Scientific Report of the 2015 Dietary Guidelines Advisory Committee

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Part D. Chapter 1: Food and Nutrient Intakes, and Health: Current Status and Trends - Continued

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Food Groups—Current Intakes and Trends

Introduction

As noted for Questions 5 and 6, to help the U.S. population meet recommended dietary goals and improve their health and well-being, the USDA recommends a food-based, total diet approach for meeting the U.S. Dietary Guidelines.44 45

The USDA Food Patterns have changed over time to be consistent with emerging science that is presented in each issuance of the Guidelines. The current USDA Food Patterns identify amounts of foods to consume from five major food groups (fruits, vegetables, grains, protein foods, and dairy) and their sub-groups (dark green vegetables, orange and red vegetables, starchy vegetables, other vegetables, beans and peas, whole grains, enriched/refined grains, meat/poultry/eggs, nuts, seeds, soy products, seafood) and are based on nutrient-dense foods.44 45 In 2010, the DGAC developed a vegetarian adaptation of the Food Patterns to provide guidance for consumers wishing to follow a vegetarian diet. For 2015, the DGAC developed a new Healthy Vegetarian Food Pattern based on food intakes of vegetarians. The 2015 DGAC also provided a Mediterranean-style Food Pattern due to the data supporting the health-related benefits of a Mediterranean-style diet (see Dietary Patterns section, Question 20, and Part D. Chapter 2: Dietary Patterns, Foods and Nutrients, and Health Outcomes). The food groups chosen for all the Patterns include primarily nutrient-dense foods. The patterns are intended to meet the RDA for nutrients so that nutritional adequacy is met without exceeding recommended energy intake. They also are designed so that they are below the 2010 DGA limits for sodium and saturated fat. Recommended amounts to consume from each food group differ depending on an individual’s energy and nutrient needs. Patterns are provided for 12 different calorie levels (Table D1.10) and assignment to one of these calorie levels is based on age, sex, and activity level (Table D1.11). In addition, the Patterns provide for limited amounts of solid fats and added sugars. The complete Food Pattern modeling report (including a listing of the nutrients considered for the Patterns) is found in Appendix E3.1, and details on the methods used to derive the Patterns have been published.44 46 47

Question 7: What are current consumption patterns of USDA Food Pattern food groups by the U.S. population?

Source of evidence: Data analysis

Conclusion

Positive, healthy eating habits provide an excellent foundation for a lifetime of healthy eating. Many young children start out eating very well, particularly with regard to intakes of fruit and dairy foods. Unfortunately, many of these early life healthy habits seem to disappear as children reach school age and beyond. Across all age and sex groups, the vast majority of the U.S. population does not meet recommended intakes for fruit, vegetables, whole grains, and dairy food groups. Each of these food groups are excellent sources of shortfall nutrients and underconsumed nutrients of public health concern. Across all age and sex groups, the vast majority of the U.S. population exceeds recommended intakes of refined grains, solid fats, and added sugars.

Implications

To realize the numerous health benefits from dietary patterns that are higher in fruit, vegetables, whole grains, lean protein, and non-fat and low-fat dairy (see Part D. Chapter 2: Dietary Patterns, Foods and Nutrients, and Health Outcomes for details on the health benefits for dietary patterns with these characteristics), action is needed across all sectors of food production, distribution, and consumption and at individual behavioral and population levels. Individuals, families, schools, worksites, healthcare and public health settings, restaurants, and other food establishments must work together to ensure that all segments of the population can:

  • Increase intake of underconsumed food groups and nutrient-dense foods, while maintaining energy balance, and without increasing saturated fat, sodium, and added sugars

Given the complexity of dietary behavior change, consumers will need access to evidence-based educational resources and intervention programs and services in public health and healthcare settings to facilitate adoption and maintenance of healthy dietary behaviors. (See Part D. Chapter 3: Individual Diet and Physical Activity Behavior Change for discussion of what works at the level of individual behavior change and Part D. Chapter 4: Food Environment and Settings for discussion of population change through environmental strategies.)

Within the Dairy and Vegetable groups, the following dietary changes in particular will help increase intake of shortfall nutrients and will decrease intake of overconsumed nutrients by the U.S. population:

  • Increasing low-fat/fat-free fluid milk and yogurt and decreasing cheese would result in higher intakes of magnesium, potassium, vitamin A, and vitamin D while simultaneously decreasing the intake of sodium and saturated fat.
  • Replacing soft drinks and other sugar-sweetened beverages (including sports drinks) with non-fat fluid milk would substantially reduce added sugars and empty calories and increase the intake of shortfall nutrients, including calcium, vitamin D, and magnesium.
  • Consuming all vegetables, including starchy vegetables, with minimal additions of salt and solid fat will help minimize intake of overconsumed nutrients – sodium and saturated fat.

Review of the Evidence

This question was answered using data from the WWEIA, NHANES dietary survey (2007-2010) and the National Cancer Institute’s examination of the usual intake distributions and percent of the U.S. population meeting USDA Food Pattern recommendations for their age and sex. 44 48 49 It is important to note that the Dietary Guidelines for Americans are established only for those ages 2 years and older. However, the WWEIA, NHANES sample includes persons from birth. The NHANES data are presented in these specific age groups that cannot be further divided.

Fruit. When consumed in the amounts recommended in the USDA Food Patterns, fruit contributes substantial amounts of two nutrients of public health concern: fiber and potassium. (Whole fruit and fruit juice provide about 16 percent of dietary fiber and 17 percent of potassium in the Food Patterns (see Appendix E-3.2: Food Group Contributions to Nutrients in USDA Food Patterns and Current Nutrient Intakes).

The majority of children ages 1 to 3 years and 4 to 8 years meet the recommended intakes for total fruit, which is 1 cup and 1 to 1.5 cups per day, respectively. Among older children (boys and girls ages 9 to 13 years), adolescents, and adults of all ages (both men and women), few people consume the recommended daily amounts, which range from 1.5 to 2 cups for older children and adolescents to 1.5 to 2.5 cups for adults (Figure D1.9). Among the overall U.S. population, approximately 15 percent meet the daily fruit intake recommendation while nearly 80 percent do not meet the recommendation.

More than half of the daily fruit intake for all age and sex groups in the U.S. population (ages 1 year and older) comes from whole fruit (Figure D1.10). Among both boys and girls ages 1 to 3 years, whole fruit comprises slightly more than half of the daily fruit intake and the remainder is consumed though 100% fruit juice. The American Academy of Pediatrics (2001)50 recommends that young children limit their juice intake to 4 to 6 ounces per day. Six ounces of juice is 0.75 cups; the average juice intakes fall within this recommended limit suggesting that juice is not overconsumed among many young children. Among children ages 4 to 8 and 9 to 13 years, fruit intake includes both 100% juice and whole fruit, but whole fruit comprises the majority of intake. Among middle aged and older adults, most of the fruit intake is from whole fruit, albeit below recommended levels, rather than 100% juice.

Vegetables. Vegetables are excellent sources of many shortfall nutrients and nutrients of public health concern. When vegetables are consumed in the amounts recommended in the USDA Food Patterns, vegetables contribute the following (expressed as averages over all the calorie levels): fiber (38 percent), potassium (36 percent), iron (19 percent), folate (23 percent), and vitamin A as provitamin A carotenoids (34 percent). Note that select vegetables do contribute to calcium intake, including spinach, collard greens, turnip greens, but these vegetables are often consumed in smaller amounts than is needed to be considered important sources of calcium (Table D1.6 and Appendix E-3.2: Food Group Contributions to Nutrients in the USDA Food Patterns and Current Nutrient Intakes).

The U.S. population consumes few vegetables (Figure D1.11). Only 10 percent and 15 percent of boys and girls ages 1 to 3 years, respectively, consume the recommended 1 cup of vegetables per day. For children ages 4 to 8 years, less than 5 percent consume the recommended amount of 1.5 to 2 cups of vegetables per day. Vegetable consumption is lowest among boys ages 9 to 13 years (1 percent consume the recommended 2 to 2.5 cups per day) and girls ages 14 to 18 years (less than 1 percent consume the recommended 2 to 2.5 cups/day). Vegetable intakes increase slightly during the adult years, but intakes are still very low. Among young adult males and females ages 19 to 30 years, less than 10 percent meet the 2 to 3.5 cups/day recommendation. Intakes increase only slightly in subsequent age decades (31 to 50 years). Middle aged adults (51 to 70 years) are somewhat closer to the goal as they have the highest vegetable intakes. Even so, only about 20 percent of men and about 30 percent of women meet the daily recommendation of 2 to 3.5 cups per day. Although these intake levels are still below optimal, the positive gains in vegetable consumption are noteworthy. However, vegetable intakes fall again among older adults (71 years and older), with less than 20 percent of men and women meeting intake recommendations. Overall, nearly 90 percent of the U.S. population does not meet daily vegetable intake recommendations.

The USDA Food Pattern food group for vegetables includes five subgroups: dark green vegetables, red and orange vegetables, beans and peas, starchy vegetables, and other vegetables. The U.S. population does not meet intake recommendations for any of these vegetable subgroups (Figures D1.12 to D1.16). More than 80 percent of the U.S. population does not meet the intake recommendation for dark green vegetables, starchy vegetables, and beans and peas, while more than 90 percent do not meet the recommended intakes for red and orange vegetables. “Other vegetables” (Figure D1.16) is a broad group that includes iceberg lettuce, green beans, cucumbers, celery, onions, summer squash, mushrooms, and avocados. More than 50 percent of males and females ages 51 to 70 years meet or exceed the recommended intake amounts of other vegetables and among all ages, nearly 40 percent meet or exceed the recommended intake. Intake of “other vegetables” is more likely to meet recommendations than the other four subgroups, but consumers should be encouraged to increase intake of all vegetables. To meet total vegetable recommendations, higher intakes of all vegetable subgroups are needed, particularly those subgroups where intake is minimal, such as dark green and orange and red vegetables, which are excellent sources of vitamin C, folate, magnesium, and potassium.

Potatoes (white potatoes) are the most commonly consumed single vegetable, and make up about 80 percent of all starchy vegetable consumption.51 They account for 25 percent of all vegetable consumption and are a good source of both potassium and fiber. Among children and adolescents ages 2 to 19 years, they account for 28 percent to 35 percent of total vegetable consumption, with a higher percentage of vegetables consumed as potatoes among boys than girls in each age category. Potatoes are consumed in a variety of forms, with about 31 percent being boiled (including mashed and in dishes such as potato salad, soups, and stews), 22 percent as chips, sticks, or puffs, 19 percent as French fries, 17 percent as baked, and 12 percent as home fries or hash browns.

Grains (whole and refined). The 2010 Dietary Guidelines for Americans recommended that half of all grain intake should come from whole grains. The 2015 DGAC brings forward this recommendation and here we give rationale and results to support this decision. The background and summary of previous food pattern modeling with respect to grains is important to present here so as to provide context for the 2015 DGAC recommendations.

Whole grains are those “foods made from the entire grain seed, usually called the kernel, which consists of the bran, germ and endosperm. If the kernel has been cracked, crushed or flaked, it must retain nearly the same relative proportions of bran, germ and endosperm as the original grain in order to be called whole grain.”52 p.134 Examples of whole grains are brown rice, popcorn, bulgur, whole wheat, oats, and barley. If whole grains were consumed in the amounts recommended in the Food Patterns, whole grains would provide substantial percentages of several key nutrients, such as about 32 percent of dietary fiber, 42 percent of iron, 35 percent of folate, 29 percent of magnesium, and 16 percent of vitamin A (see E-3.2: Food Group Contributions to Nutrients in USDA Food Patterns and Current Nutrient Intakes).

Across all ages and both sexes, the U.S. population does not meet the goal for whole grain intake, as nearly 100 percent of the population consumes amounts that are below the recommended intake levels (Figure D1.17), which range from 1.5 ounce equivalents (oz eq) for young children up to 3 to 3.5 oz eqs for older children and adolescent and adult females. Adolescent and adult males are advised to consume 3 to 4 oz eqs per day. The inadequate intake of whole grains leads to underconsumption of several shortfall nutrients and nutrients of public health concern. Refined grains, such as white flour and products made with white flour, white rice, and de-germed cornmeal, are part of the intake recommendation because they are commonly enriched with iron and several B vitamins, including thiamin, niacin, and riboflavin (e.g., enriched flour, 21 CFR 137.165).53 p.452 Since 1998, enriched grains also have been fortified with folic acid and are thus an important source of folic acid for women of childbearing potential.53 54 The effect of the folic acid fortification on the health status of the U.S. population was extensively reviewed by the 2010 DGAC and so was not re-reviewed by the 2015 DGAC. The 2010 DGAC concluded that strong and consistent evidence demonstrates a large reduction in the incidence of neural tube defects (NTDs) in the United States and Canada following mandatory folic acid fortification. They also found only limited evidence to suggest a decline in stroke mortality in the United States and Canada and an increase in colorectal cancer in those countries following mandatory folic acid fortification. Due to the very limited evidence, cause and effect cannot be attributed for folic acid fortification and either stroke or colorectal cancer incidence. The 2015 DGAC brings forward those results with no notable changes in the interpretation of the data presented in 2010. Despite the B vitamins and iron that can be obtained from enriched and fortified refined grains, products made with refined grains also may be a source of excess calories and added sugars. (See Question 11c, food categories, below, and added sugars discussion in Part D. Chapter 6: Cross-Cutting Topics of Public Health Importance.) Figure D1.18, documents that the U.S. population consumes far too many refined grains. In the overall population for all ages and for both males and females, about 19 percent meet the recommendation for refined grains, while more than 70 percent exceed the recommendation. Intake of refined grains is particularly high among boys and girls ages 4 to 8 years and girls ages 9 to 13 years.

Due to the overconsumption of refined grains and the underconsumption of whole grains relative to the 2010 recommendation that “half of all grain intake should come from whole grains,” the DGAC decided that it was important to examine the impact on nutrient intake if: (1) refined/enriched grains intake were reduced to no more than 25 percent or 15 percent of the total grains intake; and (2) overall grain intake were reduced. The Committee relied on food pattern modeling analyses conducted by the 2005 and 2010 DGACs to answer these questions, and brings forward their recommendations, as reiterated below.

The key finding from the 2010 DGAC modeling report was: “As shown by food pattern modeling, consumption of all grains as whole grains, without including any fortified whole grain products, would lower dietary folate and iron intake levels to less than adequate amounts for individuals in population groups who may be at high risk for inadequate intakes of these nutrients. Individuals are encouraged to consume most of their grains as fiber-rich whole grains, and when doing so, should select some of these fiber-rich whole grains as products that have been fortified with folic acid and possibly other nutrients”. 55 p.146

In its analysis, the 2005 DGAC reported that non-whole grains contributed important amounts of certain nutrients to the dietary patterns, including folate, iron, calcium, fiber, thiamin, riboflavin and niacin.56 append G-2 The 2005 DGAC concluded that including only 3 oz eqs of whole grains, with no non-whole grains, in the food patterns would lower intake of many of these key nutrients and perhaps place certain individuals at risk of nutrient inadequacy. However, the 2010 DGAC found that consuming all grains as whole grains would provide for nutrient adequacy in the patterns if fortified ready to eat (RTE) whole grain breakfast cereals were substituted for RTE refined grain breakfast.55 append E.7 The 2015 DGAC concluded that consumption of only whole grains with no replacement or substitution would result in nutrient shortfalls.

Dairy. Dairy foods in the USDA Food Patterns include fluid milk, cheese, yogurt, ice cream, milk-based replacement meals and milk products, including fortified soymilk, but do not include almond or other plant-based “milk-type” products. Dairy foods are excellent sources of nutrients of public health concern, including vitamin D, calcium, and potassium. Consumption of dairy foods provides numerous health benefits including lower risk of diabetes, metabolic syndrome, cardiovascular disease and obesity.57-62 When consumed in the amounts recommended by the Food Patterns, on average across the calorie levels, dairy foods contribute about 67 percent of calcium, 64 percent of vitamin D, and 17 percent of magnesium (see Appendix E-3.2: Food Group Contributions to Nutrients in the USDA Food Patterns and Current Nutrient Intakes). The Patterns recommend consumption of low-fat and fat-free foods in the Dairy group to ensure intake of these key nutrients while minimizing intake of saturated fat, which is a nutrient of concern for overconsumption.44

More than 60 percent of young boys and girls ages 1 to 3 years meet or exceed the recommended intake of 2 cup eqs per day, with most of this intake coming in the form of fluid milk (see Figure D1.19 and Appendix E-3.4: USDA Food Patterns—Adequacy for Young Children). Intake falls in older children to about 30 percent of boys and girls meeting or exceeding the recommended 2.5 cup eqs per day for those ages 4 to 8 years and 3 cup eqs per day for children ages 9 to 13 years. About 30 percent of adolescent boys meet or exceed the recommended 3 cup eqs per day, but less than 10 percent of adolescent females meet or exceed this recommendation. An age-related decline in dairy intake appears to begin in adolescence and intakes persist at very low levels among adult females across the age distribution. Less than 5 percent of adult females consume the recommended 3 cup equivalents per day. Overall, more than 80 percent of the entire U.S. population does not meet the daily dairy intake recommendation.

To determine the extent to which individuals could meet recommendations for calcium and other shortfall nutrients intake, given various levels of dairy foods in the Food Patterns, the 2015 DGAC conducted a food pattern modeling analysis (see Appendix E-3: Dairy Group and Alternatives). The DGAC considered nutrient adequacy of the Food Patterns under the following scenarios: 1) no dairy was consumed; 2) calcium was obtained from non-dairy sources (including fortified foods); and 3) the proportions of yogurt and cheese in the patterns were modified. The DGAC further evaluated the relationship between changes in the types of beverages consumed (milk, fruit juices, fruit drinks and sports beverages) and diet quality.

If no dairy is consumed, the modeling analysis shows that levels of calcium, magnesium, iron, vitamin A and riboflavin, drop below 100 percent of goals, and intake levels of potassium, vitamin D and choline also drop substantially. When no dairy is consumed, calcium intake levels drop by 68 to 88 percent in all age and sex groups, while vitamin D intake is lowered by 20 to 30 percent (see Appendix E-3.6: Dairy Group and Alternatives, Table 2). Most of the milk alternatives are fortified with calcium, so similar amounts of calcium can be obtained from fortified rice, soy and almond milks, and fortified juices, but absorption of calcium is less efficient from plant beverages.63 Magnesium intake also is comparable from plant-based milk alternatives. However, vitamin D and potassium amounts vary across these milk alternatives (see Appendix E-3.6: Dairy Group and Alternatives, Table 3). Calorie levels also are higher for most of the plant-based alternative milk products for a given calcium intake level. In other words, to obtain a comparable amount of calcium as one cup eq for non-fat fluid milk, the portion size required to meet the calcium intake need results in higher energy intake (see Appendix E-3.6: Dairy Group and Alternatives, Table 4).

Currently, the U.S. population consumes the recommended 3 cup equivalents/day as 53 percent fluid milk, 45 percent cheese, and 2 percent as yogurt. Through the food pattern modeling, the DGAC examined the effect on nutrient intake if fluid milk were to be increased and cheese decreased. Increasing the proportion of fat-free milk, while decreasing the proportion of cheese, would increase the intake of magnesium, potassium, vitamin A, vitamin D and would decrease intake of sodium and saturated fat (see Appendix E-3.6: Dairy Group and Alternatives, Table 5). A potential approach to increasing intake of shortfall nutrients and nutrients of public health concern while simultaneously decreasing intake of overconsumed nutrients of public health concern would be to increase intake of fat-free or low-fat fluid milk in lieu of cheese.

If milk is completely eliminated from the diet and replaced by soft drinks, fruit drinks, sports beverages, and other sugar-sweetened beverages, diet quality deteriorates significantly, making it very hard for individuals to meet nutrient recommendations (see Appendix E-3.6: Dairy Group and Alternatives, Table 6). Indeed, among U.S. adolescents’ milk consumption is very low as are intakes of the “shortfall” nutrients.

Protein Foods. Protein Foods comprise a broad group of foods including meat, poultry, fish/seafood, eggs, soyvi, nuts, and seeds. Dairy also contains protein, but since it has its own food group, its nutrient contributions are counted in its own group. The inclusion of both animal and non-animal protein foods allows vegetarian options to be accommodated. In addition to providing essential amino acids, some protein foods are important sources of iron, and iron is a shortfall nutrient and nutrient of public health concern among adolescent and adult females. Meat foods in the protein group provide heme iron, which is more bioavailable than non-heme plant-derived iron. Heme iron is especially important for young children and women who are pregnant.

Nearly 80 percent of boys and 75 percent of girls ages 1 to 3 years meet or exceed the protein foods recommendation of 2 ounce equivalents per day (Figure D1.20). Similarly, more than 60 percent of boys and girls ages 4 to 8 years meet or exceed the recommended intake of 3 to 4 oz eqs/day. Intake declines somewhat for boys and girls ages 9 to 13 years, as approximately 40 percent and 45 percent meet or exceed the recommended 3 ounce equivalents/day. Although nearly 60 percent of adolescent males ages 14 to 18 years meet the 5.5 to 6.5 oz eq/day recommendation, less than 25 percent of females ages 14 to 18 meet their 5-5.5 oz eq/day recommendation. Intakes begin to increase again for adult males across the age distribution, and about 62 percent of males ages 31 to 50 and 78 percent of males 51 to 70 years meet the 5.5-6.5 oz eq/day intake recommendation. For adult females ages 19 to 30 years, slightly more than 40 percent meet the 5 to 5.5 oz eq/day recommendation and approximately 50 percent of those ages 31 to 50 and about 50 percent of those 51 to 70 years meet the recommendation. Protein foods intake declines in both men and women older than age 71 years; about 30 percent of women and about 50 percent of men meet the recommendation. Across all age groups and in both males and females, nearly 60 percent of the U.S. population meets the protein foods intake recommendation. Although some groups in the U.S. population do not consume recommended amounts from the protein foods group, intakes of protein (as grams/day) are adequate across the population and protein is not a shortfall nutrient. Notably, protein intake also comes from dairy and grains in addition to the foods included in the protein foods group.

Most of the protein foods intake across all age groups and for both males and females comes from meat, poultry, and eggs (Figure D1.21). Nearly 80 percent of the U.S. population meets the intake recommendation for this protein foods subgroup (although less so for adolescent girls and older women).

In 2010, the DGAC recommended that seafood intake be increased to eight ounces per week for adults. In reviewing the WWEIA/NHANES data, the DGAC 2015 found that the U.S. population has low seafood intake. Across all age groups and for both males and females, only 10 percent of the population meets the 2010 intake recommendations (Figure D1.22). Intake is highest in adult men and women, but remains very low. In the highest intake group, males ages 51 to 70 years, 21 percent of the population meets the intake recommendation.

In addition to reviewing WWEIA/NHANES data, the 2015 DGAC considered the potential influence on diet quality of substituting seafood for terrestrial animal foods (e.g., beef, poultry, pork, game meats). This question was addressed by the 2010 DGAC through a modeling analysis, and the 2015 DGAC decided to bring forward those modeling results. These results indicate seafood could be increased to 8 ounces/week (for adults) with no negative impact on nutrient adequacy.55 app E3.10 This 8 oz amount contributes energy, protein, selenium, vitamin D, and vitamin B-12. With respect to fatty acids, fish is rich in the long-chain eicosapentanoic acid (EPA) and docosahexonoic acid (DHA) and has a higher proportion of total fatty acids coming from polyunsaturated and monounsaturated fatty acids relative to saturated fatty acids. The 2015 DGAC also has examined the sustainability of fish production and consumption, and these results are discussed in Part D. Chapter 5: Food Sustainability and Safety.

Nuts, seeds, and soy. Nuts, seeds, and soy provide protein, selenium, polyunsaturated fatty acids, fiber, magnesium, and zinc. Nuts, seeds, and soy are less commonly consumed protein foods (Figure D1.23). Even so, overall approximately 40 percent of the U.S. population meets or exceeds the food pattern recommended intake of these protein foods.

Empty calories. Solid fats that occur naturally in foods such as meat, dairy, and some tropical foods (e.g., coconut), and sugars that are added to foods either by the consumer or by food manufacturers are referred to as “empty calories” because both provide calories, but few or no nutrients. For the purposes of the USDA Food Pattern Food Groups, the term solid fats and added sugars is an analytic grouping, but going forward for 2015, the DGAC has elected to use the term “empty calories.”

Calories from solid fats and added sugars are included for the USDA Food Patterns because they are a component of the diet that should be limited because they are not nutrient-dense and the solid fats contribute to saturated fat intake, which is overconsumed in the U.S. population (see Nutrient Intake/Nutrients of Concern section, Questions 1 and 2). Solid fats and added sugars are not food groups on their own, as are protein foods, dairy, grains, fruits, and vegetables, but they are included in the Food Patterns because they are an integral component of many foods consumed by the U.S. population either because they occur naturally (in the case of some solid fats) or they are added to foods, such as added sugars or fat added during processing, cooking, or other aspects of food preparation. Additional details about added sugars and saturated fat are provided in Part D. Chapter 6: Cross-Cutting Topics of Public Health Importance.

Because added sugars and solid fats are not nutrient dense and solid fats contribute to saturated fat intake, the USDA Food Patterns recommend that intake be limited. The guidance on the approximate amounts of solid fats and added sugars that can be part of a healthful diet is as follows: children ages 2 to 8 years: 120 calories/day; children 9 to 13 years: 120 to 250 calories/day; girls ages 14 to 18 years: 120 to 250 calories/day; boys ages 14 to 18: 160 to 330 calories/day; adult women: 120 to 250 calories/day; and adult men: 160 to 330 calories/day. Intake limits varies by age and sex and are based on residual calories after all food group intakes are met. The intake limits include solid fats and added sugars from all sources in the diet: from sugar in sugar-sweetened beverages, including coffee and tea, and breakfast cereals, to solid fats in burgers, sandwiches, and pizza, to the combination of solid fats and added sugars in snacks and desserts such as cookies, cakes, ice cream, and donuts. Question 11 of the Food Categories section of this Chapter provides information on food sources of solid fats and added sugars.

The intake of solid fats and added sugars is very high across all age groups and for both males and females in the United States, with nearly 90 percent exceeding the recommended daily limits (Figure D1.24). Particularly noteworthy is that nearly 100 percent of boys and girls ages 1 to 3 and 4 to 8 years exceed the recommended limit for solid fats and added sugars (see Part D. Chapter 6: Cross Cutting Topics of Public Health Importance).

For additional details on this body of evidence, visit:

Question 8: What are the trends in USDA Food Pattern food group consumption by the U.S. population?

Source of evidence: Data analysis

Conclusion

The U.S. population has made few dietary changes over time:

  • Fruit intake has remained low but stable.
  • Vegetable intake has declined, particularly among children of all ages, adolescents, and young adult males.
  • Whole grain intake has slightly increased between 2001-2004 and 2007-2010, particularly among middle aged and older adults.
  • Dairy intake has been relatively constant over time, but has decreased for girls ages 4 to 8 years and young adult males, and has increased for adults ages 51 to 70 years.
  • Added sugars intake has decreased for both males and females across all age groups between 2001-2004 and 2007-2010, but intakes still exceed the limit in the USDA food patterns.

Implications

Individuals and families must make conscious and focused decisions about choosing nutrient-dense foods. In addition, to continue progress toward consumption of a healthy diet among all age and sex groups, action is needed along the entire food processing, delivery, and service supply chain in order to provide the U.S. population with affordable and accessible foods that are nutrient dense and low in added sugars and sodium.

Poor nutritional intake is linked to numerous diet-related chronic diseases (see Part D. Chapter 2: Dietary Patterns, Foods and Nutrients, and Health Outcomes) and the prevalence of these conditions is too high in the United States (see Health Conditions section, Questions 15 to 17, below). The health of the nation hinges in part on improving dietary intake at individual and population levels, and changes in line with those suggested here could have a measurable positive impact on the health of the population.

Given the complexity of dietary behavior change, consumers will need access to evidence-based educational resources and intervention programs and services in public health and healthcare settings to facilitate adoption and maintenance of healthy dietary behaviors. (See Part D. Chapter 3: Individual Diet and Physical Activity Behavior Change for discussion of what works at the level of individual behavior change.) In addition, these efforts should be complemented with research-driven environmental strategies that make access to affordable healthy foods possible in retail, community, worksite, and educational settings. (See Part D. Chapter 4: Food Environment and Settings for discussion of effective environmental approaches to promote dietary change across the lifespan.)

Review of the Evidence

This question was answered using data from WWEIA, NHANES dietary survey data and the National Cancer Institute’s examination of usual intake distributions for 2001-200464 and 2007-2010.41

Fruit. Fruit intake remained relatively stable across the 2001-2004 and 2007-2010 time periods (Figure D1.25). The only group with significant changes over time was males ages 31 to 50 years, for whom mean fruit intake decreased.

Vegetables. Vegetable intake declined from 2001-2004 to 2007-2010 (Figure D1.26). Across the overall population, the mean daily vegetable intake significantly declined. Significant declines in mean intake occurred among males ages 1 to 3, 4 to 8, 9 to 13, 14 to 18, and 19 to 30 years. For females, significant decreases in mean vegetable intake occurred for those ages 1 to 3, 4 to 8, and 9 to 13 years.

Grains (whole and refined). Whole grain intake significantly increased among the overall population between 2001-2004 and 2007-2010 (Figure D1.27). Among males, significant increases in mean intake occurred for those ages 1 to 3, 4 to 8, 14 to 18, 31 to 50, and 51 to 70 years. Among females, significant increases in mean whole grain intake occurred for those ages 9 to 13, 19 to 30, 31 to 50, 51 to 70, and 71 years and older (Figure D1.27). Similarly, refined grain intake has declined in all age and sex groups between 2001-2004 and 2007-2010 (Figure D1.28).

Dairy. Dairy intake remained stable over the entire population between 2001-2004 and 2007-2010 (Figure D1.29). Significant declines in mean daily intake occurred between the two time periods for males ages 19 to 30 years and females ages 4 to 8 years. Significant increases in mean daily dairy intake occurred for both males and females ages 51 to 70 years.

Protein Foods. Protein food intake remained relatively stable for the U.S. population between 2001-2004 and 2007-2010 (Figure D1.30). Females ages 31 to 50 and 51 to 70 years had significantly higher mean intake in 2007-2010 compared to 2001-2004. These were the only groups with any significant change over time.

Added Sugars. Some improvements have been made in added sugars intake, with noticeable declines in mean intakes for all age groups and among both males and females when comparing 2007-2010 data with 2001-2004 data (Figure D1.31). As seen in Figure D1.31, intakes of added sugars are still very high, however, and are well above recommended limits, but the improvements provide some optimism for improved diets.

For additional details on this body of evidence, visit:

Food Categories—current intakes and sources of energy, nutrient, and food group intakes

The food sources of nutrients and the patterns in which they are consumed are informative in identifying strategies to modify dietary intake and eating behaviors and help Americans to choose and consume higher quality diets. We examined four questions related to the foods that are top contributors to intakes of energy, food groups, and selected nutrients in the U.S. diet. This section describes those food sources and the implications for meeting recommended or optimal intakes of various food groups and nutrients.

Question 9: What are current consumption patterns by food categories (i.e., foods as consumed) in the U.S. population?

Source of evidence: Data analysis

Conclusion

The mixed dishes food category, which includes foods commonly used as entrees, such as sandwiches, burgers, pizza, pasta or rice mixed dishes, stir-fries, soups, and meat or poultry mixed dishes, is the major contributor to three USDA Food Pattern food groups—grains, vegetables, and protein foods. Fruit and fluid milk intake are seldom consumed as part of mixed dishes. The mixed dishes food category contributes heavily to intake of energy, saturated fat, and sodium; however, mixed dishes do provide vegetables, fiber, grains, and dairy.

Implications

An important strategy for meeting recommended intake levels of calories, saturated fat, and sodium is to change the composition of mixed dishes that are high in calories, saturated fat, and sodium to better meet these nutrition goals. Food manufacturers and the food service sector (e.g., restaurants, schools) should reformulate mixed dishes to improve their nutritional profiles. Americans should be encouraged to modify recipes to lower the sodium and saturated fat content when cooking, to use appropriate portion sizes, and choose reformulated mixed dish options when available.

Review of the Evidence

These conclusions were reached by examining data from the WWEIA Food Categories for the NHANES 2009-2010 dietary survey.65 The WWEIA Food Categories provide an application that allows analysts to examine foods and beverages as consumed in the U.S. diet. Each food or beverage item (as consumed) that is included in WWEIA is placed in one of 150 mutually exclusive food categories. The focus of this categorization system is on grouping similar foods and beverages together based on usage and nutrient content.

An adaptation of the food categories was used by the 2015 DGAC for this analysis related to the “sandwiches and burgers” and “salads” categories. We placed all food items reported to be eaten as a sandwich, burger, taco, or salad item into the “sandwiches and burgers” or the “salads” categories regardless of whether the components were reported as separated ingredients or as a single combined item. For example, a food reported as a “cheeseburger” (a single item) would always be classified in the category of “burgers, sandwiches, and tacos,” but a food reported as the individual food items of a hamburger bun, a hamburger patty, and cheese, eaten as a combination, would have been classified in the categories of “rolls and buns,” “ground meat,” and “cheese.” The adaptation recoded these individually reported foods that were eaten in combination to “burgers, sandwiches, and tacos.” By doing this, the categories used for this analysis more fully represented foods as consumed rather than as ingredients.

The 150 categories from WWEIA were condensed into 9 major and 32 sub-categories for analysis of the percent of total intake for energy, nutrients, and food groups from each major and sub-category (see Appendix E-2.7: Major categories and subcategories used in DGAC analyses of WWEIA Food Categories). Analysis was conducted for the population ages 2 and older as a whole; analysis of the percent of energy intake also was conducted for males and females ages 2 to 5, 6 to 11, 12 to 19, 20 to 40, 41 to 50, 51 to 70, and 71 years and older; for race/ethnic groups including Non-Hispanic Whites, Non-Hispanic Blacks, and Hispanics ages 2 years and older; and for those with incomes less than or equal to 185 percent, or greater than 185 percent of the Poverty Index Ratio by three age groups: 2 to 11, 12 to 19, and 20 years and older.

WWEIA data show that Americans consume a substantial amount of foods in the form of mixed dishes (Figure D1.32). More specifically, 31 percent of vegetables, 45 percent of grains, 30 percent of dairy, and 45 percent of protein foods come from mixed dishes. Mixed dishes (which include foods such as sandwiches, burgers, pizza, pasta or rice mixed dishes, stir-fries, soups, and meat or poultry mixed dishes) make up 28 percent of total energy intake. Of note, only small amounts of fruits (1 percent) and fluid milk (3 percent) are consumed in mixed dishes—most are consumed as single food items, such as an apple or glass of milk (see Appendix E-2.8: Percent of total food group intake, 2009-2010, for U.S. population ages 2 years and older, from WWEIA Food Categories).

When mixed dishes contribute to dairy foods, the majority of intake is in the form of cheese. Data show that about two-thirds of all cheese intake is from mixed dishes such as pizza, burgers, sandwiches, and casseroles. Given that cheese is generally higher in saturated fat and sodium and lower in potassium and vitamin D than is fluid milk (see Question 7b, above, and Appendix E-3.6: Dairy Group and Alternatives), modifying the types of cheese products used in these mixed dishes to lower fat and sodium versions would improve their nutritional profile.

When mixed dishes contribute to the grains group, a larger percentage of refined (48 percent) than whole (19 percent) grains are consumed as part of these dishes. Substitution of whole for refined grains in mixed dishes such as burgers, sandwiches, pizza, and casseroles containing pasta or rice could improve the nutritional profile of grains that are consumed this way.

Although mixed dishes account for a substantial amount of intake of some overconsumed nutrients (43 percent of sodium, 36 percent of saturated fat), they also account for 28 percent of fiber, 29 percent of calcium, 24 percent of potassium, and 16 percent of vitamin D, all of which are underconsumed nutrients. Other food categories that contribute substantially to overall energy, sodium, saturated fat, and added sugars intake are discussed in the following two questions—Question 10: “What are the top foods contributing to energy intake in the U.S. population?” and Question 11: “What are the top foods contributing to sodium, saturated fat, and added sugars intake in the U.S. population?”

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Question 10: What are the top foods contributing to energy intake in the U.S. population?

Source of evidence: Data Analysis

Conclusion

Seventy-five percent of total energy intake in the U.S. population comes from 16 of the 32 food sub-categories, with mixed dishes, snacks and sweets, and beverages together contributing to more than half (56 percent) of energy intake in the U.S. population.

Implications

The foods with the highest contribution to energy intake are burgers, sandwiches, and tacos; desserts and sweet snacks; and sugar-sweetened beverages. Given the link to energy intake, reduced consumption of these foods and beverages or modifying the ways these foods are prepared, as well as consumption of smaller portion sizes, may help prevent excess weight gain or may help with weight reduction.

Public health strategies (e.g., programs, regulations, and policies) and product reformulation are needed to help individuals achieve recommendations.

Review of the Evidence

These conclusions were reached by examining data from the WWEIA Food Categories for the NHANES 2009-2010 dietary survey,65 as described in relation to question 9 (current consumption patterns by food categories in the U.S. population).

The top foods contributing to energy intake in the U.S. population are concentrated in several food categories, as shown in Figure D1.33. Three food categories account for more than half (56 percent) of all energy consumed: 1) Mixed dishes (which include foods such as sandwiches, burgers, pizza, pasta or rice mixed dishes, stir-fries, soups, and meat or poultry mixed dishes); 2) snacks and sweets, which includes foods such as chips, cakes, pies, cookies, doughnuts, ice cream, and candy.), and 3) beverages other than milk and 100% fruit juice (such as soft drinks, fruit drinks, coffee and tea, and alcoholic beverages)

Examining energy intake from the more specific 32 food subcategories shows that almost half of total energy intake comes from just 7 of these sub-categories (Table D1.12): Burgers and sandwiches (13.8 percent); desserts and sweet snacks (8.5 percent); sugar-sweetened beverages (6.5 percent); rice, pasta, and grain-based mixed dishes (5.5 percent); chips, crackers, and savory snacks (4.6 percent); pizza (4.3 percent); and meat, poultry, and seafood mixed dishes (3.9 percent). Further examination of the 32 subcategories shows that 75 percent of all energy intake comes from the 7 subcategories previously described, plus vegetables (including starchy vegetables), alcoholic beverages, yeast breads and tortillas, whole and 2 percent milk and yogurt, breakfast cereals and bars, poultry, and candy and sugars.

As noted in Question 9, (current consumption patterns by food categories in the U.S. population), some of the food sub-categories that provide substantial amounts of energy also provide underconsumed food groups and nutrients. On the other hand, several of these subcategories, notably desserts and sweet snacks and sugar-sweetened beverages, tend to contribute to energy intake with little contribution to underconsumed food groups (see Appendix E-2.8: Percent of total food group intake, 2009-2010, for the U.S. population ages 2 years and older, from WWEIA Food Categories) and nutrients (see Appendix E-2.9: Percent of total energy and nutrient intake, 2009-2010, for the U.S. population ages 2 years and older, from WWEIA Food Categories), but major contributions to one or more overconsumed food components (see Question 11: What are the top foods contributing to sodium, saturated fat, and added sugars intake in the U.S. population?)

Analysis of the food sources of energy by age and sex groups showed the expected higher percent of energy from dairy among children, especially young children, but no other major differences. Analysis by racial/ethnic groups and by income groups did not show major differences (see Appendix 2.10: Percent of total energy intake, 2009-2010, for age/sex groups of the U.S. population, from WWEIA Food Categories, Appendix E-2.11: Percent of total energy intake, 2009-2010, for racial/ethnic groups of the U.S. population, from WWEIA Food Categories, and Appendix E-2.12: Percent of total energy intake, 2009-2010, for age/income groups of the U.S. population, from WWEIA Food Categories).

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Question 11: What are the top foods contributing to sodium, saturated fat, and added sugars intake in the U.S. population?

Source of evidence: Data analysis

Conclusion

Mixed dishes are the largest contributor to intake of sodium (44 percent) and saturated fat (38 percent). Sodium and saturated fat have both been identified as nutrients of concern for overconsumption. Within mixed dishes, the sub-category of burgers and sandwiches is the largest contributor for both nutrients.

Sodium is ubiquitous in the food supply and many food categories contribute to intake.

Beverages supply 47 percent of added sugars intake.

Snacks and sweets also are a major contributor to added sugars (31 percent) and saturated fat intake (18 percent).

Implications

To decrease dietary intake from added sugars, the U.S. population should reduce consumption of sugar-sweetened beverages and of desserts and sweet snacks.

The U.S. population can use a variety of strategies to reduce consumption of sodium, saturated fat, and added sugars, including smaller portion sizes, reduced frequency of consumption, and recipe modification.

Given the ubiquity of sodium in the food supply, concerted efforts to reduce sodium in commercially prepared and processed foods, as well as encouragement of home cooking using recipes with small amounts of sodium are needed to decrease intake toward recommended levels.

Review of the Evidence

These conclusions were reached by examining data from the WWEIA Food Categories for the NHANES 2009-2010 dietary survey,65 as described in relation to Question 9 (current consumption patterns by food categories in the U.S. population).

The category of mixed dishes contributes substantially more saturated fat (36 percent) and sodium (43 percent) to diets of the U.S. population than does any other category. Within this category, the largest share of both saturated fat (19 percent) and sodium (21 percent) comes from the subcategory of burgers, sandwiches, and tacos. The other subcategories that also contribute notable amounts of saturated fat and sodium are pizza (approximately 6 percent for both); rice, pasta, and other grain-based mixed dishes (5 percent and 7 percent); and meat, poultry, and seafood mixed dishes (5 percent and 7 percent). Soups contribute a notable amount of sodium (4 percent) but less saturated fat (1 percent). (Figures D1.34 and D1.35).

Other food categories contributing substantial amounts of saturated fat include snacks and sweets (18 percent), protein foods (15 percent), and dairy (13 percent). Within snacks and sweets, the subcategory providing the largest share is desserts and sweet snacks (12 percent). Within protein foods, saturated fat comes from meats, in general (3 percent), deli and cured meats and poultry (3 percent), poultry (3 percent), and eggs (3 percent), with seafood and nuts, seeds, and soy each contributing less than 3 percent. Within the dairy category, higher fat (whole and 2 percent) milk and yogurt (7 percent) and cheese (4 percent) contribute the most saturated fat.

Sodium is more ubiquitous in the food supply than are other nutrients, and the food categories contributing the highest amounts of sodium include protein foods (14 percent), grains (11 percent), vegetables (11 percent), and snacks and sweets (8 percent). Sodium is distributed throughout many food categories and subcategories with the exception of fruits and fruit juice, which are notably low in sodium (0.1 percent).

The distribution of added sugars in foods as consumed differs from saturated fat and sodium (Figure D1.36) The vast majority of added sugars intake comes from the major categories of beverages (not including milk and 100% fruit juice) (47 percent) and snacks and sweets (31 percent). Grains, including breakfast cereals and bars, contribute 8 percent, mixed dishes contribute 6 percent, and dairy, including sweetened flavored milks and yogurts contribute only 4 percent of total added sugars intake (see Appendix E-2.8: Percent of total food group intake, 2009-2010, for the U.S. population ages 2 years and older, from WWEIA Food Categories).

Four additional questions were examined using the WWEIA Food Categories data. They are:

11a. What is the current contribution of fruit products with added sugars to intake of added sugars?

11b. What is the current contribution of vegetable products with added sodium to intake of sodium?

11c. What is the current contribution of refined grains to intake of added sugars, saturated fat, some forms of polyunsaturated fat, and sodium?

11d. What are the sources of caffeine from foods and beverages on the basis of age and sex categories?

With regard to Question 11a, the DGAC found that:

With regard to Question 11b, the DGAC found that:

With regard to Question 11c:

With regard to Question 11d, the DGAC found that (Figure D1.37):

  • Among children and adolescents, sugar-sweetened and diet beverages and coffee and tea contribute to overall caffeine intake at approximately equal levels.
  • Among adults, the primary sources of caffeine from all foods and beverages are coffee and tea.

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Question 12: What is the contribution of beverage types to energy intake by the U.S. population?

Source of evidence: Data analysis

Conclusion

Beverages contribute 19 percent of total energy intake. Of this 19 percent of energy, major sources are sugar-sweetened beverages (35 percent), milk and milk drinks (26 percent), and 100% fruit juices (10 percent).

Implications

The beverages that contribute the most to energy intake, particularly sugar-sweetened beverages, are those that are not nutrient dense and could be targeted for reduction. Others, like milk, fortified low-and non-fat milk, and milk beverage are good sources of key nutrients. Modifying the types of beverages consumed can reduce calories (e.g., switching from sugar-sweetened beverages to water) or improve nutrient intakes (e.g., switching from sugar-sweetened beverages to low-fat or fat-free milk). This may be an important strategy for individuals who need to reduce their energy intake and/or control their weight. Public health strategies (e.g., programs, regulations, and policies) are needed to reduce consumption of sugar-sweetened beverages.

Strategies are needed to encourage the U.S. population to drink water when they are thirsty. Water provides a healthy, low-cost, zero-calorie beverage option. Free, clean water should be available in public settings, as well as child care facilities, schools, worksites, publically funded athletic stadiums and arenas, transportation hubs (e.g., airports) and other community places and should be promoted in all settings where beverages are offered.

Review of the Evidence

These conclusions were reached by examining data from the WWEIA Food Categories data from the NHANES 2009-2010 dietary survey,65 as described in relation to question 9 (current consumption patterns by food categories in the U.S. population). For this question, a new grouping of all beverages, including fluid milk and 100% fruit juice, was created. The conclusions and details below are based on this category of all beverages (see Appendix E-2.7: Major categories and subcategories used in DGAC analyses of WWEIA Food Categories).

All beverages account for about one-fifth (19 percent) of total energy intake. Within that amount, about one-third (35 percent) is from sugar-sweetened beverages, mostly soft drinks and sweetened fruit drinks (see Appendix E-2.9: Percent of total energy and nutrient intake, 2009-2010, for the U.S. population ages 2 years and older, from WWEIA Food Categories). About 20 percent of the calories from beverages come from alcoholic beverages (21 percent), and milk and milk drinks made with whole and 2 percent fat (18 percent). About 10 percent of the calories from beverages come from 100% fruit and vegetable juice (10 percent), fat-free and low-fat milk and milk drinks (8 percent), and coffee and tea (8 percent) (Figure D1.38).

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