Policy Brief: Reforming the Dietary Guidelines

This is also a project from this semester, this time from my public policy class. I decided to post it because it’s also on the Dietary Guidelines, and you’ll likely be hearing about them a lot on this blog! It was a bit challenging to write because while there’s plenty of research on what the problem is, there really isn’t any research on possible solutions. So I had to come up with solutions on my own, and because of my limited policy knowledge, I have no idea if they’re even feasible. But I got a good grade, so I guess that’s something (:

Executive Summary

This policy brief examines the USDA Dietary Guidelines for Americans, a policy that began in 1980 and mandates the periodic release of federal nutritional guidance. Based on the rising rates of obesity and the pervasiveness of chronic diseases such as cardiovascular disease and diabetes, it is clear that the Dietary Guidelines have not achieved their goal of reducing the risk of chronic disease in Americans. In fact, research indicates that the Dietary Guidelines could actually be contributing to the current epidemics of obesity and diabetes. This is for three reasons: the Dietary Guidelines often exclude or misrepresent scientific evidence; the Guidelines have had unintended consequences for industry and consumer behavior; and the Guidelines cannot adequately address a diverse population with different nutritional needs.

Recommendations for addressing this problem fall under 3 major categories: move the responsibility for the Guidelines to a department or organization other than the USDA to avoid any bias that might result from their background in agriculture; revise the Dietary Guidelines within the current system, including a focus on whole foods rather than nutrients; or remove the Dietary Guidelines altogether. My recommendation is a combination of these: eliminate the Dietary Guidelines, but publish one last edition. This edition would be created by the CDC instead of the USDA, and would differ significantly from previous guidelines by containing only broad recommendations to purchase natural, unprocessed foods, support local farms, and seek any additional dietary advice from nutritionists who can address the individual needs of Americans.

Introduction

The Dietary Guidelines for Americans were first established in 1980 in an effort to improve the health of Americans (U.S.). They are published jointly by the US Department of Agriculture (USDA) and the Department of Health and Human Services (HHS) every five years, as required by Public Law 101-445, Section 3 (U.S.) (Slavin). The purpose of the Guidelines is to give scientifically backed dietary guidance to Americans ages 2 and older in order to promote health and prevent chronic disease. The Dietary Guidelines also form the basis of all federally funded or mandated nutrition programs (Benjamin). These programs include the National School Lunch Program, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and Elderly Nutrition Program (Dietary) (Watts). The 2010 Dietary Guidelines are the most recent edition, and they emphasize 23 key recommendations within four categories (U.S.). These categories are Balancing Calories to Manage Weight, Foods and Food Components to Reduce, Foods and Nutrients to Increase, and Building Healthy Eating Patterns. The overarching focus of the 2010 Dietary Guidelines is combating the epidemic of overweight and obesity in America.

Policy Problem

Despite the good intentions of the Dietary Guidelines, American public health has continued to decline. As of 2010, 69.2% of Americans were overweight or obese (National). Rates of diabetes have also increased dramatically (See charts 1a-b in the Appendix). Curiously, a significant increase in the rates of both diabetes and obesity coincided with the release of the first Dietary Guidelines in 1980 (Marantz). Although the percentage of Americans who are overweight but not obese remained relatively constant (around 32%) during that time period, rates of obesity increased sharply very soon after 1980, when the first guidelines were published (see charts 2-5 in Appendix). Between 1976 and 2010, the rate of obesity rose from 16.4% to 42.7% (National).

There are three main problems with the Dietary Guidelines for Americans:

The Dietary Guidelines are not based on a complete and unbiased review of all relevant nutritional science.
The Dietary Guidelines have had unforeseen effects on the food industry, contributing to an unhealthy food environment.
The Dietary Guidelines provide one-size-fits-all recommendations that do not account for the diverse needs of the American population.

This policy brief covers each of these problems in more detail below.

The Guidelines exclude or misrepresent scientific evidence

The Dietary Guidelines for Americans claim to be completely evidence based (U.S.). However, several issues arise when reviewing the scientific backing of the 2010 Dietary Guidelines.

One issue is the utilization of weak, inconclusive, or contradictory evidence to justify strong recommendations (NCPA June) (Hite). For instance, the strong recommendation to decrease the consumption of saturated fat is supported by studies that actually show both positive and negative outcomes to reducing saturated fat intake (Hite).

Another issue is the exclusion of relevant scientific data when forming recommendations. To return to the saturated fat example, only studies that were conducted in the context of moderate to high carbohydrate diets were reviewed (Hite). Studies measuring the effects of reduced saturated fat intake in the context of low-carb diets were excluded from the analysis.

Finally, the Dietary Guidelines Advisory Committee was occasionally forced to draw conclusions based on an incomplete body of science due to a lack of high-quality nutritional research (Dietary). Nutritional research is inherently difficult, and it is nearly impossible to draw solid conclusions from it (Woolf). Scientists can never know whether outcomes should be attributed to a specific nutrient, the food as a whole, or the food in the context of the rest of the diet. Double-blind trials are difficult to design, because participants can easily tell whether they’re receiving one food over another, and the execution of long-term trials where participants’ diets are tightly controlled are cost-prohibitive.

Due to these factors, it’s clear that the Dietary Guidelines are not based on a complete and unbiased review of scientific evidence.

The Guidelines have unintended consequences on industry and consumer behavior

The Dietary Guidelines have had many unintended consequences that could be negatively impacting the health of Americans. Many researchers go as far as to blame the Dietary Guidelines for causing the obesity epidemic (NCPA June) (NCPA July) (Slavin). One unintended consequence of the Guidelines was to increase the overall caloric intake of Americans, primarily in the form of refined carbohydrates (Marantz). The call in the first Dietary Guidelines to reduce the percentage of fat in the diet prompted the food industry to produce “healthy” low-fat snacks, which were instead laden with refined carbohydrates and sugars. Americans consumed more of these snack foods because they were under the impression that anything low-fat was healthy (Marantz). Additionally, fat creates a feeling of satiety, so people can typically consume more of fat-free foods without feeling full.

Another unintended consequence of the Dietary Guidelines was a reduction in the quality of school lunches and the meals of other federal nutrition programs (Willet). Like the food industry, these programs also responded to the call to lower percent calories from fat by increasing the amount of refined carbohydrates in their meals. This effort resulted in an overall increase in calories and a decline in the nutritional value of the meal.

The Dietary Guidelines are one-size-fits-all

A glaring issue with the Dietary Guidelines is that they attempt to provide sweeping nutritional recommendations for the entire American population, which is one of the most diverse on the planet. Traditionally, humans have been able to thrive on diets anywhere from 80% fat to 80% carbohydrate, and the Guidelines attempt to narrow down that scope into an ideal macronutrient ratio of 45-65% carbohydrate, 10-35% protein, and 20-35% fat (U.S.) (Slavin). The Guidelines also make countless other generalizations, such as pushing for more dairy or whole grain consumption (U.S.). Those recommendations would be detrimental to somebody who is lactose intolerant, or has celiac disease. Apart from specific dietary needs, the Dietary Guidelines also cannot adequately address the needs of growing children, the elderly, pregnant and lactating women, and Americans with diverse racial, ethnic, and socioeconomic backgrounds, all within one document. Finally, Americans have different learning styles and ways of gathering nutritional information, and one document does not successfully reach all of them (Cardello).

Thus, even if the Dietary Guidelines have not been detrimental to American public health, their ability to improve public health is severely limited.

Policy Solutions

The many voices condemning the Dietary Guidelines have also suggested reforms that might help them better serve the American public. These reforms fall into three main categories:

Transfer the responsibility for creating the Guidelines to a different organization.
Continue to reform and improve the guidelines under the current system.
Eliminate the Dietary Guidelines altogether.

These three options are discussed in greater detail below.

Transfer the responsibility to a different organization within the government

Many people blame the misrepresentation of science found in the Guidelines on the USDA’s support of agriculture (Slavin). Thus, one possible policy solution is to transfer the responsibility for creating the Dietary Guidelines to a different organization such as the CDC or IOM, “to avoid conflicts of interest at the USDA arising from its institutional mission to promote commodities” (Willett). The analysis of the evidence and the creation of the Dietary Guidelines Report are completed by the Dietary Guidelines Committee (DGAC), which is a team of qualified scientists and researchers. However, government staff writes the actual Dietary Guidelines for Americans policy document, using the DGAC Report as a guide (Slavin). The creation of the DGAC Report is transparent and open to public commentary, but the translation of that Report into the final Dietary Guidelines is not transparent, even to the DGAC (Watts).

Thus, a workable solution would be to leave the process unchanged other than to transfer the responsibility for the Guidelines from the USDA to the CDC or IOM. Whoever is chosen would be responsible for taking nominations for members of the DGAC, appointing members to the Committee, and creating the policy document based on the scientific report that the DGAC creates.

Pros:

The process stays the same other than the transfer of responsibility
This would address the common concern that agricultural interests within the USDA are affecting the accuracy of the Guidelines

Cons:

This would not address the possible issue of incomplete or inaccurate review of the science by the DGAC itself

Reform the Guidelines under the current system

Many of the solutions suggested by policy think tanks, scientists, and researchers are reforms to the Guidelines themselves, rather than to the system that creates the Guidelines. The primary recommendation is to change the current nutrient-based approach to a food-based approach, to make the Guidelines more applicable and accessible to the American public (Mozaffarian) (Slavin) (Willet). Because people consume foods, not isolated nutrients, the current approach of the Guidelines to limit certain nutrients is confusing and complicated to the public. Additionally, this nutrient-based approach causes some overly processed foods, such as processed cheese spread or pretzels, to be grouped in the same health category as foods such as sautéed vegetables and tuna canned in oil, simply based on a few specific nutrients (Mozaffarian).

Other suggestions to include in the DGA are recommendations to: support local food systems by purchasing from farmers markets and CSAs (Community Supported Agriculture); purchase grass fed beef to avoid antibiotics and increase intake of vitamins; and purchase minimally packaged and unprocessed food (Wallinga).

Thus, one policy solution would be to eliminate all mention of specific nutrients in the DGA, instead focusing on consumption of whole foods and similar broad recommendations.

Pros:

Focusing on foods instead of nutrients would solve the problem of the food industry marketing “healthy” processed foods based on the addition or subtraction of isolated nutrients
Broad guidelines have far less potential to cause unintended harm
No need to reform the system under which the Guidelines are produced
Good opportunity to change the false beliefs instilled by previous Dietary Guidelines

Cons:

The biases that influenced the previous Dietary Guidelines would still be present, because the underlying system of creating them would be the same
There is no clear mechanism for policy to make this change

Eliminate the Dietary Guidelines altogether

Finally, another option is to simply get rid of the Dietary Guidelines. The Dietary Guidelines were initially created based on limited correlational studies because they were assumed to have no potential for harm (Marantz). However, the skyrocketing obesity rates have shown that there is indeed potential for harm in the issuance of population-wide Dietary Guidelines, and thus, the best course of action might be to eliminate the Dietary Guidelines altogether. In the absence of clear, consistent evidence, the most responsible tactic could be to withhold specific nutritional recommendations. In tandem with the elimination of national Dietary Guidelines, physicians and nutritionists would need to take more responsibility for counseling their individual patients on dietary choices (NCPA June).

Pros:

Removes the possibility of doing harm to public health
Simple policy solution
More emphasis on individual nutritional advice through health care practitioners
Would encourage Americans to seek out nutritional advice from varied sources

Cons:

No national standards on which to base federal nutrition programs, such as WIC
Inability to control the quality of nutritional advice being dispensed to the public by health care professionals
No opportunity for the government to ‘undo’ the damage that has been done by the previous Dietary Guidelines and the false paradigms they have instilled

Policy Recommendation

My recommendation is a combination of the options mentioned. There should be one more edition of the Dietary Guidelines to attempt to fix the damage done thus far, but then they should be eliminated through the repeal of Public Law 101-445, section 3. The final edition of Dietary Guidelines should be created under the authority of the CDC, not the USDA, to avoid influence from agribusiness. Finally, this last edition of the Dietary Guidelines should incorporate the suggestions mentioned above: focus on foods rather than nutrients, and recommend only broad dietary changes with little possibility to do harm.

The cessation of the Dietary Guidelines must also be accompanied by higher standards for educating nutritionists, because without national dietary recommendations, Americans will need to depend on doctors and nutritionists for advice. To this end, I suggest government funding for scientific research done by the Nutrition Science Initiative (NuSI). This organization is made up of a team of researchers with no vested interest in the outcomes of their studies; they only desire to produce strong, credible nutritional research, which – as I have discussed – is sorely lacking (Attia). Additional funding of nutritional research through this impartial, nongovernmental avenue would increase the knowledge base available to nutritionists, who could then convey this knowledge to patients based on their individual circumstances. Also, this information would be available to every registered dietician, and each could form his or her own interpretation of the evidence. This would eliminate the problem encountered in the Dietary Guidelines, where one faulty interpretation of the information could color the nutritional paradigm of the entire nation.

It would also be necessary for curricula in Registered Dietician training programs to stay up-to-date with the research conducted by NuSI. To achieve this, I recommend a third party review board that would periodically investigate what is being taught at each school and rate the curriculum based on its accuracy. The review board would then publish the ratings every 2-5 years, creating accountability for nutrition education programs. This would also create a financial incentive for nutrition schools to keep up with the latest research, because students would be far less likely to attend a school with a low rating. This review board would need to receive funding from the government to reduce the likelihood of corruption due to schools bribing the review board. However, this funding could be a reallocation of the money that previously went towards developing the Dietary Guidelines, and therefore would not increase the deficit.

Lastly, it must also become more common for people to consult nutritionists when they go to the doctor, so that their individual dietary needs can be addressed on a regular basis. To encourage the adoption of this practice, I suggest a section in the final dietary guidelines strongly recommending that regular check-ups at the doctor be accompanied by an appointment with a nutritionist. If further measures are required, this can be addressed again after the other policy changes have been made.

Conclusion

To conclude, America is facing a serious public health crisis, including rising rates of obesity and other chronic disease. This problem is influenced by the national Dietary Guidelines, which have not helped the problem and have likely made it worse. Many possible solutions have been proposed, but my recommendation is to publish one last edition of the Dietary Guidelines and then transfer responsibility for nutritional guidance completely over to individual health care practitioners and nutritionists. The advice given by these healthcare professionals would be based off of federally funded nutrition science that is conducted by the Nutrition Science Initiative (NuSI). The last Dietary Guidelines would include the following recommendations:

Purchase only (or mostly) unprocessed and minimally packaged foods
Favor naturally raised meat products and naturally grown produce (i.e. grass-fed beef and organic produce over conventional beef and produce)
Support your local farmers by shopping at farmers markets and participating in Community Supported Agriculture (CSA) efforts
Make sure you see a nutritionist whenever you visit the doctor for check-ups, so they can address your individual dietary needs.

We can be confident that these few simple guidelines will not cause harm, and will provide the most basic structure for what Americans should strive for in their diets. For any nutritional needs that are more specific, Americans can look to their nutritionists and doctors for advice. With the implementation of policy to fund scientific studies through NuSI, and policy to establish a periodic review and rating system for nutrition schools and Registered Dietician certification programs, Americans can be confident that the nutritional information they’re getting is current and scientifically backed. These policy changes alone will not solve America’s health crisis, but they will make large strides towards that goal.

Works Cited

Attia, Peter, et al. Nutrition Science Initiative. 2012. Web. 22 Oct. 2012. <http://nusi.org>.

Benjamin, R. M. (2011). Dietary Guidelines for Americans, 2010: The Cornerstone of Nutrition Policy. Public Health Reports, 126, 310–311.

Cardello, H. (2010, June 21). Why We Should Dump Dietary Guidelines. Hudson Institute. Retrieved from http://www.hudson.org/index.cfm?fuseaction=publication_details&id=7866

Dietary Guidelines Advisory Committee. “Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010.” dietaryguidelines.gov. USDA, May 2010.

Hite, A. H., Feinman, R. D., Guzman, G. E., Satin, M., Schoenfeld, P. A., & Wood, R. J. (2010). In the face of contradictory evidence: Report of the Dietary Guidelines for Americans Committee. Nutrition, 26, 915–924.

Marantz, P. R., Bird, E. D., & Alderman, M. H. (2008). A Call for Higher Standards of Evidence for Dietary Guidelines. American Journal of Preventative Medicine, 34(3), 234–240.

Mozaffarian, D., & Ludwig, D. S. (2010). Dietary Guidelines in the 21st Century— a Time for Food. JAMA, 304(6), 681–682.

National Center for Health Statistics. Health, United States, 2011: With Special Feature on Socioeconomic Status and Health. Hyattsville, MD. 2012.

NCPA. (2010, July 22). Inaccurate Dietary Guidelines. National Center for Policy Analysis. Retrieved from http://www.ncpa.org/sub/dpd/index.php?Article_ID=19610

NCPA. (2011, June 7). The Washington Diet. National Center for Policy Analysis. Retrieved from http://www.ncpa.org/sub/dpd/index.php?Article_ID=20742

Slavin, J. (2012). Dietary Guidelines: Are We on the Right Path? Nutrition Today, 47(5), 245–251.

U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010.

Wallinga, D., & Clinton, S. (2010). To the distinguished members of the Dietary Guidelines Advisory Committee (Policy brief). Institute for Agriculture and Trade Policy. Retrieved from http://www.iatp.org/files/421_2_107177.pdf.

Watts, M. L., Hager, M. H., Toner, C. D., & Weber, J. A. (2011). The art of translating nutritional science into dietary guidance: history and evolution of the Dietary Guidelines for Americans. Nutrition Reviews, 69(7), 404–412.

Willett, W. C., & Ludwig, D. S. (2011). The 2010 Dietary Guidelines — The Best Recipe for Health? The New England Journal of Medicine, 365(17), 1563–1565.

Woolf, S. H., & Nestle, M. (2008). Do Dietary Guidelines Explain the Obesity Epidemic? American Journal of Preventative Medicine, 34(3), 263–265.

Appendix

Chart 1a

chart 1a