May 26, 2015

The Dietetics Organization Joins the 21st Century (Kind Of...)

If you’ve been living under a rock for the past few weeks, or, unlike me, you have an actual life, which precludes you from reading as many nutrition articles, blogs, and papers as I do, you might have missed the comments from the Academy of Nutrition and Dietetics (AND) in response to the Scientific Report of the 2015 Dietary Guidelines Advisory Committee. (The AND was formerly the ADA—the American Dietetic Association—the body that oversees the registered dietitian credential [RD].)

This thing has been making the rounds in the low-carb, Paleo, Primal and real food circles, mostly because it is a refreshing—and we might even say downright shocking—reversal of course by this supremely mainstream organization regarding some of the nutrients that have been public outlaws for the past few decades. While the AND has certainly not come out and directly endorsed higher-fat, low-carbohydrate diets, here a few general points they made about the recommendations by the 2015 Dietary Guidelines Advisory Committee (DGAC), some of which agree with the committee’s findings, and some of which don’t: 
  • Very low sodium diets are not appropriate for everyone, and may, in fact, be harmful for some populations. 
  • There is no correlation between dietary cholesterol intake and serum cholesterol levels.
  • Since the studies on saturated fat, cholesterol, and heart disease over the years have been so terribly conducted and interpreted, “the Academy suggests that HHS and USDA support a similar revision [for that of cholesterol] deemphasizing saturated fat as a nutrient of concern.”
  • Carbohydrate intake is a much stronger predictor for cardiovascular disease risk than is saturated fat, and it might not be such a bad idea to replace some amount of dietary carbohydrate with fat. 

As you can see, these points mark a huge step forward for this organization, which in the past, has been tepid, conventional, and by-the-book all the way. It’s a gutsy move, and I’m thrilled to see it happen. I applaud the AND for joining the rest of us in the 21st Century with regard to basic science about food and human health. Since I have ragged pretty hard on the AND in the past, I’m happy to be able to give credit where credit is due.

That being said, this wouldn’t be all that interesting a post if all I did was sing the praises of this document. Naturally, there are a few points of contention. So let’s look at things little more closely, celebrate the good stuff, and bring to light the not-so-good stuff. We’ll start with the not-so-good stuff and then move to the good stuff, so that we end on a positive note.

Lifestyle habits, food landscape & socio-cultural aspects of diet

I don’t take issue with much the AND says on these issues. In fact, regarding bringing attention to the harsh realities of “food deserts,” making nutritious foods available to disadvantaged people, and spearheading overall public health measures, the AND has a better track record than it does in improving the health and wellness of individuals. So I have no argument regarding their recommendations about making food labels and educational materials more accessible to those whose primary language is not English, and making things clearer even for those who are native speakers. People can’t make good choices if they don’t even understand what the labels say, or what any of it actually means. Got it. No problem there.

I do have a problem, however, when we start blaming weight gain on sedentary behavior, but single out specific sedentary behaviors as being worse than others. For example, as the AND points out: 

“High levels of screen time can also contribute to overweight or obesity by replacing more physically demanding activities. In 2009, American children spent an average of 7.4 hours per day watching media (television, computers, video games, movies, etc.), a figure even higher for minority children. The explosion of social media has led to excessive use by some to the point of becoming "problematic." Although there have been some variations by age and sex, numerous studies have linked sedentary or screen time and number of media resources in the household to overweight or obesity and detrimental impacts on physical fitness among children and youth.”

Now, I am not about to argue that several hours a day of watching TV or playing video games is not likely to contribute to obesity—in children or adults. Obviously, moving around outdoors might be better for one’s metabolic health. The issue I have is this: Why are video games and television always singled out as being causative in obesity? Why doesn’t anyone ever say that getting a PhD might cause obesity? There are a lot of subjects you could get a PhD in that would require a lot of time sitting on your rear end with your face buried in books and scientific journals. Or how about just lots of homework and studying? How come we never hear anyone say that getting a 4.0 GPA at Harvard could lead to obesity? I’m guessing that unless you have a very wealthy granddaddy making generous donations to the endowment, achieving those kinds of grades at a place like that probably requires a lot of butt-in-chair time. And how about kids and adults who play musical instruments? Some of them spend hours a day practicing. Granted, there is definitely a physical aspect to playing most musical instruments, and as an amateur musician, myself (saxophone and clarinet, btw), I know that you can be pretty wiped out after a long rehearsal. Even so, let’s face it: it’s not exactly doing a triathlon.

But we never hear “Them” (capital T) saying kids shouldn’t read, or study, or that it’s “unhealthy” to be a violin virtuoso. The reason they only rag on TV and video games is because those activities are seen as low-class. It’s a holier-than-thou, judgmental way to blame people for becoming obese by way of being lazy and lowbrow. And, frankly, it’s pretty damn insulting, considering I knew kids back in junior high who played hours of video games every day, coupled with Cheetos and Mountain Dew, but didn’t become overweight. But my sorry self, which ran 3-5 miles a day in high school and ate low fat foods, was chubby. (Must’ve been all the after-school band rehearsals!) So if we’re going to condemn the use of electronics as a cause of obesity, let’s not give the “high culture” stuff a free pass, ‘kay? (Also: as an alum of one of the top engineering universities in the U.S. [if not the world], I can tell you that most of the guys toiling away day and night in the computer engineering labs were not exactly in peak physical condition, but I’ve never once heard anyone—not anyone—say that earning a degree from a prestigious university is associated with increased risk for obesity.)

Maybe someday someone will conduct a study looking at the effect of video games and TV viewing in people who eat lower-carb Paleo diets and do intermittent fasting. Is there something inherently obesigenic about watching TV and playing video games, or is it the crap foods people tend to eat (and the ads for which they are exposed to) while they engage in these activities? Methinks we already know the answer.

Red meat & other animal protein

While the DGAC recommends that “The U.S. population should be encouraged and guided to consume dietary patterns that are rich in vegetables, fruits, whole grains, seafood, legumes, and nuts; moderate in low- and non-fat dairy products and alcohol (among adults); lower in red and processed meat; and low in sugar-sweetened foods and beverages and refined grains,” the Academy did not interpret that recommendation as impugning the healthfulness of red meat or its place in recommended meal patterns as a protein and a source of important shortfall nutrients, such as iron.”

“When simply looking at the broad category of protein, intakes ‘(as grams/day) are adequate across the population and protein is not a shortfall nutrient.’ However, when looking specifically at various sources of proteins, there is a difference in adequate intake, because animal proteins comprise a larger-than-recommended share of the overall nutrient consumed.

“Approximately 80 percent of Americans meet the intake recommendations for animal proteins (meat, poultry and eggs), but only 60 percent meet the recommendations for the larger definition of ‘meat, poultry, fish, seafood, eggs, soy, nuts, and seeds.’ Indeed, a comparison of NHANES data for the consumption of red meat alone to the USDA’s Food Patterns recommendations suggest that American adults on average eat almost as much red meat per week (20 oz) as the USDA recommends for meat, poultry, and eggs combined (26 oz). Put differently, the DGAC recommendation is consistent with existing USDA Food Patterns suggesting (a) that red meat consumption exceeds recommendations for most subgroups and (b) that a greater share of recommended protein consumption should be met by seafood, legumes, and nuts.”

Booooo! See what they’ve said here? Around 80% of Americans meet the animal protein intake recommendations, but we’re getting too much of that animal protein from red meat. They want us to eat more seafood, poultry, and eggs. And, of course, for total protein (not just animal protein), they want us eating more beans and nuts.

First, can I just say, what about the 20% of Americans who don’t meet “the intake recommendations for animal proteins?” I’m guessing we’re talking vegetarians and vegans? Does the AND want to address that can of imitation, plant-based worms?

Second, are they saying the USDA recommends 26oz of combined red meat, eggs, and poultry per week? What? No wonder so many of my female clients are starved for protein! THAT IS NOT ENOUGH! (Especially not for people who work out a lot!) And let me tell you, most people do not need more freaking turkey burgers or boneless, skinless chicken. Red meat is far more nutrient-dense than poultry and lima beans. Poultry has its place, sure, but come on.

And only 60% of the population meets the recommendations for intake of protein from the larger category of protein, which includes seafood and soy. I guess they’re completely disregarding the ever-growing number of people who are allergic to seafood or soy. Listen up, USDA and AND: We are never going to have 100% of the population getting whatever you deem is the “appropriate” amount of protein from soy or seafood, because NOT EVERYONE CAN EAT SOY OR SEAFOOD, CAPICE? And we’re probably not going to have 100% of the population meeting your “appropriate” or “adequate” intake of animal protein because you have been encouraging people to eat fewer animal foods!!

*Breathe, breathe.*

Okay, that was the bad. And, all things considered, it wasn’t that bad. Now, on to the good!


I have a multi-post deep-dive on sodium in the works for after I’m done with the cancer series I’ve been writing. I don’t want to spoil all the fun, so rather than getting into the weeds here, let’s just look at what the AND had to say. The main reason we—all of us, across the board—have been advised to limit sodium intake is that it was believed that sodium had a dose-dependent effect on blood pressure. That is, the more sodium one consumed, the higher their blood pressure would be, or, at the very least, the greater their risk for hypertension. And while this is true in a very small subset of the American population, the vast majority of people are not what is known as “sodium-sensitive hypertensives.” Meaning, if they eat more sodium, their bodies regulate fluid and electrolyte balance just fine, so that there is no dangerous elevation of blood pressure. (In fact, insulin has a much bigger influence on BP than sodium does, but I’ll save the details for the sodium series.) 

Recommending a low-sodium diet for everyone because it is protective against hypertension in a small subset of people is as misguided and potentially dangerous as recommending a 4:1-style medical intervention-type ketogenic diet for everyone because it is helpful in some cases of epilepsy. Different people, different goals, different tool.

The AND put it this way: There is “a growing body of research suggesting that the low sodium intake levels recommended by the DGAC are actually associated with increased mortality for healthy individuals. … There are instances in which it is reasonable to make recommendations that are expected to benefit only a subset of a population if the benefits far outweigh the risks, but as noted above, dietary sodium restriction is not one of them.”

Nice! The AND is all up in the DGAC’s face here, and good for them! Somebody’s got to stand up to these folks, or we’re going to end up with the same old disastrous guidelines we’ve been living with since the early 1990s.

Saturated fat & cholesterol

I can’t believe I’m about to say this, but, like I mentioned earlier, I want to give credit where credit is due. So: the AND knocked it out of the park on cholesterol! BUT, there are some problems here, too.

“The Academy supports the decision by the 2015 DGAC not to carry forward previous recommendations that cholesterol intake be limited to no more than 300 mg/day, as ‘available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol.’ Despite some criticism suggesting that this changed recommendation illustrates fundamental questions about the validity of the nutrition science upon which the Dietary Guidelines are based, the change is both consistent with current science and the DGAC’s statutory mandate.”

Didja catch the sleight-of-hand there?

The all-of-a-sudden acknowledgement that dietary cholesterol isn’t “a heart attack on a plate” “illustrates fundamental questions about the validity of the nutrition science upon which the Dietary Guidelines are based?” Um, yes. Yes, it certainly does.

“The DGAC is authorized under 42 U.S.C. 217a, Section 222 of the Public Health Service Act, as amended, with subsection (a)(2) specifying the basis for the guidelines, specifically that, ‘The information and guidelines contained in each report required under paragraph (1) shall be based on the preponderance of the scientific and medical knowledge which is current at the time the report is prepared.’ (Emphasis added.) The DGAC is statutorily required to make recommendations and they must do so with the best available science at the time."

But here’s the thing:  Just because the science was “current” at that time, and it was the “best available” (which is extremely debatable) doesn’t mean it was correct. And it wasn’t. Not even close. Acknowledgment and admission of that is what is missing here. (“Sorry, diabetics! Sorry we were so scared of fat and cholesterol that we recommended a diet in which the vast majority of calories come from carbohydrate, which is the macronutrient that is most problematic for your bodies! Our bad!”) That is what I continue to wait for.

Sure, guidelines were based on the scientific consensus at the time, but again, the consensus was wrong. Am I silly for wanting someone to come right out and admit that? I’m not asking for anyone to accept personal responsibility. That would be asking too much, I think. But couldn’t one of the heads of these organizations—as a representative of the whole group, past and present—take the heat and issue the massive, massive “mea culpa” the American people deserve?

Don’t get me wrong. This is movement in the right direction. It’s progress. Big time. But there seems to be absolutely no one in the upper echelons of these organizations who is willing to actually say, “We. Were. Wrong. And not only that, but as a result of our being wrong, the guidelines that have been institutionalized for the past few decades might have made your health much worse, inadvertent though that outcome was.”

“It has been said that the unit of measurement for scientific progress is scientific error. Every new discovery proves old conclusions wrong, and every incorrect conclusion of the past marks new knowledge that has taken its place. The Committee's willingness to update positions based on new evidence is laudable. And, to the credit of the preceding DGACs, a review of the entirety of DGAC recommendations over time shows a remarkable consistency in most recommendations. In short, Americans rightfully have confidence in the reliability of the DGAC’s process and resulting recommendations.”

Yeah, um, I’m not so sure about that last part.

But let’s get back on track. I was doing what I do best—go off on rants. Let’s get back to cholesterol.

At least they’ve acknowledged that dietary cholesterol has little to no effect on serum cholesterol. Now we just need the MDs to get their heads out of their tushes the sand and acknowledge that “high cholesterol” is not the primary driver of heart disease. And, in fact, the egregiously misguided condemnation of cholesterol both on the plate and in the bloodstream may have played—and continues to play—a causal role in the booming epidemics of Alzheimer’s disease and other neurodegenerative conditions. (And also contributes to the risk for diabetes.)

Look at the AND, telling it like it is:

“While the body of research linking saturated fat intake to the modulation of LDL and other circulating lipoprotein concentrations is significant, this evidence is essentially irrelevant to the question of the relationship between diet and risk for cardiovascular disease.

NICE! They’re saying what those of us in the LC/Paleo worlds have known for a while now: even if saturated fat consumption increases LDL cholesterol, LDL cholesterol is only a marker. It is a surrogate endpoint. We are far more interested in hard end points, such as heart disease or myocardial infarction (MI, heart attack). And because people who experience morbidity or mortality from heart disease or MI run the gamut from low to high cholesterol and just about every value in between, even if eating saturated fat does raise your LDL-C, that says nothing about your risk for cardiovascular disease.

“The 2010 Institute of Medicine (IOM) report on the use of biomarkers as surrogates for disease outcomes examined LDL and HDL as case studies and concluded unequivocally that they were not suitable for use as surrogates for the impact of diet on heart disease.”

“The evidence is clear that changes in LDL and HDL induced by diet cannot be assumed to correspond to the expected changes in actual cardiovascular disease risk, and thus this body of evidence that uses lipoproteins as surrogate endpoints for cardiovascular disease must be excluded from considerations of the impact of diet on cardiovascular health.”


“We commend the DGAC on a thorough and accurate review of the current best evidence with regard to the body of evidence relating dietary fats to cardiovascular disease outcomes. However, we are concerned that the evidence does not lead to the conclusion that saturated fats should be replaced with polyunsaturated fats for the greatest health benefit.”

And again! Man, somebody at the AND WOKE UP this year!

“…carbohydrate intake conveys a greater amount of cardiovascular disease risk than does saturated fat. Combined with the evidence from multiple studies that have estimated the impact of saturated fat to be near zero, it is likely that the impact of carbohydrate on cardiovascular disease risk is positive.”

This is huge. For the AND to say this is quite a sea change. And a very welcome one, at that.

“…the substitution of polyunsaturated fat for carbohydrate will result in a lesser net risk for cardiovascular disease than if polyunsaturated fat were substituted for saturated fat. This is true because carbohydrate contributes a greater amount to the risk for cardiovascular disease than saturated fat, so the replacement of carbohydrate will necessarily result in a greater improvement in risk. Therefore, it appears that the evidence summarized by the DGAC suggests that the most effective recommendation for the reduction in cardiovascular disease would be a reduction in carbohydrate intake with replacement by polyunsaturated fat.”

There’s a lot of roundabout verbiage there, so let me rephrase it in plain English: since carbohydrate, rather than saturated fat, is the primary driver of heart disease risk, replacing carbohydrate with fat should lead to greater reductions in risk than replacing saturated fat with polyunsaturated. (Note, however, that the AND is recommending replacing carbohydrates with polyunsaturated fat, rather than saturated. I could nitpick about this, but I’m not going to. The truth is, people probably could stand to increase their poly [and mono!] intake, if it comes from nuts, seeds, and seafood, and maybe not from lots of corn, soybean, canola, and cottonseed oils via processed foods or foods deep-fried in restaurants. So, maybe not so much increasing unsaturated fat as just changing the sources.)

WOW! How’s that for a refreshing change from the organization that oversees what amounts to the only credential that is acceptable for providing nutrition counseling in hospitals, schools, and other institutions?

Looking ahead

It remains to be seen what impact the AND’s change of heart will have on the organization’s own approach to nutrition counseling and public health education initiatives. Are they going to have a bonfire for all their old pamphlets railing against salt? What about anything that hinted of the USDA’s infamous food pyramid, which recommended that we all—all of us—base our diets on the macronutrient which, by the AND’s own admission, is the primary driver of heart disease? Will they finally lighten up on pushing whole grains—particularly for diabetics? Will they go a little easier on red meat, even if they continue to push for soy as a protein source? Will they cut it out with the low-fat dairy, now that even they have admitted saturated fat isn’t the killer they once thought it was?

Apparently not.

The comments included suggested changes regarding some of the DGAC’s findings about the “Mediterranean diet” and the DASH diet. (Dietary Approaches to Stop Hypertension.) They said:

“The common elements of these patterns are higher consumption of vegetables, fruits, whole grains, low-fat dairy, and seafood, and lower consumption of red and processed meat, and lower intakes of refined grains, and sugar-sweetened foods and beverages relative to less healthy patterns; regular consumption of nuts and legumes; moderate consumption of alcohol; lower in saturated fat, cholesterol, and sodium and richer in fiber, potassium, and unsaturated fats.”

If they’re agreeing that the Mediterranean and DASH diets are healthy, how do they reconcile some of this with everything we just looked at? Low-fat dairy? Lower in saturated fat? Lower in sodium? No wonder the public is so confused—the professionals can’t even figure this out! As for whole grains, I wish someone would say that they mean something more like a wheatberry salad, made from whole, intact wheatberries, and are not talking about granola, bread with a zillion crazy ingredients, or breakfast cereal made from “whole grains,” but which are so ridiculously processed and sugar-laden they might as well be candy.

It also remains to be seen whether the AND will reverse its position stating that “appropriately planned vegetarian diets, including total vegetarian or vegan diets, are healthful, nutritionally adequate...”

Nevertheless, all things considered, these comments from the AND are a pretty big deal. (And worthy of a very long blog post.) I’m still waiting for that mea culpa, but I’m not holding my breath.

For a look at what other people are saying about the AND response to the DGAC report, check out the following, who write way more succinctly than I do: 

Remember: Amy Berger, M.S., NTP, is not a physician and Tuit Nutrition, LLC, is not a medical practice. The information contained on this site is not intended to diagnose, treat, cure, or prevent any medical condition


  1. Butts in chair syndrome does go across many activities.

    It seems that there is more emphasis on homework and studying at the expense of physical fitness at all levels in the education system. When one must make a choice between finishing that last report, lab, reading assignment, etc. to get ones mark to pass, and to not do something physical, the former generally gets the priority. It does not help that high school programs make physical education an optional course.

    Has anyone plotted/graphed the increase (a perceived increase) in time spent hitting the books against the increase in weight? Maybe research would show that the hours at studying have not drastically increased, pointing to other factors such a decrease in physical activity and an increase in poor diets.


  2. If dietary cholesterol has little to no effect on serum cholesterol, and your cholesterol numbers are not an indicator of your risk for cardiovascular disease, what indicators should we be looking at to get an idea of our cardiovascular health?

    I don't want to wait for my hard end point of a heart attack to be the indicator of my poor cardiovascular health. I need an earlier indicator to tell me my what my cardiovascular risk is.

    1. This is an excellent question, for which I do not have an equally excellent answer. For starters, I'd keep an eye on triglycerides and HDL, including the ratio of the two. LDL isn't "useless," but it seems that we should be more concerned with the LDL *particle number,* rather than the amount of cholesterol inside any of those given particles, and it is the latter which is measured/reported in a typical "cholesterol" test or lipid panel at the doctor's office. There are more advanced tests (NMR, VAP, Berkeley Protocol) that can break down the particle numbers as well as give you an indication as to whether your LDL particles are predominantly the "large, buoyant" type, of the "small dense" type. The small, dense ones seem to be more likely to cause trouble in the arterial walls. You can also get a coronary artery calcium scan, which actually measures the calcium deposits in your arteries, but of course, that's not a typical measurement a doc would do. You would have to request it, and she/he would probably look at you like you're nuts.

      Keep an eye on anything having to do with insulin resistance and glycemic control. Ivor Cummins has several great blog posts on the relationship between insulin and heart disease risk -- and he, like everyone, writes way shorter posts than I do. ;-)

    2. A great book for laypeople:
      The Great Cholesterol Myth, by Stephen Sinatra, MD, and Jonny Bowden:

  3. Given all the wrong going on at your beloved AND, TN's evaluation of the revised dietary guidelines was as balanced as one could expect from a restless and impatient mind. The ship still has to change its heading by many degrees but it is definitely not blasting towards that big block of ice anymore. Major achievement, kudos to those like you who fought hard for it.