1989a).
b The average nutrient intake by the U.S. population cannot be directly compared
with the quantities specified in the Diet and Health recommendations, because the latter
are goals for individuals. For example, if the goal for mean total fat intake by individuals
is <30% of kcal, then the mean intake by the population would have to be substantially
below 30% of kcal to achieve an intake of 30% by all people from age 2 (unless, of
course, they all consumed exactly 30% of their calories from fat). Thus, the quantita-
tive gap between this recommendation and the current intake by the U.S. population is
wider than is apparent from the table.
c From USDA (1986c, 1988).
sufficient evidence that even further reductions in intake of total fat,
saturated fat (to 8 or 7% of calories), and cholesterol (to 250 or 200
mg or even less per day) might confer even greater benefits. It con-
cluded, however, that its recommended levels are more likely to be
adopted by the public because they can be achieved without drastic
changes in usual dietary patterns and without undue risk of nutrient
deficiency (NRC, 1989a).
Table 4-2 presents the total fat, saturated fat, and cholesterol in-
take by adult men and women ages 19 to 50 and of children ages 1 to
5 as determined by recent USDA surveys (USDA, 1986c, 1988~. It
shows that total fat and saturated fat intake in the U.S. population
will need to be reduced substantially if this most important of the
Diet and Health recommendations is to be met. In addition, men will
need to reduce their cholesterol intake, whereas the intake of many
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IMPROVING AMERICA'S DIET AND HEALTH
women and children appears to be within the recommendations. Since
many people will find it difficult to make the dietary changes required
to meet this recommendation overall, implementors face the challenge
of educating and motivating them to action.
The major dietary sources of total fat, saturated fat, and choles-
terol in the United States are meats (especially beef and pork); processed
or convenience meat products (e.g., hot dogs and luncheon meats);
whole-milk dairy products (e.g., milk, cheese, and ice cream); eggs;
fats and oils (butter, margarine, mayonnaise, and salad and cooking
oils); and grain-based but fat-rich products such as doughnuts, cook-
ies, cakes, and crackers (Block et al., 1985~. Altogether, animal products-
which include red meats (beef, lamb, pork, and veal), poultry, fish
and shellfish, separated animal fats (such as tallow and lard), milk
and milk products, and eggs contribute more than half of the total
fat in U.S. diets, three-fourths of the saturated fat, and all the choles-
terol (NRC, 1988~.
Consumers will be better prepared to compare food products and
evaluate promotional claims if they learn the difference between the
percentage of fat by weight in a product and the percentage of calo-
ries from fat. Percentage of fat by weight refers to the quantity of fat
in a product divided by the total weight of the product (which includes
components such as carbohydrate, protein, and alcohol, if present,
that supply calories to the diet as well as noncaloric water an ingre-
dient found in substantial amounts in most foods, even in solid or
dry ones). In contrast, the percentage of calories from fat refers to
the number of calories from a food supplied by fat divided by the
total number of calories (from carbohydrate, protein, fat, and alcohol)
supplied by the food. The value for percentage of fat by weight is
lower often substantially lower than the value for percentage of
calories from fat. The difference is based largely on the water content
of the product. For example, ground beef labeled extra lean that con-
tains 16% fat by weight would derive more than 53% of its calories
from fat. Two percent milk contains 2% fat by weight (most of the
rest of its weight is water), but 36% of its calories come from fat. It
should be remembered, however, that as long as the total fat content
of the diet remains within 30% of total calories, the percentage of
calories from fat in any food product is not important. There is room
for some high-fat foods in low-fat diets.
One practical strategy for reducing total fat, saturated fat, and
cholesterol in the diet is to limit the consumption of meat, fish, and
poultry to 3 oz cooked weight (about the size of a deck of playing
cards) at any meal and to a maximum of approximately 6 oz/day.
This action will also help to keep protein intake at recommended
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INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
93
levels. USDA surveys show that total intake of meat, poultry, and
fish averages 9.5 oz for adult men ages 19 to 50 (USDA, 1986c) and
5.4 oz for women of the same age range (USDA, 1988~. Following are
information and guidelines for selecting meat, poultry, and fish products
to help meet this particular Diet and Health recommendation:
General
· Meat, poultry, and fish provide essential nutrients. Meat is an especially
good source of iron and zinc.
· Poultry and fish are generally lower in fat compared with beef or pork.
· USDA regulations allow fresh cuts of meat and poultry to be labeled
extra lean if they contain no more than 5% fat by weight and lean or lowfat if
they contain less than 10% fat. Even most of the leanest meats, however,
provide substantially more than 30% of their calories as fat. Fully trimmed
lean beef, for example, supplies from 29% (for top round) to 41% (for tenderloin)
of calories from fat after cooking (Beef Industry Council and Beef Board,
1990~.
· Choose the leanest looking cuts of meat and poultry and remove visible
fat on the outside of the cut and between the muscles.
Meat
· The leanest cuts of beef include round tip, top loin, top round, eye of
round, tenderloin, and sirloin (Beef Industry Council and Beef Board, 1990~.
· The leanest cuts of pork include tenderloin, loin chops, and smoked
ham (Giant Food, Inc., 1988~.
· Most trimmed cuts of veal, except the breast, are considered to be lean.
The leanest cuts of lamb include the trimmed leg and loin (e.g., loin chops)
(Giant Food, Inc., 1988~.
· When buying graded beef, choose the select grade (formerly known as
good) over that labeled choice or, especially, prime. Select contains less intra-
muscular fat (known as marbling) than choice or prime beef.
Ground Beef and Turkey
· Ground beef, the single largest source of fat in U.S. diets (Block et al.,
1985), is exempt from USDA definitions of lean and extra lean meats. Even ground
beef labeled extra lean is a relatively fatty product, which after cooking is
approximately 16% fat by weight and derives more than 53% of its calories
from fat (NRC, 1988~. To minimize fat intake from ground beef, drain off the
fat after cooking. In meatloafs and other dishes where the fat cannot be
drained, use ground sirloin.
· Ground turkey is lower in fat than ground beef (about 7 to 14% by
weight) (Giant Food, Inc., 1988), but commercially available products get
approximately 45% of their calories from fat because manufacturers grind up
the turkey skin with the meat (Nutrition Action, 1989b).
· To obtain a lower-fat alternative to prepackaged ground beef or turkey,
select a lean cut of meat or skinned turkey breast and ask the butcher to
grind it.
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IMPROVING AMERICA'S DIET AND HEALTH
Organ Meats
· These products derive at least one-quarter of their calories from fat and
are particularly high in cholesterol. Each ounce of cooked beef liver, for
example, derives 27% of its total calories from fat and supplies 110 mg of
cholesterol (USDA, 1986a).
Poultry
· Skinless turkey contains less fat than chicken. In roasted white meat,
7% of total calories is provided by fat compared with 23% in dark meat
(USDA, 1979~.
· Removing the skin from chicken reduces the amount of calories from
fat from 44 to 23% in cooked white meat and from 56 to 42% in dark meat
(USDA, 1979~.
· Roasting a chicken breast without skin rather than frying it reduces the
amount of calories from fat from 22 to 19% (USDA, 1979~.
Luncheon or Deli Meats
· Because these products are usually high in fat and sodium, their con-
sumption should be limited. Sliced roast beef, turkey, or lean ham are relatively
low-fat choices. Processed meats that are at least 95% fat free by weight are
preferable; however, even a 95% fat-free ham with 23 calories per slice still
contains 35% of calories as fat. Approximately 80% of the calories in beef hot
dogs come from fat; turkey or chicken hot dogs are marginally lower (ap-
proximately 70%) (USDA, 1979, 1986a).
Fish and Seafood
· The fat content of these foods is low to moderate and is largely unsat-
urated. In particular, fatty fish (such as salmon, mackerel, and tuna) supply
n-3 fatty acids, which lower triglyceride levels when substituted for saturated
fatty acids (NRC, 1989a). Consumption of fish one or more times per week
has been associated with a reduced risk of coronary heart disease.
· Compared with tuna canned in water or brine, tuna in oil contains up
to 500% more fat and more than double the percentage of calories from fat
(37 compared with 17%) (NRC, 1988~.
· Broiling rather than breading and frying a lean halibut steak reduces
the amount of calories from fat from 47 to 18% (NRC, 1988~.
Frozen Entrees
· These popular products usually contain meat or poultry combined with
a sauce, grain, vegetable, and sometimes a dessert. As a general rule, an
entree containing less than 10 g of fat is likely to derive less than 30% of its
calories from fat. According to a recent survey, the product lines of numer-
ous frozen entree manufacturers ranged from 14 to 54% of total calories from
fat; many are also high in sodium (Liebman, 1988a).
Dairy products are a major source of total fat, saturated fat, and
cholesterol in the diets of the U.S. population. They are also the
major food source of calcium, a nutrient in short supply in the diets
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AL
INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
101
(3J Maintain protein intake at moderate levels.
The Committee on Diet arid Health reported that there are rro knower
benefits from and possibly some risks in consuming diets rich ire
animal protein. It noted that increased risks of certain cancers (especially
those of the breast and colon) and heart disease have been associated
in some population studies with diets high in meat (and, therefore, in
animal protein) and with high protein intake alone in laboratory studies.
That committee concluded, however, that it is not known whether
these adverse effects are due solely to the usually high total fat, saturated
fatty acid, and cholesterol content of diets that are rich in meat or
animal protein or to what extent protein per se or other factors also
contribute to these adverse effects. The Committee on Diet and Health
recommended that total protein intake not exceed twice the RDA for
all age groups. Table 4-3 can be used to determine this maximum
recommended intake.
Approximately two-thirds of the protein in U.S. diets comes from
animal products and one-third comes from plants. The main sources
TABLE 4-3 RDAs for Protein and Maximum Recommended Intakesa
Maximum
Recom
Median mended
Age, RDA, Weight, RDA, Intake (2x
Category years g/kg kg g/day RDA),g/day
Children,
both sexes 2-3 1.2 13 16 32
4-6 1.1 20 24 48
7-10 1.0 28 28 56
Males 11-14 1.0 45 45 90
15-18 0.9 66 59 118
19-24 0.8 72 58 116
225 0.8 79 63 126
Females 11-14 1.0 46 46 92
15-18 0.8 44 44 88
19-24 0.8 58 46 92
225 0.8 63 50 100
a The RDA for protein ranges from 1.2 g/kg (2.2 lb) of body weight for children ages
2 to 3 to 0.8 g/kg for adults past age 18 (approximately 0.54 and 0.36 g of protein per
pound of body weight, respectively). For those within the range of ideal body weight
for height, the maximum recommended protein intake (twice the RDA) can be calcu-
lated by multiplying one's weight in kilograms by the appropriate RDA as g/kg and
then multiplying that result by 2. Those who are substantially underweight or over-
weight can approximate their RDA for protein by using the median weights in column 4.
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IMPROVING AMERICA'S DIET AND HEALTH
TABLE 4-4 Approximate Protein Content of Foods
Food Product Serving Size Amount of Protein,
g/serving
Milk or yogurt
Cheese
Meat, poultry, and fish
Whole egg
Legumes
Cereals and pasta
Bread
Starchy vegetables
Vegetables
1 cup
1 oz
1 oz
0.5 cup cooked
0.5 cup cooked
1 slice
0.5 cup cooked
0.5 cup cooked or
1 cup raw
7
SOURCE: ADA and ADA (1986,1989).
are fresh and processed meats, dairy products, and grains (particu-
larly bread, rolls, and crackers) (Block et al., 1985~. According to a
recent survey, men from ages 19 to 50 consumed an average of 98 g/
day, whereas women in the same age range and their children ages 1
to 5 averaged 61 and 53 g/day, respectively (USD A, 1986c, 1988~.
These average protein intakes are substantially greater than the RDAs
but less than twice the RDA, suggesting that the majority of people
in the United States already meet this dietary recommendation. Those
who eat large amounts of meats and dairy products may, however,
consume protein at levels higher than twice the RDA. Most foods,
except fruits and purified fats and sugars, contribute some protein to
the diet (see Table 4-4~.
The Committee on Diet and Health recommended that protein in-
take not be increased to compensate for the calories lost in cutting
back on fat in the diet. Protein intake can be maintained at moderate
levels (between the RDA and twice the RDA) by limiting intake of
meat, fish, and poultry to 6 oz or less per day while consuming at
least six servings of grains and legumes and five servings of fruits
and vegetables. Modest reductions in protein intake that may occur
by modifying dietary patterns to meet dietary recommendations should
be of no nutritional consequence to most healthy people.
(4) Balance food intake and physical activity to maintain appropriate
body weight.
The Committee on Diet and Health reported that excess weight is
associated with an increased risk of several disorders, including
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INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
103
noninsulin-dependent diabetes mellitus, hypertension, coronary heart
disease, osteoarthritis, and endometrial cancer. The risks appear to
decline following a sustained reduction in weight. Increased abdominal
fat carries a higher risk for these disorders than do comparable fat
deposits in the hips and thighs.
That committee noted that body weight and body mass index are
increasing in the U.S. population and other westernized societies,
whereas caloric intake is decreasing. The undesirability of continu-
ing this trend as well as the proven association of moderate, regular
physical activity with reduced risks of heart disease led that committee
to recommend that people in the United States increase their physical
activity, improve physical fitness, and moderate their food intake to
maintain appropriate body weight.
As part of a package of preventive health care, implementors of
dietary recommendations should encourage and help people to engage
in regular physical activity and to improve their eating habits. Exercise
programs can be tailored to individuals with the help of qualified
health-care professionals. All healthy people can work some exercise
into their daily lives, from walking more often to taking the stairs up
or down one or two flights rather than riding an elevator. Successful
exercise programs are composed of activities that are convenient, en-
joyed, and fit to one's routine schedule and physical abilities or limitations.
Because fat contains more than twice the calories of equal amounts
of carbohydrates or protein, attempts at weight loss may succeed
with a strategy that combines increased physical activity with a re-
duction in caloric intake by replacing foods high in fat with low-fat
alternatives or other foods that are rich in complex carbohydrates but
relatively low in fat. Moderate physical activity on a regular basis
should be considered an essential component of any biologically ra-
tional and safe weight loss program. Regular activity helps to guard
against excessive weight gain that tends to occur with aging and
enables those at desirable weights to eat more food, thereby increas-
ing the nutritional quality of the diet if food choices are made in
accordance with the principles of dietary recommendations.
(5J The committee does not recommend alcohol consumption. For those
who drink alcoholic beverages, the committee recommends limiting consumption
to the equivalent of less than one ounce of pure alcohol in a single day. This
is the equivalent of two cans of beer, two small glasses of wine, or two
average cocktails. Pregnant women should avoid alcoholic beverages.
The Committee on Diet and Health reported that excessive alcohol
consumption increases the risk of heart disease, hypertension, chronic
liver disease, some forms of cancer (of the oral cavity, pharynx, esophagus,
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IMPROVING AMERICA'S DIET AND HEALTH
and larynx, especially in combination with cigarette smoking), neu-
rological diseases, nutritional deficiencies, and many other disorders.
Even moderate drinking carries some risks in circumstances that re-
quire neuromotor coordination and judgment, e.g., when driving ve-
hicles and working around machinery. In addition, consumption of
even small amounts of alcohol can lead to dependence. The Commit-
tee on Diet and Health noted that a causal association has not been
established between moderate alcohol drinking and a lower risk of
coronary heart disease. It specifically recommended against alcohol
consumption by pregnant women because of the risk of damage to
the fetus and the fact that no safe level of alcohol intake during
pregnancy has been established.
There is approximately 0.40 oz of pure alcohol (ethanol) in a 12-oz
bottle or can of most U.S. beer (which ranges from 3.2 to 4.0% ethanol
by volume), a 3.5-oz glass of wine (from 11 to 13% ethanol in most
table wines), and 1 oz of 80 proof (40% alcohol) distilled spirits such
as whiskey (NRC, 1989a). These amounts should be considered one
serving. To limit ethanol consumption to less than 1 oz/day, alco-
holic beverage consumption should be limited to no more than two
servings per day. Those who drink more potent alcoholic bever-
ages malt liquor beers containing more than 4% ethanol, fortified
wines such as sherry and port that may contain approximately 20%
ethanol, or distilled spirits greater than 80 proof- should limit them-
selves to less than two servings per day.
Alcoholic beverages such as wine or vermouth may be used in
cooking to saute or flavor foods. Until recently, it was believed that
the ethanol was evaporated by the heat of cooking, but recent re-
search shows that up to 85% of it may remain in the heated entree
(Science News, 1989~. Thus, pregnant women and others who wish
to avoid ethanol should refrain from cooking with alcoholic bever-
ages. As a practical matter, however, a negligible amount of ethanol
is consumed from a dish cooked with up to several tablespoons of an
alcoholic beverage and thus need not be considered.
(6) Limit total daily intake of salt (sodium chloride) to 6 g or less.
According to the Committee on Diet and Health, studies of human
populations around the world have shown that diets containing more
than 6 g of salt per day are associated with elevated blood pressure.
While susceptibility to salt-induced hypertension is probably geneti-
cally determined, no reliable genetic marker has yet been identified.
Therefore, the salt-sensitive individuals who are likely to benefit most
from this recommendation cannot yet be identified. That committee
concluded that this recommendation to limit salt intake would have
no detrimental effect on the general population.
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INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
105
The Committee on Diet and Health recommended limiting salt in-
take to 6 g (6,000 ma) or less per day as a practical and achievable
goal for people in the United States. It noted, however, that a greater
reduction in salt intake (i.e., to 4.5 g or less) would probably confer
even greater health benefits. Since salt is 40% sodium by weight, 6 g
of salt is equivalent to 2.4 g (2,400 ma) of sodium. One teaspoon of
salt (5 g) contains 2,000 mg of sodium.
Salt intakes by the U.S. population are difficult to determine, partly
because of difficulties in measuring salt added during cooking and at
the table. Data from a variety of sources suggest that total daily per
capita intake in the United States ranges from 10 to 14.5 g. About
one-third of this is estimated to be provided naturally in foods, one-
third is added during food processing, and one-third is added at
home during cooking or at the table (NRC, 1989a). A careful study in
Great Britain, however, indicates that only 10% of dietary salt intake
was naturally present in foods, whereas 15% came from salt added
during cooking and at the table and fully 75% came from salt added
during processing and manufacturing (Sanchez-Castillo et a]. 1987a h)
To meet this dietary recommendation, many people will need to
make substantial changes in the foods they eat and in the ways they
prepare them. Specifically, the consumption of processed foods that
contain high levels of added sodium or are salt-preserved and salt-
pickled should be limited. Most modern processing methods increase
sodium and reduce the potassium content of foods. For example, the
sodium content of 1/2 cup of fresh green peas is 2 ma; those same
peas frozen or canned would contain approximately 70 and 186 ma
of sodium per ounce, resnectivelv (USDA 1984).
, , ,
1 ~ -rig ~ ~---~~~ ~~~~~~
White bread, rolls, and crackers supplied the most sodium in U.S.
diets, according to NHANES II (Block et al., 1985), since sodium is
added in manufacturing these products. Processed meats including
hot dogs, ham, and luncheon meats were the second largest contribu-
tors of sodium. Given the high sodium content of many processed
foods, more than 6 g of salt might be consumed, for example, simply
by eating several frozen prepared pancakes for breakfast, a can of
soup for lunch, and a frozen entree for dinner.
To reduce salt intake to recommended levels, consumers should
study food product labels to identify product choices within catego-
ries (e.g., soup and cereals) that are lowest in sodium (and fat). Un-
der current regulations, products may carry the term sodium free if they
contain less than 5 mg of sodium per serving; products labeled very low
sodium and low sodium must not exceed 35 and 140 mg per serving,
respectively. Products labeled reduced sodium must contain at least 75%
less sodium than the regular version of the product (IOM, 1990~. For
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IMPROVING AMERICA'S DIET AND HEALTH
example, tomato puree labeled no salt added, unsalted, or without added
sail contains approximately 50 mg of sodium per cup compared with
1,000 mg/cup in the version with added salt (USDA, 1984~. Salt-
containin~ canned vegetables, legumes, and other products can be
drained and rinsed to remove some of their sodium. One study
showed that rinsing canned green beans for 1 minute before heating
them in water removed 40% of their sodium and that rinsing water-
packed tuna for the same length of time decreased its sodium content
by 76 to 79% (without simultaneously reducing the iron content)
(Vermeulen et al., 1983~.
v
Many consumers may not realize that products that do not taste
salty may still contain considerable amounts of salt. For example, a
single ounce of ready-to-eat breakfast cereal may contain more than
300 mg of sodium (Consumer Reports, 19891. A serving of apple pie
at a fast-service food establishment may contain more than twice the
sodium of a regular order of salted fries (Jacobson and Fritschner,
1986~. Unless a food product lists its sodium content on the label, it
will be difficult for most people to learn this information from other
sources.
In addition to limiting the intake of many processed foods, salt
intake can be reduced by minimizing its use at the table and in food
preparation. Foods on the plate should always be tasted before salt-
ing, of course, but home cooks may not realize that salt can often be
omitted or reduced in recipes without affecting their taste adversely.
Lemon juice and salt-free seasonings consisting of herbs or spices
alone or with dried vegetables are recommended alternatives to salt.
Some consumers may find the use of light salts to be a helpful interim
measure; they contain potassium chloride in addition to sodium chloride
and supply approximately half the sodium of regular salt.
High sodium intakes are most commonly associated with diets
high in prepared, processed foods or with heavy discretionary use of
table salt. Low intakes of sodium are associated with diets consisting
largely of fresh fruits, vegetables, cooked legumes, and grain products-
foods that naturally contain little sodium. Dairy products contain
moderate levels of sodium. An 8-oz glass of milk supplies about 120
mg (USDA, 19761; most natural cheeses contain between 100 and 400
mg/1.5-oz serving (Liebman, 1986~. Generally, natural hard cheeses
are lower in sodium than processed cheeses, cheese foods, and cheese
spreads. Unprocessed cereal grains such as oats and brown rice are
very low in sodium, although products made from them (e.g., ready-
to-eat cereals) may contain substantially more (pasta is a notable ex-
ception). For example, one slice of enriched white bread or whole-
wheat bread contains from approximately 65 to 160 mg of sodium
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INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
107
per slice (Consumer Reports, 1988~. Rich baked goods are often high
in sodium as well as in fat and simple sugars. Generally, fresh meats,
poultry, arid fish supply less than 90 mg of sodium per 3-oz serving,
while the same size serving of processed meat such as sausages, lun-
cheon meat, and frankfurters contain from 750 to 1,350 mg (USDA,
1986d).
Since the dietary recommendation to limit salt intake is indepen-
dent of caloric intake, the ease of compliance is likely to depend on
the amount of food consumed; it is easier to limit sodium intake
when consuming 1,500 compared with 3,500 kcal/day. Those with
high caloric needs may not be able to meet this recommendation
unless special measures are undertaken to curtail the use of processed
foods and the salt shaker.
(7J Maintain adequate calcium intake.
The Committee on Diet and Health recommended that food choices
be made to obtain adequate calcium, a nutrient essential for proper
growth, development, and maintenance of the bones. Certain seg-
ments of the U.S. population are susceptible to inadequate calcium
intake, especially adult women because of their low caloric intake
and adolescents because of their high requirements for this mineral.
RDAs for calcium are 800 mg/day for children through age 10 and
for adults beyond age 24. RDAs increase to 1,200 mg/day for adolescents
from ages 11 through 24, the critical years of bone mass accretion,
and for pregnant and lactating women, to meet the calcium needs of
their offspring.
Dairy products are rich sources of calcium. They contribute more
than 55% of the calcium intake of the U.S. population (Block et al.,
1985~. Skim, low-fat, and whole milk contain equivalent amounts of
calcium, approximately 300 mg/cup (USDA, 1976~. Thus, calcium
intake can be maintained while total fat and saturated fat are being
reduced by dietary patterns that include the use of skim and low-fat
milk. Most hard cheeses contain from 100 to 200 mg of calcium per
ounce (Dairy Nutrition Council, Inc., 1989~. People who cannot or do
not drink milk should be encouraged to eat cheese or yogurt (which
contains approximately 300 mg of calcium per cup). Lower-fat versions
of these products and yogurt made with nonfat milk are available.
Calcium intakes in the United States are low for groups other than
adult men. The most recent national survey indicated that the aver-
age daily calcium intakes of adult men and women ages 19 to 50 and
of children ages 1 to 5 were 919, 621, and 824 ma, respectively (USDA,
1986c, 1988~. Nutrition educators frequently recommend that older
children, adolescents, and young adults consume 3 cups of milk per
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108
IMPROVING AMERICA 'S DIET AND HEALTH
day or its equivalent in other dairy products to supply approximately
75°/O of the RDA for calcium from this group, and it is recommended
that adults from age 24 consume the equivalent of 2 cups/day. Non-
fat dry milk powder, which contains 377 mg of calcium in 0.25 cup
(USDA, 1976), can be added to recipes (e.g., small amounts to baked
goods and meatloafs) to provide additional calcium.
Nondairy sources of calcium include green vegetables, such as collards
(218 mg/1 cup chopped, raw), kale (90 lug), mustard greens (58 mg),
and broccoli (42 ma) (USDA, 1984~. Other calcium-containing foods
include tofu prepared with calcium, lime-processed tortillas, the soft
bones of fish such as salmon and sardines, and calcium-fortified foods
(NRC, 1989b). One orange contributes 52 mg of calcium (USDA,
1982~; cooked legumes can provide 35 to 80 mg/cup (USDA, 1986b).
(8) Avoid taking dietary supplements in excess of the RDAs in any one day.
As noted by the Committee on Diet and Health, vitamin and min-
eral supplements are taken by a large percentage of the U.S. popula-
tion every day; they are often self-prescribed and their use is not
usually based on known nutrient deficiencies. The committee recognized
that some population subgroups (e.g., those suffering from malabsorption
syndromes) may require supplements and recommended that they be
used only under professional supervision.
Most healthy people who eat diets that are in conformance with
dietary recommendations and that contain adequate calories will come
close to meeting or exceed the RDAs for nutrients and therefore have
no need for supplements. As stated earlier, RDAs are defined as
levels of intake of essential nutrients judged to be adequate to meet
the known nutrient needs of practically all healthy people. Because
RDAs include a margin of safety, they exceed the actual requirements
of most people. Therefore, people who do not consume RDA levels
of all nutrients are not likely to be malnourished. Those concerned
about the nutritional quality of their diet should consult a qualified
health-care professional for an evaluation; if a supplement is indicated,
one can be recommended that will compensate for nutrients in short
supply in the diet.
Consumers who choose independently to take dietary supplements
should limit themselves to products that do not contain excessive
amounts of any nutrients. Label information pertaining to the U.S.
Recommended Daily Allowances (USRDAs) can be used to evaluate
and compare products. USRDAs are a set of values developed by the
Food and Drug Administration on the basis of the 1968 (seventh)
edition of the RDAs (NRC, 1968) to be used as standards for the
nutritional labeling of foods and dietary supplements. The USRDAs
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INTERPRETATION AND APPLICATION OF RECOMMENDATIONS
109
are generally the highest RDA values for each nutrient (excluding
values for pregnant and lactating women) given in that edition, in
which nutrient allowances were generally higher than they are in the
most recent (tenth) edition (NRC, 1989b). Thus, USRDAs are very
generous standards. A healthy person who takes a daily supplement
containing 100% of the USRDA for nutrients will probably consume-
from food and the supplement some vitamins and minerals at lev-
els two to three times his or her RDAs and thus will very likely
exceed his or her actual nutrient requirements. These levels, while
not known to be harmful, are unlikely to confer better health.
(9) Maintain an optimal intake offluoride, particularly during the years
of primary and secondary tooth formation and growth.
The Committee on Diet and Health recommended that people of
all ages consume water with a natural or added fluoride content ranging
from 0.7 to 1.2 parts per million to reduce the risk of dental caries.
Drinking such water is especially important for children during the
years of primary and secondary tooth formation and growth. In the
absence of optimally fluoridated water, that committee supported
the use of dietary fluoride supplements in amounts recommended by
the American Dental Association, the American Academy of Pediatrics,
and the American Academy of Pediatric Dentistry (these levels are
summarized in NRC, 1989a).
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Representative terms from entire chapter:
total fat
