2015-2020 Dietary Guidelines: What Are They, How Have They Changed, and How Can You Use Them?

2015-2020 Dietary Guidelines: What Are They, How Have They Changed, and How Can You Use Them?

November 1, 2019 3 By Ewald Bahringer


Welcome to the NDEP Webinar
Series, “The Dietary Guidelines for Americans 2015-2020:
What Are They? How Have They Changed? And How Can You Use
Them In Practice?” My name is Betsy Rodríguez,
Deputy Director of the National Diabetes Education
Program at the Centers for Disease Control and Prevention. And today, I will serve
as your moderator. Today two nutrition experts will
discuss recommendations for developing healthier eating
patterns; suggestions for small, manageable dietary changes;
and resources for putting the guidelines into practice. Before I introduce our
presenters, I would like to go over the purpose of today’s
webinar, which includes the following learning objectives:
explain the purpose of the dietary guidelines and how they
have changed, and how they should be used in diabetes
education; describe the impact that changes to the dietary
guidelines can have from the broader public health nutrition
work; name the tools to apply the recommendations in public
health; and finally, identify aspects of culture that
can facilitate the use of the dietary guidelines. This is the first of our
four questions that we will be asking during our webinar. We call them ‘Knowledge Check.’ If you are in front of a
computer, feel free to answer it directly in your screen. And the question reads, ‘The
main theme of the Dietary Guidelines 2015-2020 is…?’ I will give you a couple
of seconds to answer. Eating patterns,
food and drinks? Compare diets to
recommendations? Guidelines in shifts
and food choices? Or all of the above? So our poll has been closed. And as you can see here, 85
percent of the participants answered all of the above,
which is the correct answer. Good. As a brief background to food
guidance and nutrition education, as early as 1917 the
USDA and FDA worked together to devise recommendations called,
‘Choose Your Food Wisely.’ In the 1940s, the Guide to Food
Eating provided the foundation diets for nutrition adequacy,
and included daily number of servings needed for each
of seven food groups. In 1956, ‘Food for Fitness, A
Daily Guide Basic Four’ was published and included four
groups-milk, meat, vegetable and fruit, and bread
and cereal groups. Other guides follow, up to
the current MyPlate system, introduced along by
the 2010 Dietary Guidelines for Americans. The initial approach of the
early government document was to prevent nutrient deficiencies. All of the guidelines
that have been published since 1980 are shown here. They evolved over time to
make better use of nutrition science and to better
communicate the science. The 1980s-1985 version of the
dietary guidelines were small brochures aimed at consumers. The information came mainly from
the experts appointed to the Dietary Guidelines
Advisory Committee. The committee members drew
from their collective knowledge of nutrition research. Then the 2000 version was a
39-page document that was both for consumer-oriented and
for policy documents. This reflects the move by the
government toward helping nutrition educators,
dietitians, and other nutrition professionals to better
understand the science behind the consumer material. In 2005, we got a 70-page
booklet that served as a policy document and represented a
departure by acknowledging that in nutrition education,
nutritionists and policymakers all need the science in plain
language that will serve as the foundation for the work. Research and review of the
scientific literatures served as the basis for
these guidelines. The 2010 document, again, was a
policy document intended for policymakers to design and
carry out nutrition-related programs, and nutrition
educators and healthcare professionals developing
nutrition curricula, teaching tools, and advice for consumers. In 2010, a robust systemic
approach was used to organize and evaluate
the science on which the guidelines are based. For the remainder of today’s
presentation, we will be providing details, especially
about the newly developed 2015-2020 Dietary Guidelines. That was a short brief
history to set the foundation for today’s webinar. So let’s have another
knowledge check. What changed in the Dietary
Guidelines 2015-2020? And again, let me
give you another couple of seconds to answer. No longer have the quantitative
requirements for dietary cholesterol, that’s choice A. Choice B, added sugar
quantitative requirements. C, emphasis on food patterns
rather than individual’s nutrients and specific food. D, all of the above. And E, nothing changed. So most of the people answer all
of the above, 68 percent of the people, and that’s
the right answer. Good. So as you can see there
is a lot to cover today. So as I said before, today we
have a superb group of experts from the nutrition field that
I’m sure will enlighten us with valuable information
regarding the Dietary Guidelines for Americans. I am very pleased to introduce
Dr. Jennifer Seymour, a Senior Policy Advisor at the Division
of Nutrition, Physical Activity, and Obesity at CDC. She was CDC Lead for the
development of the Dietary Guidelines for Americans
2015-2020, a member of the Healthy Weight Commitment
Evaluation Advisory Committee, and the
Feeding American Nutrition Advisory Team. Then we will have Lorena Drago,
Founder of Hispanic Foodways, who specialized in the
multicultural aspect of diabetes management education. She has served for the Board of
the American Association of Diabetes Educators, and
Latinos and Hispanics in Dietetics and Nutrition. Lorena is also an award-winning
author of many diabetes books and chapters among
other accomplishments. Welcome ladies. Dr. Seymour, from now
on known as Jenna, the microphone is yours. Thank you Betsy. It’s very nice to be speaking
to all of you today. So I am going to start out with
some of the basic overview of the dietary guidelines-what
it is, what it’s not. So the dietary guidelines
really provide evidence-based recommendations about a healthy
and nutritionally adequate diet. It’s important to know that they
focus on disease prevention, rather than disease treatment. So, of course, as diabetes
educators, a lot of you may say, “Well then, how is
this relevant?” It is important to know that, of
course, a healthy diet is really good thing for everyone
to be thinking about. But it shouldn’t really-the
guidelines that are for disease prevention, sort of in
general-should not override
specific advice for someone who has
a specific chronic disease. Now, the guidelines also-and I
should say, let me just step back and say-and of course
Lorena, after me, is going to be talking much more specifically
about ADA recommendations. So, we’ll really let
you see both sides. And then of course, the dietary
guidelines, really, it’s a policy of the
federal government. And therefore it informs
federal food, nutrition, health policies, and programs. So it’s important to understand
a little bit about the way that the guidelines are created. As Betsy pointed out, the
guidelines have changed quite a bit over the years. And really, in the last 15
years, have particularly gone much more from a very simple
booklet for the consumer, to much more of a
very large policy. So, in general, we think
of the dietary guidelines from a three-step process. There’s a lot of detail on this
slide, and I’m not going to go into all of it, but I think it
gives you a little more detail for the people who really
want to understand how the guidelines are created. What I’m going to say is that
the first part of the process is a review of the
science that is done by a federal advisory committee. And that advisory committee
spends two years doing a really detailed process and ends up
producing a report that is provided to the secretaries
of HHS and USDA. This year that report
was over 500 pages long. So it’s a very intense,
detailed report about what we know about nutrition currently. The second part of the process
is the actual development of the dietary guidelines. And this part is really where
the government takes the previous edition to the dietary
guidelines, the report from the advisory committee, comments
that come in from the public and from federal agencies, pulls it
all together, and really works for-usually it takes about a
year, really, to put all of that together, into what
becomes the policy that is known as the dietary guidelines. And it’s really important to
know that currently this very large-this document is over a
hundred pages long-it’s really designed for policymakers
and for professionals. And isn’t really
intended for the public to understand nutrition. But, so that’s where the third
part of the process comes in, which is the implementation of
the dietary guidelines, really figuring out how to use it. And part of that is about
creating materials that will end up being for the public. But also part of it is about
using this in the programs and all the different ways that
the federal government might use these guidelines. And I’ll talk about
that in more detail at the end of the presentation. So what is in the guidelines? The guideline starts out, it
has an executive summary, an introduction, three main
chapters, and appendices. What I’m going to focus
on in this presentation is the three main chapters. But there really is a lot of
detail there for someone who wants to know a lot
more about what’s going on in the guidelines. So what are the
actual guidelines? There are five overarching
guidelines that are part of the DGA 2015-2020. The first guideline is to
follow a healthy eating pattern across the lifespan. And this really is a very big
change from previous guidelines that really focused much more
on-think earlier-there was much more focused on
specific nutrients. Then as things started to change
over time, there was a bit more of a focus on food groups. But the real very big change
with these guidelines is a heavy focus on eating patterns, and
really understanding the whole way you eat is what matters. The second guideline: getting
at the same idea, it’s really talking about and
focusing on variety, nutrient density, and amount. Really understanding that you
need to eat a variety of foods. You really want to have foods
that are very nutrient-dense. This is getting at the idea that
you want foods that have a lot of the nutrients that we need in
our diets without a lot of the nutrients that we shouldn’t
be eating very much of, and certainly without
too many calories. And that also gets into amount,
really thinking about the amount of food that you
consume in terms of the calories that you are taking in. And then the third guideline is
to limit calories from added sugars and saturated fats and
to reduce sodium intake. And so this is where we do get
back to the nutrients that are real issues in the diet, but
this should be thought of within the context of that
healthy eating pattern. So the fourth guideline gets at
the idea of the need to shift to healthier food and
beverage choices. And I’ll really show you
a lot more detail about the shift as we go forward. But it’s really the idea that
right now the way Americans are eating is really
not fitting into that healthy eating pattern. And there are ways that you can
shift your diet much more towards a healthy
eating pattern. And then finally, the fifth
guideline really is about that bigger support that is needed
for healthy eating patterns to be possible for people to really
getting at the role of all the different ways that the food
environment, and where we live, and where we work, and all
those different ways that we interact with food clearly plays
a role in whether we are going to have a healthy
eating pattern or not. OK. So let’s focus very much
on what’s in Chapter 1. This is where we
really talk about the healthy eating patterns. So what actually is a
healthy eating pattern? The most important thing is that
it really encompasses everything that you eat and drink. A healthy eating pattern
includes vegetables and really making sure you get a variety of
those vegetables from all the different food-all the different
groups of vegetables-dark green, red, orange, legumes, starchy,
and other vegetables. It includes fruits, especially
whole fruits, really whole fruits over having
a lot of juice as the way you get fruit intake. Grains, very important, and to
make sure that at least half your grains are whole grains. Fat-free and low-fat dairy,
including milk, yogurt, cheese, and, for people who can’t or
who choose not to consume milk, fortified soy beverages. And then of course, a variety
of protein foods, including seafood, lean meat,
poultry, eggs, legumes, nut seeds, and soy products. And oils as opposed to
the unhealthy solid fats. So of course, a healthy eating
patterns also limits saturated trans-fat, added
sugars, and sodium. And what you might notice here
is that dietary cholesterol is not listed here. I’ll talk about
dietary cholesterol in more detail in a little while. So, of course within the key
recommendations, there are also a number of quantitative
recommendations that really do get at very specific areas where
we know that there needs to be limits on how much
someone is consuming. The big addition in these
guidelines is to consume less than 10 percent of calories
per day from added sugars. Something that’s been
more consistent in the guidelines over a number of
years is to consume less than 10 percent of calories
from saturated fats. Also quite consistent over the
years has been to consume less than 2,300 milligrams
per day of sodium. And then finally, also,
certainly for the last two editions of the guidelines, if
alcohol is consumed, it should be consumed in moderation, which
is up to one drink per day for women and up to two drinks per
day for men, and of course, only by adults of legal drinking age. And then finally, not a
quantitative recommendation, but there is a recommendation to
meet the Physical Activity Guidelines for Americans. In the past, the dietary
guidelines often did also talk about physical activity, sort of
as an aside, and eventually it became clear that
there really should be physical activity guidelines. And so in 2008, that’s when
physical activity guidelines were created for the first time. And there’s a lot of detail
within those guidelines that maybe another webinar on
physical activity guidelines would be a good thing. So of course, it’s important
to really think about the principles of healthy
eating patterns. Really understanding the idea
that a diet as a whole is what matters, that really
understanding that there are synergistic ways that our diet
works together, that what you eat, what you drink, they
have an impact on each other. And that really just thinking in
terms of eating more healthfully as just having an impact on one
aspect of your diet is really probably not going to get you
to a healthy eating pattern. It’s also very important to know
that nutritional needs should really be primarily met with
foods as opposed to supplements. There are certainly needs for
supplements, that, for various people and for various
different reasons. But there is so much
more to the food that we eat than what is in supplements. And so it’s really important to
get away from a message, that I have heard in the past, that
someone who says, “Oh, I can just take a multivitamin
and then I’ll be OK.” And there really is so much more
in our food that you will never get from a multivitamin
and that’s an important thing to keep in mind. And then, of course, it’s
really important to know that healthy eating
patterns are adaptable. They really can be tailored to
all kinds of sociocultural and personal preferences. And there are many kinds of
diets that can fit in to the overall broad
perspective of what is a healthy eating pattern. So what is the science
behind healthy eating patterns? So in general, a lot of people
may think, when they know about the dietary guidelines, about
using scientific studies to determine what might be said
in the dietary guidelines. But there actually is a lot more
that goes into-certainly those systematic reviews and
scientific research play a very important role. But there’s also really a need
to think through, sort of food pattern modelling, really trying
to understand how can you really go through and figure out all
the ways that the person can get the nutrients that they need,
while staying within calorie limits, while also not getting
too much of the nutrients that we are eating too much of
currently, and really trying to think through all of those
aspects, and come up with patterns that-from
out of that model. And then of course it’s also
important to realize that there is a need to analyze current
intakes, really understanding what’s already going on, what
needs to be improved within diet, and how does that
play into what is going to be suggested as a healthy diet. So let’s look in a little more
detail about a couple of things. I already mentioned a
variety of vegetables. But it’s important to know that
within vegetables, all different forms of vegetables
can be a part of a healthy eating pattern. You can have fresh, frozen,
canned, dried options, and including vegetable juices. But of course, you should
keep in mind, again, the idea of nutrient density. Vegetables should be consumed
in a nutrient-dense form with limited additions of salt,
and butter, and cream sauces. Also, with dairy, you should
really be thinking about including fat-free and low-fat,
1 percent dairy, including milk, yogurt, cheese, or
fortified soy beverages. I did, sort of in the corner of
my eye, see that someone asked the question about rice
milk, and things like that. This was addressed by the
Dietary Guidelines Committee. And what they looked into and
really decided was that a big role that was being played by
the dairy products in our diet was as a protein source. And that soy milk has a pretty
consistent amount of protein as compared to dairy products,
whereas things like rice milk and almond milk
and other forms do not. And so that is why they chose
not to include other forms of beverages besides dairy
in this recommendation. So fat-free or low-fat milk and
yogurt in comparison to cheese contains less saturated fat and
sodium, and more potassium, Vitamin A, and Vitamin D. So it’s important to also think
in terms of when you’re thinking about the dairy products you
consume that there really are different choices that can
be made that will be better for a healthy eating pattern. So of course, there are all
those other components within a healthy eating pattern that
really need to be thought about and considered when
figuring out what to eat. And they include the added
sugars, saturated fat, trans fat, dietary cholesterol,
sodium, alcohol, and caffeine. I’m going to focus on two
specifically next, that have been talked about a fair
amount since these dietary guidelines were released. The first is cholesterol. So the quantitative
recommendation was removed. But there is a statement in the
guidelines that says individuals should eat as little dietary
cholesterol as possible while consuming a healthy
eating pattern. Now, I saw a question
before the webinar began that asked about this. And so I want to specifically
point out that if the sentence stopped after the word
possible, it would have a very different meaning. So this is not suggesting
that people need to drastically limit their dietary
cholesterol intake. What it is saying is that people
should eat as little cholesterol as possible while consuming
a healthy eating pattern. And that’s an important
addition, because, really, when you look at the dietary
guidelines, look at a Healthy US-Style Eating Pattern, and
really took general US-style habits but came up with a
healthy eating pattern that met all the criteria, and really
found that within that, the diet was getting between
100 milligrams and 300 milligrams of cholesterol. And so it’s really-it’s not
actually saying, as little as possible, because, of course,
you could get to zero by eating absolutely no animal products. But that is not what the dietary
guidelines are suggesting. So I think that’s an important
point to keep in mind. So for caffeine, there was
discussion-it’s not a key recommendation-but there was
discussion about the fact that the people can consume
caffeinated beverages. What’s important to know
here is that most caffeine evidence focuses on coffee. So there really hasn’t been the
kind of studies on all kinds of other caffeinated beverages. And so this recommendation
should not be taken as a recommendation to
consume a whole bunch of other caffeinated beverages. But it really does say that
three to five eight-ounce cups per day can be included in
the healthy eating pattern. It’s important to note though
that there’s nothing that suggests that a person who
isn’t consuming caffeine really should start in any way. And it really is also important
to think about, what else you get when you are having
caffeine in your diet. Thinking about all the different
creams and whole and 2 percent milk or added sugars that are
put in a lot of caffeinated beverages, really need to be
thought of in terms of the calories that that
adds to your diet. And so I won’t go
into much detail here. But I just want to say there are
a lot of callout boxes in the dietary guidelines that go into
any number of details about a whole bunch of issues that
may be of interest to people. And I think one thing that’s
important to note, and again, I saw some questions from
when people registered about different kinds of diets. There are all kinds of diets
that can fit the healthy eating patterns described in
the dietary guidelines. There are three specific ones
that are described and pointed out in the dietary guidelines. That’s the Healthy US-Style
Dietary Eating Pattern, the Healthy Mediterranean-Style
Eating Pattern, and the Healthy Vegetarian Eating Pattern. And so yes, vegetarianism
definitely can fit within the guidelines and it does show
that pattern in the guidelines. But there are other healthy
eating patterns that are outside of these three that
clearly would fit within the dietary guidelines. So there are a lot of different
ways to meet the guidelines. Now let’s shift to
shifting eating patterns. This is the content
of Chapter 2. So what’s important to see
here, and I’ll try to make this picture as clear as
possible pretty quickly. Think of the orange bars as
sort of more the negative and the blue bars as the positive. What this graphic is really
showing here is that there are areas that need a lot
of work for Americans. You can see that Americans are
just not eating the vegetables that they should, that over
80 percent of people are not getting enough vegetables. It’s really 75 percent
not getting enough fruit. Total grains, looks
a little bit better. But I’ll show you
why that might not be so good on the next slide. Dairy products, really
over 80 percent, again, not getting enough. Protein foods, again,
looks a little bit better. But there might be
something more behind that. Oils, as opposed to solid
fats, really there’s still more need to shift that as well. And then you can see going
in the other direction, people are consuming way too much added
sugar, saturated fat, and sodium, really got close-we’re
getting up there-close to 100 percent of people consuming
more sodium than they should. So like I said, I want to make
sure, for the two areas where it looks like we’re in pretty good
shape for Americans, it’s important to look at this
in a little more detail. So for whole and refined grains,
if you look at the blue bars, that represents the
recommendations, and then the orange is refined
grain intake, and the green is whole grain intake. And so what you can see is that
overall for most men, and then the second column is women, you
can see that our refined grain intake is well over the
recommendations, except for some older men who are getting
very close there. But the intake of whole grains
is well below recommendation. So overall, grain consumption
is in fairly good shape among Americans, but we need
to change the types of grains that are consumed. And the same
thing for protein. I’ll just specifically show
this chart on seafood intake. So if you look at, again,
the blue bars being recommendations, and the orange
being where intake is, you’ll see we’re all well below
the recommendations for seafood consumption. So just let’s think a little bit
about the way you might shift toward healthy eating patterns. So its things like increasing
vegetables and mixed dishes while decreasing the amount of
refined grains, meats high in saturated fat, and/or sodium,
in those mixed dishes. You could think of it as the
pizza that you really might want to start moving towards a whole
grain crust that’s got quite a bit more vegetables on it, and
removing the pepperoni, and really thinking from those
perspectives, that perspective. Really trying to make sure
you’re adding seafood into meals twice per week, and replacing
the meat, poultry, and eggs. Using vegetable oils in place
of solid fats and things using oil-based dressings and spreads
on food instead of those made with solid fats like butter. Choosing beverages with no
added sugar, like water. And using the nutrition
facts label to compare sodium content in various foods. These are just a couple of ideas
of things-the kinds of shifts you can do towards
healthier eating patterns. So I think to save a little
time, I’m going to skip past that overview slide and
just go to…. Let’s look at a little bit at
the food sources of some of these nutrients that we really
need to reduce in our diets. What you can see is, certainly
for added sugar, the plurality coming close to the
majority of added sugar is coming from beverages. And so this is a
really big component of the added sugar intake. If you add in snacks and sweets,
that makes up 78 percent of the added sugar that
people consumed. And so right there, those really
are the big areas to be thinking of in terms of how to
reduce added sugar intake. If you look at saturated fat,
the bulk of saturated fat is coming from these mixed dishes. That’s things like the pizzas,
the burgers, the meat, poultry, seafood dishes, you can think of
these as the stews, the soups, the rice and grain dishes. These are all the
different things that make up mixed dishes. And then you can see
there’s also a big component made up of snacks and sweets. So… And then if you look at
sodium, again, it’s the mixed dishes, and there’s a
fairly big component also from snacks and sweets. I wouldn’t put that in the… as one of the higher ones for
sodium, but it really should be thought about the mixed dishes,
the snacks and sweets, and then the beverages kind of together
as a bulk area, really are where the sodium, saturated fat, and
added sugar are coming from. And so those are real areas to
focus on in terms of trying to move people towards the fruits,
vegetables, grains, low-fat dairy, and good protein sources,
and moving away from these areas where people are getting
really heavy nutrients that we want to stay away from. OK. So then the third chapter is
really focusing on supporting healthy eating patterns. So I certainly hope
that a lot of you have seen the socio-ecologic model. This is one particular
version of it. What I would say is that if you
start over to the right, in the yellow section of this, you can
see that this is really where a lot of people talk about
nutrition and really changing things within nutrition, talk
about it from those individual factors from the perspective of
the food and beverage intake and the physical activity
for an individual. But there really are so many
different ways that the settings that people are in-the early
care for children, the schools-for adults, their work
sites-and for everyone, the recreational facilities-the
food service and retail establishments. These are all areas where you
can constantly be barraged with all the wrong foods to eat,
or you could really have an environment that allows and
makes it so much easier for people to consume the foods that
would be healthy for them. And of course, there are also
the sectors, the government, how transportation affects people,
all the different agricultural food and beverage industry,
retail, and how all of that affects people’s intake. And then, of course, there are
all the social and cultural norms and values that go into
how and why people eat. And it really is important to be
thinking about and taking into account all of these different
aspects in order to really be thinking about how to
help people get to those healthy eating patterns. And then, just quickly, I want
to talk a little bit about-so this is getting at some of
the tools on the more environmental or policy end. There are so many
different ways that the dietary guidelines are used. For instance in schools. I think, probably a lot of
people have heard because it’s got a lot of attention-the
changes to the school breakfast program-the changes to the
school lunch program-the changes to competitive foods in schools,
that was known as Smart Snacks-all kinds of wellness
policies-the changes to food in the child and adult care
food program, as well as things, like in work sites. We currently, at CDC, have
food service guidelines that we put together based on the
2010 dietary guidelines. They are currently right now
being updated and being expanded to include the entire federal
government to create guidelines for the foods served throughout
the federal government that will be based on the 2015-2020
Dietary Guidelines. And these trickle down. States end up using them to come
up with state guidelines for the food that will be served
in any state facilities. Local facilities can do this
also, and then, also just private work sites can
take this on as well. And we’ve seen a lot of private
work sites that set standards about the kind of food. And all of this, the food
service guidelines that I’m talking about are based on
the dietary guidelines. To look at it from a more direct
to consumer perspective, I know that Betsy at the beginning
talked about MyPlate briefly. So, MyPlate is created by the
Department of Agriculture. And it really is a simple
graphic that represents the dietary guidelines. It really shows the idea of a
plate and the portion of foods on that plate in terms of trying
to get at the idea of what a healthy eating pattern
would look like. And there’s a lot more detail,
and they go into any number of examples, and really thinking
through the idea that maybe not everyone eats on a plate. And so there are other ways of
thinking about those foods and there’s a lot of information. And it really is a very good
source for people to really be able to track their own diet, to
track some progress, to really get some understanding about
the details for a more general audience than the dietary
guidelines themselves. And then finally, I want
to give one example, there are many out there. But one example of the way the
dietary guidelines are being used to really make
a big difference to the labelling of food. So there was a whole process to
change the labelling of food that started long before
these dietary guidelines. But the process was very
much influenced by what was being changed in the 2015
through 2020 guidelines and when the guidelines came out. Some issues were tweaked here. So what you can see on
the left is-that is the current nutrition facts label. That is what a lot of people
have probably seen if they look at packaged food to
see what is in it. The label on the right is
how it is going to change. And some foods have
already made this change. The new label was announced
just quite recently, just a couple of months ago, from FDA. Manufacturers have-big
manufacturers have until 2018 for this change to happen;
small manufacturers until 2019. But you will start seeing this
as companies get it ready and are ready to make the change. And some things that I would
point out are a much bigger serving size, so people really
understand what this information on this label-it’s
about how much of the food that is in that product. The calories are much
bigger to really make sure that people are seeing this. And calories from fat have been
removed since there really has been much more of a move towards
saying people should consume healthy fats not unhealthy fats,
as opposed to telling people that fats in general are bad. You can see that, if you go
farther down in the list that added sugars have
been added to this. And the percent daily value is
based on that 10 percent of calories as a maximum
recommendation that is in the dietary guidelines. There are a number
of other changes. I could only show really
these two on here. But I would advise anyone who
really is much more interested to go and see, because they
really are going to be for packages of food, like say, a
20-ounce soda that people really might drink at one sitting. That really-that is now going to
have a label that describes what is in that full 20-ounce soda
because it really is likely to be consumed all at once. And it was very confusing for
people to see an eight-ounce soda and they might assume that
what they were seeing on that label represented what was
in that 20-ounce soda. And there will be any number of
other changes that I think would take a little too
long to go into here. So now I just want to point out
that, as I’ve said, there are so many things to see, so
much more detail here. So dietaryguidelines.gov is
the place to go to get all the information, to see the
dietary guidelines. This is where you can download a
copy or PDF of the guidelines. This is where you can order a
hard copy of the guidelines. There are additional resources
at health.gov and at choosemyplate.gov which is where
all the MyPlate information is. There’s a lot more to see here. So now, before we turn over
to Lorena, we just have one knowledge check question. So this one is, Do you know
how the Dietary Guidelines for Americans are used? So A, is to learn how to
control diseases like diabetes? B, to inform policymakers
and health professionals, not the general public? C, to teach to help providers
how to educate their patients? D, all of the above? Or E, none? So, 70 percent of the people
said all of the above. The answer is actually to
inform policymakers and health professionals. So I do think that it is
important to make clear that, like I said, the dietary
guidelines are designed to be for disease prevention
but not really to control specific diseases. And we did think, when we’re
talking about this, that that third one, teach providers
to educate patients could be a little bit confusing. I certainly think that the
guideline is a resource for professionals to read
and understand. But I wouldn’t say that there’s
anything in it that directly teaches providers how
to educate patients. So really, the inform
policymakers and health professionals is the
correct answer there. OK. So now I am going to turn the
presentation over to Lorena. Thank you very much Jenna. That was great. I was taking my notes as well. Good afternoon everyone. So let me just move quickly
into the second part of the presentation, and that is the
American Diabetes Association’s Nutrition Recommendations
and pretty much the practical application. So, how do we take this
information for patients with diabetes and how do we put
it all together when we are teaching patients and
their families about food. So I will be pointing out what
are the similarities, as well as some of the differences in
both the nutrition guidelines, as well as in the
dietary guidelines. So one thing that Jenna had
talked about at the beginning of her presentation was, how
this was-the emphasis was really on dietary patterns. So, not just specific “diet” or
not something that is extremely prescriptive, but we are
learning that not one size fits all of eating approach. So that means that we have an
array of different dietary patterns that fit and also
that can work very well to accommodate the patient’s
socioeconomic status, cultural, and eating habits. So at the end, the eating
patterns should emphasize glucose, blood
pressure, and lipids. And we want to emphasize that
the eating patterns, the recommendation should fit the
individual and fit for her needs, and that is
ideally provided by a registered dietitian. So I am going to focus on
just a few nutrients and look at the recommendations. The first one is carbohydrates. When I first started teaching
diabetes education, there was a lot of prescriptive
amount of what the recommendation should be. It was either 50 percent,
40 percent of the calories, 30 percent if you were
recommended in a low-carbohydrate diet. So as the recommendations
have changed over the years, those numbers have changed. Now ultimately, the evidence
is inconclusive for an ideal amount of carbohydrate. So this has to be done
collaboratively with the patients looking at their
blood glucose levels and other parameters, as well
as keeping that enjoyment of eating and food. So the amount of carbohydrates
and the available insulin will be the most important
factor that influences that glycemic response. And that is what should
be considered when we are recommending an amino pattern. So the patient that has type 2
diabetes, if there is enough endogenous insulin, the best
approach is to look at their blood glucose levels,
pre-prandial, post-prandial, and then based on those
recommendations, as well as other markers, that should be
the carbohydrate, the amount of carbohydrate that
should be recommended. And that is usually how I
approach the recommendation of the carbohydrate. So it could range between
30 percent of the total daily calories, to 40 to 50 percent. Again, taking into account that
not one size fits all and that I want to look, in general, at
the patient’s profile and their blood results in order to
make a recommendation about the amount of carbohydrates. And I usually use diagrams which
I will share with you later on in practice, as to
how does this look? So I do show, well, we need
the carbohydrates that you’re consuming, but we also want to
take into the account your endogenous insulin or the
insulin that you are using. And then that will determine
whether your blood glucose levels are elevated
or they are not. And there are other multiple
factors to change those numbers. So after giving that
prescription, what would be the best way for the patient to
monitor the amount of carbohydrates that
they are consuming? It depends on the patient and
also the level of literacy of that patient and
prior education. So, I already know that patients
that only want to use their hands as a guide, then I
indicate the hands to use to provide them with an
average of the amount of foods that they are consuming. There are other individuals that
like to know the exact amount of carbohydrates that
they are eating. And they are using apps,
or they’re just simply counting their carbohydrates. And that also works for them. For other patients, I choose the
plate method, because I find that by using the plate
method and kind of estimating the amount of carbohydrates. It’s perhaps easy for some
individuals that may have literacy problems
and they are not as adept at multiplying and adding. So whatever method you use,
there are many different ways. And the evidence is Level B. And this is the
level of evidence. So that means that
this is supported by well-conducted cohort studies. And I think that that gives the
educator a great way and latitude to making a selection
that suits the patient. So where do these carbohydrates
should come from? Vegetables, fruits, whole
grains, legumes, and other sources that are nutrient-dense. So here it aligns with the
message of the dietary guidelines: the sources, the
nutrient-density that Jenna had mentioned at the beginning,
the variety of the different fruits and vegetables. So we are pretty much preaching
exactly the same message. And of course, we are
talking about the amount. I always like to
use the Ps and Qs. And when I talk to patients,
I always say, remember the Ps, to mind your Ps and Qs. P for portion and Q for
quality of the food. And most of the time, if you’re
minding your portions and the quality of the food,
you are probably doing everything the right way. So here we have again, how to
translate the message of the nutrient-density that will be
the quality, and the amount, that will be P for
portion-minding the Ps and Qs. What about sugar? And I wanted to include
this for two reasons. Because the recommendations for
ADA do allow for some amount of sugar consumption, as long as
you’re substituting for the same amount of calories of
other carbohydrate foods. Now what happens is that
the recommendation has to be very clear to the patient
that while it might be OK to substitute for another food
that has equal amounts of carbohydrates, we have to
go back to the original message of a nutrient density. And that is what should prevail. The other issue is where does
the added sugars are coming from and the excess consumption
of added sugars. And in certain communities, it
is extremely important to always address what beverages, if the
patient or the community that you’re teaching, what
are they drinking? And that should be
part of every single assessment, in my opinion. Another recommendation is the
emphasis of consuming fruits in its natural state when
possible, because of the fiber and the nutrients. And juice, even when there’s no
added sugar to the juice, even when the patient says, “I drink
juice because it’s natural, and I do not drink
sweetened beverages.” It is still very important to
relay the message that most of us do not drink two to
three ounces of juice. Most of us, in our home, do not
have glasses that only hold three to four ounces of juice. So most likely, the average
person might be drinking between eight to 12 ounces
of juice per day. And that has an impact
on blood glucose levels. Remember, what affects blood
glucose levels is the amount of carbohydrates and the
amount insulin available. So if the amount of
carbohydrates increased by the increasing consumption of
sugars, even when they are coming from fruit juice,
that will have a negative impact on blood glucose levels. So again, the key message
is, consume fruits in its natural state when possible. And let’s be mindful of the
juices, because that will be one item that the patient or the
client is not going to consider to have a problem later on. So here it is, something that,
again, perfectly aligns with the recommendations, and that is
sugar-sweetened beverages. And I have added a
picture of ginger. The reason that I have ginger is
because most people, at least the communities that I served,
do not consider ginger ale or other sweetened beverages
to have the same impact as colas or sodas that are not. So pay attention, especially
when you’re communicating with patients that have low health
literacy, it’s very difficult for them to sometimes
translate the message. So if you say, “Do not drink
sodas or sweetened sodas,” they might not translate that message
to ginger ales or any other sodas that you have
not mentioned. So that is just one
tip that I have found out to be true most of the time. I’m moving on to fats because
the other recommendation with the dietary guidelines
was about fats. And once again we used to have a
very prescriptive message in the past that 30 percent, and
perhaps the nutritionists, the dietitians in the group would
probably remember, no more than 30 percent of the calories
should come from fats. Well, here, again, it appears
that it’s also inconclusive and the goal has to be
individualized. We went through the
fat-free years in which everything was fat-free. And then what happened was, once
the fat is removed from the product, in order to
have more palatability, more carbohydrate was added. So the consumption
of carbohydrates increased to replace the fat. And then that had a
more detrimental effect on the cardio-metabolic profile. So be aware of
sharing that message that we have shared for so long. It is also a little difficult
to say not all fats are bad-and that’s part of the message-but
also that the quality is important and remember
the Ps and Qs. Even when you’re sharing
the types of fats that are healthier, it has to be
conveyed into the right amount. And it has to be
part of that eating pattern, not isolated nutrients. And then I just want to
focus on the saturated fats, the cholesterol, and trans fat. That the recommendations are
the same as that recommended for the general population. Therefore, the recommendation
of saturated fats will be less than 10 percent of the calories. The sodium recommendation, it
will be exactly the same-of less than 2,300 milligrams-again,
very much aligned with the dietary guidelines. One thing that is very
important, and that’s why I have that folder here that says
top-secret salt mission, is that most people believe that most
of the sodium that they consume comes from the salt shaker. And that’s why I love Jenna’s
slide that shows that almost 50 percent of the sodium that we
consume are the mixed dishes, the snacks, and even the sweets. So this is the key message. Ask the educator that you need
to translate that message and work on the implementation,
where it comes from. So now I just want to just give
you a few minutes of respite before the end of the
presentation and allow you to see the beautiful view and
the beautiful sea because this will be a great
segue– — to talk about the different eating patterns. And the first one that I have
here is the Mediterranean style. So I just wanted
you to just help you travel to the Mediterranean. And these are-and since you’re
going to receive copies of the slides later on they will be
available, I am not going to read through all of them. But I just want to highlight
that the key of the different eating patterns, the
Mediterranean, which is the stew of different countries, but it
focuses on whole grains-once again, we are repeating the same
thing-using healthy fats such as olive oil; consume moderate
amounts of certain foods that are high in saturated fats; and
also focusing on locally growing fruits and vegetables and
a variety-and, of course, a glass of wine at times. So I love that piece. Then there’s the
vegetarian or vegan. That will also be an option
for patients that want to do or try something different. And then the low-fat diet is
one that is a little bit more focusing on the amount of fat
reduction to the right amount. And again, the emphasis is
on the right kind of fat. And then we have two more
recommendations of the different ones that have been proven to
have yield optimal results, and that it is the low-carbohydrate
diet, as well as the DASH diet or the Dietary Approaches
to Stop Hypertension. So the key message that I
want to leave you with is, there are different patterns. So whether someone chooses a
little bit lower carbohydrate, a little bit higher
carbohydrate, a different variety, there is a
choice for someone that should be individualized. And I think that it speaks
beautifully how it dovetails that it is individualized. And I also wanted to add
something else, which is, if you’re looking at patients
from different countries and cultures, there is a way to find
out what is it that they’re eating, and then adapting
things if its needed to the recommendation based on
their favorite foods. So the last few minutes that I
have left, I just want to tell you something that I find to
be very helpful in practice. The first is using
risk communication. And I just want to go briefly
through what it is to use risk communication when
you’re talking to the patient or the client. When you tell someone that he or
she is at risk of-and I’m using this example of cardiovascular
risk-it is important to talk about, what is someone’s risk? Am I in danger? If my blood pressure is high, or
if my cholesterol level is high, or if I smoke, what is my risk
based on those markers compared with someone that doesn’t
have those conditions? And that’s why I always
like to use graphs. So in this example, based on the
risk factors, you can see the cardiovascular mortality once
there are more risk factors. So it is important to
communicate that to the patient. Instead of just providing them
with a blanket statement about hypertension leads
to…define it. Where is the patient? And what are the risk factors? The other thing that is
important when it comes to risk communication is not
just to throw the numbers. Not to say, “Your goal
should be less than seven when it comes to A1C levels.” But, tell the patient
what is your level, and this is what the goal should be. Make it very specific so that
the patient can understand what is the goal, and where is he
or she compared to that goal? Show them the risk factors. The other thing that
is important is explain numbers that need explanation. And the A1C, this is the chart
that I really love because it has side by side the A1C and the
blood glucose levels that the patient is more familiar with. So I numbered it from nine
to seven for someone who doesn’t understand what A1C means,
might not be taking seriously because it’s only two points. So if I have an A1C of 9, and
the goal is of 7, in my head, I’m thinking, “It’s not so bad. I’m only two points
away from the goal.” However, if it’s explained that
a 9 means an average of 212, and the goal is 154, immediately,
I can see that there is almost 60 points between where I am
and where I am supposed to be. Also provide treatment
strategies, and ask what are you doing and then
make a suggestion. It’s very important to show and
to show and ask the patient if this is something that he or she
will be amenable to changing. I focus on three things. What am I going to say? What am I going to show? And what is the
patient going to do? So let me just give you a
few examples of what I mean. If my key message is – I want
the patient to choose whole grains, reduce the saturated
fats and replace it with poly-unsaturated fats, not
carbohydrates – I want to focus on the patient’s reduce in
sodium and added sugars. So these are some
of the examples that I choose from my real life. So what am I going to say? And I’m using the
example of whole grains. Well, going back to
risk communication, I want to be very specific. I want to tell them, “Well, if,
some studies have shown, that if you eat more whole
grains, you’re going to reduce type 2 diabetes.” And what does that mean? I want to quantify
it, if possible. So I can use examples of
two servings, or I can say, “Well, three servings of
whole grains have shown to reduce this percentage.” I’d like to be as exact
as possible so that it is tangible, what I am saying. Then what am I going to show? And that is the show and tell. That is the props session. What are you going
to show so that-most of us are visual learners. So I always think, how can
I convey this message and translate that into application? Well, I like to use analogy. In order for me to explain what
is a whole grain that I am telling the patient
to consume, I compare that to the yolk, to an egg. And I say, “Well,
just like an egg has three parts, so does the grain. And we want to make sure that
all those three parts are there when you eat them because each
one brings you that nutrient density that you need
in order to have the effects that you would want.” I also want to focus on what
is the patient going to do? And usually a patient has
already given you what he or she is eating, and then
you talk about swapping. And it has to be based on what
the patient wants to change. And in this example, I am
talking about saturated fats. Again, I talk about
what are saturated fats? And again, specific, I say,
“Well, in terms of reduction of the food that you’re consuming
that has saturated fat, you might see, based on the studies
that there, your LDL or bad cholesterol, or your healthy
cholesterol, can drop from 150 to 135 milligrams
per deciliter.” I also want to ask them about
the food so that then I can provide suggestions, and then
we will share decision-making because the patient can
decide what goals to choose. And because my population
is Hispanic, I usually have everything in
English and Spanish. I have mentioned how much I
enjoy having-creating my own teaching materials and
I like to use graphs. In this example, on the left
is what I call their saturated fat-based budget, which is
about-based on a 1,200 to 1,500 calorie-less than 10 percent of
the calories from saturated fat. So I used the concept
of budgeting. Budgeting saturated
fat, budgeting carbohydrates, et cetera. And then, I give them an example
of different foods, and based on their serving
size, the amount of saturated fat that each one has. This is a slide that can be used
not just for patients that have restricted health literacy
but everyone can appreciate the message at that point. So right there I can see
the difference between whole milk and 1-percent. You can see the difference
between one cut of meat and another cut of meat. And this creates awareness
to show, where is their diet? That will suggest choosing
what are the items that they should be looking at and then
thinking about recreating so that overall their eating
patterns becomes better. So again, I do a lot of
swapping with the patients. And you can see here, this
is a just an example of what the patient just gives me. And last but not least, I-this
is a project that we created for patients that, instead of going
to restaurants, they’ll be using small mom-and-pop stores, and
they were consuming a lot of different sandwiches,
especially at lunch time. And we were concerned
about the amount of sodium. So we wanted to help them to
select the cold cuts that had the least amount of sodium. So we created this handout. And as you can see here, going
back again to my love of graphs, we indicated what were the
different types of cheeses and cold cuts, which one had more
or less amount of sodium. So that when there’s not the
best choices, I want to offer the better choices, the
more realistic choices. But everything is guided. And even there are some
recommendations here that says, “If you consume the high-sodium
lunch, then this is what you can do at night and have
these others choices that are lower in sodium.” Because I am not focused
on just one meal. I am focused on what is
done day-in and day-out. So circling back again to the
healthy eating patterns, not just demonizing one
meal versus another. And to make sure that your
patients know, always use what we call the ‘Teach-Back.’ Have the patient tell you,
what did I learn today. Ask the patients
to demonstrate or explain what you have just said. When you go home, how
would you share this with your husband or your children? And how would you reconstruct
this meal to make it healthier? Then you know whether
your explanation actually was clear to the patient. So this one of my favorite
slides, and one boy tells the other one, “I taught
my dog how to sing.” And then the young man says,
“I don’t hear anything.” And he responds, “I
said I taught him how to sing, not that he learned.” So remember, information
is not education. So to conclude, I just want
to show you some of the questions that you can pose
to use the teach-back method. You can say things like, “Using
your own words, you tell me…” Or many times, I say, “I have
given you so much information. Can you tell you me
in your own words…” Or, “How could you describe
this to someone else?” So we have to come to the
end of this presentation. And this is the knowledge
check question. The amount of saturated fat for
someone with diabetes should be? Individualized? Less than 10 percent
of the calories? Less than 30 percent
of calories? Depends on the
triglycerides level? OK. So let’s me show you. Fifty-five percent
of you says less than 10 percent of the calories. So that is the correct answer,
because the recommendations are that the amount of fat that is
recommended is the same as the general population and the
recommendations from the dietary guidelines do specify that the
consumption of saturated fats should be less than 10 percent. So I am going to pass this over
to my friend, Betsy, who will give you a summary
of the presentation. Thank you very much. Thank you Jenna and
thank you Lorena. We have been blessed
of having these great two speakers with us today. As we conclude our overview this
webinar today, we are reminded of the important potential for
the guidelines to implement policy as well as practice. Given the significant
nutrition-related health issues facing the US population, such
as cardiovascular diseases, type 2 diabetes, and certain
cancers, the importance of the best possible science to inform
the public regarding dietary recommendations is a paramount. Managing the chronic disease
like diabetes requires multiple decisions each day on a
range of complex process. There are no vacations,
no time-outs. At best, conditions like poverty
and food insecurity, only complicates diabetes
self-management. At worst, they make effective
self-management impossible. This simple fact is true for the
millions of Americans who live with diabetes while
facing food insecurity. We’re hoping that with
today’s webinar, healthcare professionals remind ourselves
that we all have a critical role in implementing dietary
guidelines recommendations to people with diabetes
and at risk. Now, we’re moving
into the Q&A section. We have been getting a
lot of great questions and Jenna answered some of those. We will try to get to as
many questions as possible. So let me see what
questions we have here. Betsy? Yes. So there’s a
question that I just saw that I’d be happy to answer. It was a question around the
WHO and the American Heart Association are recommending an
amount of added sugar that would be significantly
less than what’s in the dietary guidelines. So what I would say in response
to that is it’s very important to understand that the dietary
guidelines is saying, a maximum of less than 10
percent of calories. That is not to suggest that 10
percent of calories is good or right, but that it
really is a maximum. And actually when the advisory
committee did an analysis and looked at how much added sugar
could be included in people’s diets, what they really found,
in order to then also get all the healthy nutrients you need,
what they found is really it’s between 4 percent and 9 percent
of calories, depending on the number of calories you
should be consuming. And so really that
recommendation of less than 10 percent is setting it at a
high goal from the understanding that right now Americans’
consumption is above that. And so there’s no question that
we want to be moving people, that no one would be satisfied
with getting everyone to 10 percent, that this is pushing
for and really trying to. But this is the first time that
the dietary guidelines have had a quantitative recommendation
for added sugar. And I think that’s important
to realize that the dietary guidelines are not always about
the optimal diet but about moving people in the
right direction. And right now our added
sugar consumption is well above the 10 percent. And so, and that is
just a recommendation to less than 10 percent. Thank you, Jenna. Thank you, Jenna. I have a question
here for Lorena. Yes. Lorena, how do we explain to
patients why their total carbs do not equal to fiber
and total sugars? Yes. The way that I explain it is,
I use a nutrition facts label. And then I say that
there are different types of carbohydrates. And that the total
already includes the others, the sugars, et cetera. So that’s the way
that I explain that. And there were recommendations
in the past that the dietary fiber was subtracted from the
total amount of carbohydrates, which later on changed
to only half of the total fiber would be reduced. And now it’s pretty much
whatever the amount of carbohydrate is there, that’s
the amount of it that we count. So I just want to just say that
I usually say everything is already included in
the total amount. So that’s the
message that I say. And then I use the example,
if it’s 20 grams of carbohydrates, and when they
look at sugars, it says 10, I say, you don’t have to count
this twice but the 10 is already part of the 20 grams
of carbohydrate. Thank you Lorena. And now, Jenna, I have a
question here that says, what about recommendations for eggs? I’m telling my patients
one or two egg yolks per day. Then, egg white for patients
with no cardiovascular diseases. Yes. So, of course, it’s important to
know and I would not want to say anything if the patients
that you are treating specifically have diabetes. So I’m going to say, if that’s
true, there probably will be a different answer
to this question. But if I would say that that’s a
very reasonable recommendation in general, and it really is
kind of moving away from the, sort of, very rigid anti-egg
view that may have come in the past when there were more strict
limits on dietary cholesterol. And it really did hurt the
egg industry in a major way that people were really avoiding
eating eggs that really are a very healthy protein source
when kept in moderation. I just wanted to add
a little bit to what Jenna just said about the eggs. And the emphasis that I try to
do is to show that saturated fats and trans fat usually
have much more of an impact on dietary cholesterol in general. So I do what Jenna says is just
very safe recommendations when it comes to dietary cholesterol. But to understand that about
3 percent of the dietary cholesterol is what impacts
blood cholesterol levels, and then to focus more
on the saturated fats and trans fat in the diet. Good. I have a question
here for you Lorena. It says, are there
are substitution list for ethnic foods? Are there substitutions? Well, yes. Yes, there are. There are certain sources
that have looked at different foods of different ethnicities
and religious groups, and what are their healthier
alternatives. So there is a source of that. So I was the co-editor
and co-writer of this particular book. So it sounds like a
shameless plug, but there are sources that provide this. Will high fructose
be eliminated? So at this point, I assume
high-fructose corn syrup, so of course, high-fructose corn
syrup is considered an added sugar, and certainly will
be taken into account. Will it be eliminated? There is no, at this point,
no regulation that is going to eliminate it from food. I think there is pressure. There are a lot of people,
just in the general public, who are pushing against it. And so products are taking
it out and replacing it. But I think it is important to
note that if they just replace it with other sugar, that’s
really not addressing the problem of added sugar
in people’s diet. And so I do think it is
important to note that there are a lot of people who maybe feel
like, “Well, if I drink the soda that’s made with sucrose that
somehow that’s OK because it’s no longer high-fructose
corn syrup.” And I think it is important to
note that it’s still sugar and a lot of sugar
certainly in a soda. And it’s all added sugar and no
other beneficial ingredients. And so I think that we need to
get away from the notion that if we just get rid of high-fructose
corn syrup that we’d be-that people would be OK consuming
other kinds of sugar. Thank you Jenna. I would like to have more
time for more questions but we’re running out of time. Also, we are in the process
of updating one of the most popular resources for the
National Diabetes Education Program, which is the bilingual
recipe book, Tasty Recipes for People with Diabetes
and Their Families. So stay tuned in the next few
months to see our updated booklet reflecting
some of the changes that have been discussed here today. I’d like to also mention
to you that the NDEP webinar series is offering
continuing education credits. You will have to complete
an online evaluation in order to claim your credits. Just go to the CDC TCEO at the
link that is showing at the top of your screen and
follow the instructions. You will receive a certificate
of completion too. I’d like to thank everybody
that joined us today. It has been an
amazing participation. You have seen my
contact information during the Q&A session. So please feel free
to contact me. Thank you Jenna, and thank
you Lorena for sharing your expertise and words of wisdom. Everyone else, see you
next time for another great NDEP webinar series. Thank you again and goodbye.