4
Overview of Health and Diet in America

Most of the goals of front-of-package rating systems and symbols are related to helping consumers make more nutritious food choices, given an environment in which the impact of diet on health is of increasing concern. One of the committee’s guiding principles assumes a focus on the nutrients and food components most strongly associated with the diet-related health risks affecting the greatest number of Americans. Given this principle, it was important to consider the current state of the average American’s diet as well as the health status of the population.

In the United States, poor diet was once associated with undernutrition. Today it is more often associated with excess, particularly excesses in calories, saturated fats, trans fats, added sugars, and sodium (DGAC, 2010). The poor diets and sedentary lifestyles of the American public have led to high rates of obesity, overweight, and diet-related chronic diseases, including cardiovascular disease (CVD), hypertension, dyslipidemia, type 2 diabetes, osteoporosis, and certain types of cancer (HHS/USDA, 2005a). It has been estimated that poor diet quality and physical inactivity contributed to approximately 16.6 percent of U.S. deaths in 2000, compared to 14 percent in 1990 (Mokdad et al., 2004).

As shown in Table 4-1, the three main causes of death in the United States are heart disease, cancer, and stroke.1 Together with diabetes, the sixth leading cause of death, they are the major contributors to the morbidity, mortality, and healthcare costs in this country. All of these chronic diseases are made more likely by the presence of overweight and obesity. Brief overviews of these conditions and the overconsumption of dietary factors that contribute to them are provided below.

OVERWEIGHT AND OBESITY

According to the National Center for Health Statistics, about two-thirds of U.S. adults and about one-third of children aged 2 through 19 years are overweight or obese (Ogden et al., 2010). While obesity is far from a new problem in our nation, its rise over recent decades and its subsequent impact on rates of chronic disease and premature death are of increasing public health priority.

Obesity, defined in adults as a body mass index (BMI) greater than or equal to 30, has become increasingly prevalent over the past three decades, its prevalence doubling between the 1976–1980 and the 1999–2000 National Health and Nutrition Examination Surveys (NCHS, 2010). Only recently has the rate of obesity in adults leveled off, albeit at record high levels. The rates of overweight (BMI of 25–29.9) have remained fairly constant

1

Available online: http://www.cdc.gov/nchs/fastats/lcod.htm (accessed July 27, 2010).



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4 Overview of Health and Diet in America Most of the goals of front-of-package rating systems and symbols are related to helping consumers make more nutritious food choices, given an environment in which the impact of diet on health is of increasing concern. One of the committee’s guiding principles assumes a focus on the nutrients and food components most strongly associated with the diet-related health risks affecting the greatest number of Americans. Given this principle, it was important to consider the current state of the average American’s diet as well as the health status of the population. In the United States, poor diet was once associated with undernutrition. Today it is more often associated with excess, particularly excesses in calories, saturated fats, trans fats, added sugars, and sodium (DGAC, 2010). The poor diets and sedentary lifestyles of the American public have led to high rates of obesity, overweight, and diet-related chronic diseases, including cardiovascular disease (CVD), hypertension, dyslipidemia, type 2 diabetes, osteoporosis, and certain types of cancer (HHS/USDA, 2005a). It has been estimated that poor diet quality and physical inactivity contributed to approximately 16.6 percent of U.S. deaths in 2000, compared to 14 percent in 1990 (Mokdad et al., 2004). As shown in Table 4-1, the three main causes of death in the United States are heart disease, cancer, and stroke.1 Together with diabetes, the sixth leading cause of death, they are the major contributors to the morbidity, mortality, and healthcare costs in this country. All of these chronic diseases are made more likely by the presence of overweight and obesity. Brief overviews of these conditions and the overconsumption of dietary factors that contribute to them are provided below. OVERWEIGHT AND OBESITY According to the National Center for Health Statistics, about two-thirds of U.S. adults and about one-third of children aged 2 through 19 years are overweight or obese (Ogden et al., 2010). While obesity is far from a new problem in our nation, its rise over recent decades and its subsequent impact on rates of chronic disease and premature death are of increasing public health priority. Obesity, defined in adults as a body mass index (BMI) greater than or equal to 30, has become increas - ingly prevalent over the past three decades, its prevalence doubling between the 1976–1980 and the 1999–2000 National Health and Nutrition Examination Surveys (NCHS, 2010). Only recently has the rate of obesity in adults leveled off, albeit at record high levels. The rates of overweight (BMI of 25–29.9) have remained fairly constant 1 Available online: http://www.cdc.gov/nchs/fastats/lcod.htm (accessed July 27, 2010). 

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 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS TABLE 4-1 Top 10 Leading Causes of Death in the United States: All Ages, 2007 Deaths per 100,000 Population Cause 616.1 Heart disease 562.9 Cancer 135.9 Stroke 128.0 Chronic lower respiratory disease 123.7 Unintentional injuries (accidents) 74.6 Alzheimer’s disease 71.4 Diabetes 52.7 Influenza and pneumonia 46.5 Nephritis, nephrotic syndrome and nephrosis 34.8 Septicemia SOURCE: http://www.cdc.gov/nchs/fastats/lcod.htm. during this time, but the increased rates of those classified as obese, and the shift of those classified as healthy to overweight status has resulted in Americans weighing much more than they did in the 1960s (NCHS, 2010). Childhood obesity, defined as a BMI at or above the sex- and age-specific 95th percentile BMI cut points from the 2000 CDC Growth Charts, has also recently leveled off after several decades of increase, again at record high levels. These alarming trends have given rise to a major, national public health campaign to reduce obesity rates over the next decade. Obesity and overweight increase the risk for premature death and a host of co-morbidities. Co-morbidities include coronary heart disease (CHD) and stroke, type 2 diabetes, metabolic syndrome, certain types of cancer, sleep apnea, osteoarthritis, gallbladder disease, fatty liver disease, and pregnancy complications. 2 In 2006 three of the most prevalent co-morbidities, heart disease, stroke, and diabetes, together accounted for approximately 34 percent of age-related deaths (NCHS, 2010). Additionally, in a prospectively studied cohort of U.S. adults, Calle et al. (2003) estimated that 14 percent and 20 percent of cancer deaths among men and women, respectively, were due to overweight and obesity. It has been estimated that $169 billion in annual medical sav - ings could potentially be saved if overweight and obesity problems were eliminated in the United States, and even modest caloric reductions (100 calories per day) across the population could save as much as $58 billion in medical costs (Dall et al., 2009). Overweight and obesity are the result of excess calorie intake or inadequate energy expenditure or both. While total daily caloric expenditure is difficult to quantify because of limited national surveillance, the increase in caloric consumption has been well documented (DGAC, 2010). According to the loss-adjusted USDA food avail - ability data, daily per capita intake increased by 617 calories between 1970 and 2008 (DGAC, 2010). The three largest contributors to the increased calorie intake were added fats and oils (34 percent); flour and cereal products (31 percent); and caloric sweeteners (9 percent) (DGAC, 2010). Caloric sweeteners, or added sugars, include all refined sugars, corn sweeteners, honey, and edible syrups. In the 2005 Dietary Guidelines for Americans (HHS/USDA, 2005b), a new concept regarding excess, non- essential calories was introduced. The term was “discretionary calorie allowance” or the balance of calories remain - ing in a person’s energy allowance after accounting for those consumed when meeting recommended nutrient intakes through healthful foods. Only a relatively small number of discretionary calories remain to be consumed as high-energy, low-nutrient foods (i.e., foods high in added sugars, fats, or alcohol) or as additional high-nutrient foods in excess of the levels needed for a healthy diet (e.g., additional fruit and vegetables or whole grains). For example, a person consuming 1,600 calories per day would have 130 discretionary calories, while a person con - suming 2,000 calories a day would have 265. A high intake of added sugars or fat has the potential to contribute to overconsumption of discretionary calories by Americans. Because the concept of discretionary calories has been difficult to translate into meaningful consumer education (DGAC, 2010), the 2010 Dietary Guidelines Advisory Committee (DGAC) referred to the non-essential or extra calories coming from solid fats (i.e., saturated and trans 2 Available online: http://win.niddk.nih.gov/publications/health_risks.htm (accessed July 8, 2010).

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 OVERVIEW OF HEALTH AND DIET IN AMERICA TABLE 4-2 Top 10 Foods Contributing Solid Fats (i.e., Saturated and trans Fats) in the American Diet Food Category Total Energy Contribution from Solid Fats (%) Grain-based desserts 10.9 Regular cheese 7.7 Sausage, franks, ribs, bacon 7.1 Pizza 5.9 Fried white potatoes 5.5 Dairy desserts 5.1 Whole milk 4.6 Mexican mixed dishes 4.4 Pasta and pasta dishes 4.2 Burgers 4.1 SOURCE: Bachman et al., 2008. fats) and added sugars as “SoFAS” and estimated that Americans currently consume about 35 percent of their total calories from these sources (DGAC, 2010). The Dietary Guidelines Advisory Committee recommended that no more than 5 to 15 percent of total calories should be derived from SoFAS. This was not broken down separately into guidelines for calories from fats and calories from added sugars. Calories from Fat Fat is the most calorically dense macronutrient, with a gram of fat contributing 9 calories, compared to 4 calories for a gram of carbohydrate or protein and 7 calories for a gram of alcohol. For this reason, being atten - tive to calories from fat as part of total calorie intake can be important for weight control. Unsaturated fats (poly - unsaturated and monounsaturated) are beneficial, while most saturated fats and trans fats have negative effects on lipid profiles and cardiovascular disease risk (see discussion in later section on cardiovascular disease). Saturated fats are naturally present in animal fats but can also be made from unsaturated fats through the pro - cess of hydrogenation. Using NHANES 2001–2002 data, Bachman et al. (2008) identified the top sources of solid fats (a term used by some nutritionists to describe the combination of saturated and trans fats) of in the American diet. As shown in Table 4-2, these include grain-based desserts; regular fat cheese; sausage, franks, ribs, and bacon; pizza; fried white potatoes (French fries); and dairy desserts. Sources for children aged 2 to 18 years are similar except that the number one source for children aged 2 to 8 years is whole milk (DGAC, 2010). Calories from Added Sugars Individuals in the United States consume a substantial percentage of their total calories as added sugars (DGAC, 2010). NHANES estimates from 2001 to 2004 indicate that the mean intake of added sugars for all persons was 22 teaspoons per day (355 calories), which far exceeds the allowance for discretionary calories (Johnson et al., 2010). In 2010 new recommendations from the American Heart Association were released that advised con - sumption of added sugars be only 5 percent of daily calories (Johnson et al., 2010). For adult women, this would be fewer than 100 calories (about 25 g or 6 teaspoons) per day, and for adult men, fewer than 150 calories (about 37.5 g or 9 teaspoons) per day. Based on NHANES 2003–2006 data, 13 percent of the American population had an added-sugars intake of more than 25 percent of calories (Marriott et al., 2010). As shown in Table 4-3, the major contributors of added sugars (comprising roughly 72 percent of added sugars consumed), are regular soft drinks or sodas, grain-based desserts (cakes, cookies, and pies), fruit drinks, dairy desserts, and candy.3 These top five categories are also low in nutrient density. In 2005–2006 NHANES, soda was the top beverage choice for children and adolescents, 2 to 18 years of age, supplying more calories than any other 3 Available online: http://riskfactor.cancer.gov/diet/foodsources/added_sugars (accessed August 3, 2010).

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 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS TABLE 4-3 Top 10 Foods Contributing Added Sugars in the American Diet Food Categories Total Added Sugars Consumed (%) Soda/energy/sports drinks 35.7 Grain-based desserts 12.9 Fruit drinks 10.5 Dairy desserts 6.6 Candy 6.1 Pre-sweetened cereals 3.8 Sugars/honey 3.5 Tea 3.5 Yeast breads 2.1 Syrups/toppings 1.9 SOURCE: NCI, 2010. single beverage (DGAC, 2010). Adolescents consume an average of 300 calories per day from sugar-sweetened beverages, accounting for 13 percent of their daily caloric intake (Wang et al., 2008). Unlike most other carbohydrates, added sugars contribute no nutrients besides energy. Although calorically there is no difference between added sugars and sugars found naturally in fruits and vegetables, the benefit of fruits and vegetables containing naturally occurring sugars lies in the vitamins, minerals, antioxidants, and phytonutrients they provide. Milk products contain lactose, a naturally occurring sugar, as well as protein, calcium, and other nutrients. Dietary guidance focuses on reducing added sugars because foods high in added sugars often supply calories—as well as saturated fats and sodium—but few essential nutrients other than energy. The IOM Dietary Reference Intakes (DRIs) report on macronutrients suggests that “added sugars” should be less than 25 percent of calories per day in order to protect against the dilution of micronutrients in the diet (IOM, 2002/2005). For both genders and most age groups, consumption of 25 percent or more of calories from “added sugars” is associated with a significant decrease in the consumption of micronutrients (IOM, 2002/2005). Recent data from Marriott et al. (2010) support this relation for all age groups. The 2005 Dietary Guidelines for Americans concluded that the problem with added sugars is not that sugars themselves are detrimental to health but that sugars provide only calories (HHS/USDA, 2005a). There is, however, evidence that small amounts of added sugars may have a beneficial effect on micronutrient intake by improving the palatability of foods and beverages that otherwise may not be consumed (FAO/WHO, 1998; Frary et al., 2004). Examples, particularly for children and adolescents, include sweetened dairy foods and bever - ages and presweetened cereals. Individuals who consume low levels of added sugars (5 to 10 percent of calories) tend to have higher micronutrient intake than those for whom added sugars account for less than 5 percent of total calories (IOM, 2002/2005; HHS/USDA, 2005a). The 2010 Dietary Guidelines Advisory Committee report noted that the role of dietary sugars in the obesity epidemic is controversial, with many opposing views and mixed results. Limited evidence shows that intake of sugar-sweetened beverages is linked to higher energy intake in adults, but the evidence is inconsistent regarding associations with obesity (DGAC, 2010; Johnson et al., 2010). The 2010 Dietary Guidelines Advisory Committee report noted that a moderately sized body of evidence suggests that under isocaloric controlled conditions, added sugars (including sugar-sweetened beverages) are no more likely to cause weight gain in adults than any other source of energy (DGAC, 2010). However, the preponderance of observational data for children and adolescents indicates that sugar-sweetened beverage intake can contribute to excess caloric intake, weight gain, and greater adiposity (DGAC, 2010). CARDIOVASCULAR DISEASE CVD comprises many conditions, including CHD and cerebrovascular disease which are, respectively, the first and third most common causes of death in the United States. The American Heart Association has estimated

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 OVERVIEW OF HEALTH AND DIET IN AMERICA that 81 million American adults, or about one in three, have one or more types of CVD (AHA, 2010). Among the modifiable risk factors for CVD are body weight (as discussed previously), dyslipidemia, elevated blood pressure, and diabetes—all of which can be influenced or reduced through dietary factors. Dyslipidemia Dyslipidemia (abnormalities of blood lipid levels) is a powerful risk factor for atherosclerotic diseases, particularly CHD. Dyslipidemia is generally defined as including at least one of the following disorders: a high concentration of low-density lipoprotein (LDL) cholesterol, a low concentration of high-density lipoprotein (HDL), or a high triglyceride concentration. The primary focus of prevention and treatment is on reducing LDL choles - terol (NIH, 2001). High LDL concentrations are associated with atherogenesis, or plaque development. Even in early life, the lowering of LDL levels can slow or even prevent atherogenesis and subsequent plaque development (HHS/USDA, 2005a), making dietary factors related to dyslipidemia a lifelong concern. In 2006 approximately 32 percent of the adult population greater than 20 years old had an LDL cholesterol concentration considered to be “borderline high” (greater than 130 mg per deciliter) (AHA, 2010). The dietary factors most directly related to LDL concentrations are saturated fatty acids (SFAs) and trans fatty acids. The National Cholesterol Education Program has estimated that a reduction of one percentage point in energy from saturated fat decreases serum LDL concentrations by about 1 to 2 percent (NIH, 2002). Data from NHANES 2005–2006 estimated that the intake of saturated fat in America has remained stable over the last 15 years at 11 to 12 percent of calorie intake despite long-standing recommendations for Americans to reduce levels to below 10 percent (DGAC, 2010) or even to below 7 percent of calorie intake (the American Heart Association recommendation) (Lichtenstein et al., 2006). Trans fat intake has been more difficult to estimate than saturated fat intake. Prior to the introduction of trans fat on the Nutrition Facts panel in 2006, it was estimated that trans fat comprised approximately 3 percent of calorie intake.4 However, as a result of this new labeling requirement combined with bans in certain localities on the use of partially hydrogenated fat plus heightened public awareness, many foods have been reformulated to lower or elimi - nate their trans fat (Eckel et al., 2007; Mozaffarian et al., 2010). Thus determining an accurate current estimate of trans fat intake will not be possible until nutrient composition databases are updated and more recent intake surveys are analyzed. Nonetheless, since an ideal diet would be as low in trans fat as possible (IOM, 2002/2005), it can be assumed that even at the current (likely reduced) intake levels, trans fat consumption remains a concern. The effect of dietary cholesterol on LDL cholesterol concentrations, within the context of current U.S. intakes, is relatively small compared to that of saturated and trans fatty acids (Clarke et al., 1997; Howell et al., 1997). Although cholesterol remains a nutrient that should be limited because of its ability to increase the risk of elevated blood LDL cholesterol concentrations (DGAC, 2010), the overconsumption of cholesterol is less of a public health concern than the overconsumption of saturated and trans fats and sodium. A majority of women, children 2 to 13 years of age, and girls 14 to 18 years of age have cholesterol intakes at or below recommended levels (DGAC, 2010). Instead, overconsumption of cholesterol is mainly a problem for men and boys aged 12 to 19 years (ARS, 2010; DGAC, 2010). In addition, dietary sources of cholesterol largely track with saturated fat. Hence, if sources of saturated fat intakes (which are higher than recommended for much of the population) are reduced, intakes of dietary cholesterol will be as well. In contrast, unsaturated fats have a number of health benefits. Some polyunsaturated fatty acids are essential nutrients needed for healthy physiological function (DGAC, 2010). In addition, the 2010 Dietary Guidelines Advisory Committee found strong and consistent evidence that dietary polyunsaturated fats are associated with improved blood lipids related to CVD, in particular when these fats replaced saturated and trans fats in the diet (DGAC, 2010). A recent pooling project concluded that diets with higher polyunsaturated fat to saturated fat ratios were associated with lower CHD rates (Jakobsen et al., 2009). Omega-3 fatty acids from polyunsaturated fat may have an independent beneficial effect on CVD outcomes. Moderate evidence shows that consumption of two 4 68 FR 41442.

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 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS TABLE 4-4 Top 10 Foods Contributing Sodium to the American Diet Food Categories Total Sodium Consumed (%) Mixed dishes (sandwiches, pizza with meat, burgers, Mexican entrees, pasta dishes) 44 Meat, meat alternatives (chicken, cheese, eggs, bacon/sausage, beef) 15.5 Grains (bread, cold cereal, rice, pancakes, waffles, French toast, crackers) 11.4 Vegetables (green salads, fried and non-fried potatoes, cooked tomatoes, cooked green beans) 9.3 Sweets (cookies, cakes/cupcakes, ice cream, pies/cobblers, doughnuts) 5.0 Condiments and oils (catsup, mustard, relish, soy sauce, gravy, salad dressing, pickles, olives, margarine) 4.3 Salty snacks (corn-based snacks, popcorn, potato chips, pretzels, party mix) 3.4 Milk (plain 2% milk, plain whole milk, plain skim milk, plain 1% milk, yogurt) 2.9 Beverages (noncarbonated sweetened drink, non-diet soda, diet soda, coffee, beer) 2.2 Beans, nuts, seeds (baked or refried beans, nuts, beans, protein or meal enhancement, peanut or almond butter) 2.1 SOURCE: IOM, 2010. servings of seafood per week providing an average of 250 mg of omega-3 fatty acids is associated with reduced cardiac mortality (DGAC, 2010). Hypertension Hypertension, also referred to as high blood pressure, is estimated to affect a third of U.S. adults (Fields et al., 2004; IOM, 2010). An additional third of U.S. adults are considered to have pre-hypertension (Cutler et al., 2008). As with adults, blood pressure levels have increased among U.S. children and adolescents over the past two decades (DGAC, 2010). Elevated blood pressures are associated with serious health conditions, including stroke and cardiovascular disease events. Even in childhood elevated blood pressure is a concern, especially since it may lead to increased cardiovascular disease risk later in life (DGAC, 2010). Multiple diet-related factors influence the development of elevated blood pressure, including excess weight, inadequate potassium intake (see page 48), and high alcohol consumption (IOM, 2005). As previously discussed, the majority of the American population is now overweight or obese and is therefore at greater risk for hypertension. In addition, it is important to note that a large body of evidence indicates that a high intake of sodium adversely affects blood pressure (e.g., IOM, 2005, 2010). Over the past four decades sodium intake in the United States has trended upward across both age and gender groups, and it currently averages 3,400 mg per day (IOM, 2010). This exceeds the Upper Intake (UL) levels of the IOM and the recommendations of the 2005 Dietary Guidelines for a daily sodium intake of less than 2,300 mg in the general population and less than 1,500 mg for higher-risk subpopulations; similarly it exceeds more recent recommendations from the 2010 Dietary Guidelines Advisory Committee that most Americans should consume only 1,500 mg of sodium per day (IOM, 2005, 2010; DGAC, 2010). The top contributors to sodium intake are mixed dishes (e.g., sandwiches, pizza with meat, and hamburgers and cheeseburgers), meat and meat alternates, and grain products (e.g., bread, cold cereal, and rice) (see Table 4-4) (IOM, 2010). TYPE 2 DIABETES Type 2 diabetes, one of three main types of glucose intolerance, accounts for 90 to 95 percent of all diag - nosed cases of diabetes (NDIC, 2008) It was previously referred to as non-insulin-dependent diabetes mellitus or adult-onset diabetes. The onset of type 2 diabetes is closely associated with excess body weight gain. More than 85 percent of people with type 2 diabetes are overweight. Of the estimated 23.6 million Americans with diabetes, approximately 5.7 million of these cases are undiagnosed (NDIC, 2008). Many more Americans are at high risk for the disease without knowing it.5 5 Available online: http://www.diabetes.org/diabetes-basics/type-2 (accessed July 12, 2010).

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 OVERVIEW OF HEALTH AND DIET IN AMERICA Complications from diabetes are numerous, and its healthcare costs are staggering. In 2004 heart disease and stroke were noted on, respectively, 68 percent and 16 percent of diabetes-related death certificates among those 65 years or older.6 Diabetes is also the leading cause of both nervous system disease, amputations, dental disease, and complications during pregnancy. In 2007 the total direct and indirect cost of diabetes in the United States was estimated to be $174 billion.7 Weight loss can prevent or delay the onset of type 2 diabetes (Hamman et al., 2006). Diet and physical activity interventions are effective and feasible approaches to reducing the incidence of type 2 diabetes and are often more cost effective than medications.8 CANCER The American Cancer Society estimates that about one-third of cancer deaths expected to occur in 2010 will be related to overweight or obesity, physical inactivity, and poor nutrition (ACS, 2010). In 2007 the World Cancer Research Fund and the American Institute for Cancer Research together published an extensive report on the rela - tionship between food, nutrition, and physical activity and the prevention of cancer (WCRF/AICR, 2007). While numerous dietary factors (e.g., carotenoids, lycopene, fiber, selenium, sugar, fatty acids, etc.) were linked to either decreased or increased risks of specific types of cancer, the evidence is difficult to synthesize, and firm judgments on their relationships generally have not been made. The report did, however, conclude that “maintenance of a healthy weight throughout life may be one of the most important ways to protect against cancer” (WCRF/AICR, 2007). NUTRIENTS AND FOOD GROUPS TO ENCOURAGE Shortfall Nutrients Nutrients known to be beneficial or necessary for humans to sustain health are numerous, but recent analyses have found only a few nutrients for which Americans have an insufficient intake that is linked to clinically impor- tant conditions. A review by the Dietary Guidelines Advisory Committee 2010 reported insufficient intakes of vitamin D, calcium, potassium, and fiber among Americans (DGAC, 2010). Vitamin D Vitamin D has a long-established role in maintaining bone health and is critical to calcium absorption within the body. Classic deficiencies of vitamin D result in rickets in children and bone mineral loss in adults. A number of benefits from vitamin D beyond bone health have been suggested, including improved immune function, cancer risk reduction, and prevention of diabetes, but evidence-based reviews have been carried out for only some health outcomes (Cranney et al., 2007; Chung et al., 2009). There is currently much discussion about the levels of defi - ciency within the U.S. population, but agreed-upon definitions for deficiency or insufficiency of vitamin D do not currently exist, with those in use varying greatly. A report from the IOM concerning nutritional requirements for vitamin D and calcium will be released in 2010. Fortified foods remain an important source of vitamin D since it is found naturally only in fatty fish, egg yolks, and liver. In addition, vitamin D can be synthesized endogenously when skin is exposed to sunlight. Calcium Adequate intake of calcium is necessary for bone health as well as for basic biological functions such as nerve transmission, vasoconstriction, vasodilation, and muscle contraction. The major sources of calcium in the American 6 Available online: http://www.diabetes.org/diabetes-basics/type-2 (accessed July 12, 2010). 7 Available online: http://www.diabetes.org/diabetes-basics/type-2 (accessed July 12, 2010). 8 Available online: http://www.diabetes.org/diabetes-basics/type-2 (accessed July 12, 2010).

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 FRONT-OF-PACKAGE NUTRITION RATING SYSTEMS AND SYMBOLS diet are also the most bioavailable. Although there are additional sources of calcium, fluid milk and milk products provide more than 70 percent of the calcium in American diets (DGAC, 2010). However, with the exception of boys and girls aged 1 to 3 years, NHANES data from 2003 to 2006 indicate that a majority of people in the United States do not meet the Adequate Intake (AI) level for calcium from consuming foods alone (DGAC, 2010) and that adolescents and adults consume only about half the recommended amount of fluid milk and milk products. Potassium Adequate potassium intakes are associated with optimal blood pressure (DGAC, 2010) and may reduce the risk of developing kidney stones and bone loss (HHS/USDA, 2005a). Additionally, many clinical trials show that potassium supplementation reduces blood pressure (IOM, 2005). Diets low in potassium and high in sodium are associated with higher blood pressure levels than diets containing adequate potassium and high sodium intake (IOM, 2005). African Americans and hypertensive individuals may benefit most from an increased potassium intake. Data from NHANES 2007–2008 estimated the mean intake in the United States to be 2,290 mg/day for women and 3,026 mg/day for men (ARS, 2010), substantially lower than the recommended AI of 4,700 mg. The main sources are milk, coffee, poultry and beef and mixed dishes prepared from these meats, orange and grapefruit juice, and many other fruits and vegetables. Fiber Fiber may protect against cardiovascular disease, obesity, and type 2 diabetes, and it is essential for digestive health (Lairon et al., 2005; Estruch et al., 2009; DGAC, 2010). It has been reported to promote satiety, leading to reduced energy intake and lowering the risk of overweight and obesity (Heaton et al., 1978). Dietary (total) fiber is listed on the Nutrition Facts panel. From NHANES data it is estimated that usual intakes are 15 g/day and that less than 5 percent of the U.S. public consumes 25 g per day (DGAC, 2010). The Adequate Intake for total fiber is 14 g/1,000 calories (25 g/d total fiber for women and 38 g/d for men) based on the level observed to protect against coronary heart disease (IOM, 2002/2005). Sources of dietary fiber include whole grains, legumes, vegetables, fruits, and nuts. The 2010 Dietary Guidelines Advisory Committee report (DGAC, 2010) recommends that more whole grains be substituted for refined grains in the diet and concludes that there is an urgent need for an international definition of whole grain and for methods to measure its content in foods. Shortfall Food Groups The shortfall nutrients in the American diet are an indicator of low intake of certain food groups, namely fruits, vegetables, whole grains, and “fat free” or “low fat” milk and milk products. The 2010 Dietary Guidelines Advisory Committee examined data published by the National Cancer Institute (NCI) regarding usual food intake 9 and identified several shortfall food groups which are “consumed in amounts lower than the minimum levels rec - ommended in the USDA Food Patterns to meet IOM nutrient intake recommendations for each age–sex group” (DGAC, 2010). Vegetable intakes fall below recommended intakes for most Americans, and more than 75 percent of adult men and women and boys and girls aged 9 to 18 years consume less than the recommended amount of fruit per day. Most Americans consume more total grains servings per day than recommended. However, more than 95 percent of all age–sex groups fail to consume the recommended amount of whole grains, which is 50 percent of the total grains consumed. The intake of fat free or low fat milk and milk products is also less than the recom - mended amounts for most adults and for most children and adolescents. The shortfall food groups discussed above have been targeted for increase by both the 2005 Dietary Guide - lines Advisory Committee and the 2010 Dietary Guidelines Advisory Committee. In particular, the 2010 Dietary Guidelines Advisory Committee emphasized a total diet approach that is: 9 Available online: http://riskfactor.cancer.gov/diet/usualintakes/pop/#results (accessed August 4, 2010).

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 OVERVIEW OF HEALTH AND DIET IN AMERICA • Energy balanced, limited in total calories, and portion controlled • Nutrient-dense and includes — Vegetables, fruits, “high-fiber” whole grains — “Fat free” or “low fat” fluid milk and milk products — Seafood, lean meat and poultry, eggs, soy products, nuts, seeds, and oils • Very low in solid fats (i.e., saturated and trans fats) and added sugars Promotion of healthy dietary patterns and of the consumption of under-consumed food groups has been rec - ommended as the primary approach to increasing the intake of the shortfall nutrients (DGAC, 2010). FINDINGS From reviewing diet-related health in the United States, it is clear that the greatest nutritional challenge our nation faces is chronic diseases caused by excess intakes rather than deficiencies. Two key findings from this review include: Finding 1: Obesity, cardiovascular disease, type 2 diabetes, and certain types of cancers are the health risks affecting the greatest number of Americans that are also most strongly associated with diet. Finding 2: Americans consume too many calories, saturated fats, trans fats, and added sugars; too much sodium; and too little vitamin D, calcium, potassium, and fiber. These findings were critical in developing conclusions on the criteria for FOP systems, since one of the committee’s guiding principles identified in Chapter 1 states that FOP systems should focus on the nutrients or food components most strongly associated with the diet-related health risks affecting the greatest number of Americans. The remaining chapters of this report consider how FOP systems may best address the diet and health concerns identified in these findings. REFERENCES ACS (American Cancer Society). 2010. Cancer facts and figures 00. Atlanta, GA: American Cancer Society. AHA (American Heart Association). 2010. Heart disease and stroke statistics: 00 Update at a glance. Dallas, TX: American Heart Association. ARS (Agricultural Research Service, USDA). 2010. What We Eat in America, NHANES 2007-2008. Revised Aug 2010. http://www.ars.usda. gov/SP2UserFiles/Place/12355000/pdf/0708/Table_1_NIN_GEN_07.pdf. Bachman, J. L., J. Reedy, A. F. Subar, and S. M. Krebs-Smith. 2008. Sources of food group intakes among the U.S. population, 2001–2002. Journal of American Dietetic Association 108:804–814. Calle, E. E., C. Rodriguez, K. Walker-Thurmond, M. J. Thun. 2003. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of U.S. adults. New England Journal of Medicine 348(17):1625–1638. Chung, M., E. M. Balk, M. Brendel, S. Ip, J. Lau, J. Lee, A. Lichtenstein, K. Patel, G. Raman, A. Tatsioni, T. Terasawa, and T. A. Trikalinos. 2009. Vitamin D and calcium: Systematic review of health outcomes. Eidence Report/Technology Assessment No. . AHRQ Publica- tion No. 09–E015, Rockville, MD: Agency for Healthcare Research and Quality. Clarke, R., C. Frost, R. Collins, P. Appleby, and R. Peto. 1997. Dietary lipids and blood cholesterol: Quantitative meta-analysis of metabolic ward studies. BMJ 314(7074):112–117. Cranney, A., T. Horsley, S. O’Donnell, H. A. Weiler, L. Puil, D. S. Ooi, S. A. Atkinson, L. M. Ward, D. Moher, D. A. Hanley, M. Fang, F. Yazdi, C. Garritty, M. Sampson, N. Barrowman, A. Tsertsvadze, and V. Mamaladze. 2007. Effectiveness and safety of vitamin D in relation to bone health. Eidence Report/Technology Assessment No. . AHRQ Publication No. 07-E013. Rockville, MD: Agency for Healthcare Research and Quality. Cutler, J. A., P. D. Sorlie, M. Wolz, T. Thom, L. E. Fields, and E. J. Roccella. 2008. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988–1994 and 1999–2004. Hypertension 52:818–827. Dall, T. M., V. L. Fulgoni, Y. Zhang, K. J. Reimers, P. T. Packard, and J. D. Astwood. 2009. Potential health benefits and medical cost savings from calorie, sodium and saturated fat reductions in the American diet. American Journal of Health Promotion 23:412–422. DGAC (Dietary Guidelines Advisory Committee). 2010. Report of the Dietary Guidelines Adisory Committee on the Dietary Guidelines for Americans, 00. Washington, DC: U.S. Department of Health and Human Services, U.S. Department of Agriculture.

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