House Agriculture Committee leaders push for Whole Milk for Healthy Kids Act in 2025; legislation aims to restore whole and 2% milk in federal school meals programs

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WASHINGTON, Jan. 6, 2025—U.S. House Agriculture Committee Chairman Glenn “GT” Thompson (R-Penn.) and Ranking Member Angie Craig (D-Minn.) expressed support for the new Congress passing the Whole Milk for Healthy Kids Act in 2025 during remarks this weekend at the Pennsylvania Farm Show. Chairman Thompson is the lead sponsor of the bill, which Ranking Member Craig has cosponsored. The legislation would reinstate whole and 2% milk in federal school meals programs. Congressman Thompson is also a senior member of the House Education and Workforce Committee, which oversees child nutrition programs in the U.S. House of Representatives.

The House of Representatives passed the bipartisan bill 330-99 in December 2023, but the Senate did not take up the legislation before the previous Congress adjourned. In her remarks in Pennsylvania, Rep. Craig said she would “work together on this” with U.S. Sen. Amy Klobuchar, the new ranking member of the U.S. Senate Agriculture Committee.

“The Whole Milk for Healthy Kids Act enjoys widespread bipartisan support in Congress, and among parents, nutritionists and school meals professionals alike,” said Michael Dykes, D.V.M., president and CEO, International Dairy Foods Association (IDFA). “We’re so pleased to see congressional leaders working together in a bipartisan fashion to pass commonsense legislation that will improve access to nutritious milk options for our kids. IDFA urges the House and Senate to pass this legislation this year.”

Whole and 2% milk provide children with 13 essential nutrients for growth, development, healthy immune function, and overall wellness. Since whole and 2% milk were banned from school meals menus more than a decade ago, school milk consumption and meal participation have declined, meaning children are consuming fewer essential nutrients. This is especially concerning considering underconsumption of milk and dairy products is prevalent among school-aged children, where between 68% and 94% of school-age boys and girls are failing to meetDietary Guidelines for Americans 2020 - 2025 Make Every Bite Count With the Dietary Guidelines DietaryGuidelines.gov This publication may be viewed and downloaded from the internet at DietaryGuidelines.gov. Suggested citation: U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020. Available at DietaryGuidelines.gov. 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December 2020 Dietary Guidelines for Americans 2020 - 2025 Make Every Bite Count With the Dietary Guidelines Ninth Edition • DietaryGuidelines.gov Table of Contents Message From the Secretaries ����������������������������������������v Vegetables ......................................................................31 Fruits .................................................................................32 Acknowledgments��������������������������������������������������������������� vi Grains ...............................................................................32 Executive Summary ����������������������������������������������������������� vii Dairy and Fortified Soy Alternatives ...........................33 Protein Foods ..................................................................33 Introduction �������������������������������������������������������������������������������1 Setting the Stage ................................................................... 3 Oils.....................................................................................35 Grounded in Science and Focused on Beverages ........................................................................35 Public Health .................................................................... 3 Dietary Components of Public Health A Spotlight on Dietary Patterns ..................................... 6 Concern for Underconsumption .................................36 Healthy Dietary Patterns at Every Life Stage.............. 6 Guideline 4: Limit Foods and Beverages Dietary Guidelines for Americans: Higher in Added Sugars, Saturated Fat, and What It Is, What It Is Not ...................................................... 7 Sodium, and Limit Alcoholic Beverages ........................37 Quantitative Guidance on Foods, Added Sugars .................................................................41 Not Nutrient Requirements ............................................ 7 Saturated Fat ..................................................................44 Health Promotion, Not Disease Treatment ................ 7 Sodium .............................................................................46 Developing the Dietary Guidelines for Americans ........... 7 Alcoholic Beverages ......................................................49 Stage 1: Identify Topics and Supporting Support Healthy Dietary Patterns Scientific Questions ........................................................ 8 for All Americans .................................................................50 Stage 2: Appoint a Dietary Guidelines Advisory Looking Toward the Life Stages ......................................50 Committee To Review Current Scientific Evidence .. 8 Stage 3: Develop the Dietary Guidelines ....................11 Chapter 2: Infants and Toddlers ���������������������������������51 Introduction ..........................................................................53 Stage 4: Implement the Dietary Guidelines ...............12 Putting the Key Recommendations Into Action ...........54 A Roadmap to the Dietary Guidelines Feed Infants Human Milk for the First for Americans, 2020-2025 ..................................................14 6 Months, If Possible .....................................................54 Provide Infants Supplemental Vitamin D Chapter 1: Nutrition and Health Across Beginning Soon After Birth ...........................................56 the Lifespan: The Guidelines and Key Introduce Infants to Nutrient-Dense Recommendations ������������������������������������������������������������ 15 The Guidelines .....................................................................17 Complementary Foods at About 6 Months Old ......56 Guideline 1: Follow a Healthy Dietary Pattern at Introduce Infants to Potentially Allergenic Foods Every Life Stage ...................................................................19 Along With Other Complementary Foods .................58 What Is a Dietary Pattern? ............................................19 Encourage Infants and Toddlers To Consume a The Health Benefits of a Healthy Dietary Pattern ...23 Variety of Complementary Foods and A Healthy Dietary Pattern Supports Beverages To Meet Energy and Nutrient Needs......59 Appropriate Calorie Levels ...........................................23 Establish a Healthy Beverage Pattern ......................61 Most Americans Do Not Follow a Healthy Dietary Pattern During a Healthy Dietary Pattern .................................................26 Toddler's Second Year of Life ...........................................63 Guideline 2: Customize and Enjoy Food and Current Intakes ....................................................................65 Beverage Choices To Reflect Supporting Healthy Eating ................................................67 Personal Preferences, Cultural Traditions, Accessing a Healthy Dietary Pattern .........................68 and Budgetary Considerations .........................................27 Looking Toward Chapter 3: Guideline 3: Focus on Meeting Food Group Needs Children and Adolescents .................................................68 With Nutrient-Dense Foods and Beverages, and Stay Within Calorie Limits .........................................30 Page i | Dietary Guidelines for Americans, 2020-2025 Chapter 3: Children and Adolescents ��������������������� 69 Chapter 6: Older Adults ������������������������������������������������� 121 Introduction ..........................................................................71 Introduction ........................................................................123 Healthy Dietary Patterns ....................................................72 Healthy Dietary Patterns ..................................................124 Current Intakes ....................................................................75 Current Intakes ..................................................................126 Special Considerations ......................................................87 Special Considerations ....................................................128 Sugar-Sweetened Beverages ......................................87 Protein ............................................................................128 Dairy and Fortified Soy Alternatives ...........................88 Vitamin B12 .....................................................................128 Adolescent Nutrition ......................................................88 Beverages ......................................................................129 Supporting Healthy Eating ................................................89 Supporting Healthy Eating ..............................................129 Accessing a Healthy Dietary Pattern .........................90 Healthy Eating Through the Lifespan ...........................130 Looking Toward Chapter 4: Adults ..................................90 Appendixes �������������������������������������������������������������������������� 131 Chapter 4: Adults ����������������������������������������������������������������91 Appendix 1: Nutritional Goals for Age-Sex Groups ....131 Introduction ..........................................................................93 Appendix 2: Estimated Calorie Needs ..........................139 Healthy Dietary Patterns ....................................................95 Appendix 3: USDA Dietary Patterns ...............................142 Current Intakes ....................................................................97 Special Considerations ....................................................101 Dietary Fiber ..................................................................101 Calcium and Vitamin D ...............................................101 Saturated Fat ................................................................102 Sodium ...........................................................................102 Added Sugars ...............................................................103 Alcoholic Beverages ....................................................104 Supporting Healthy Eating ..............................................104 Accessing a Healthy Dietary Pattern ......................105 Looking Toward Chapter 5: Women Who Are Pregnant or Lactating and Chapter 6: Older Adults ............................................106 Chapter 5: Women Who Are Pregnant or Lactating �������������������������������������������������������������������������107 Introduction ........................................................................109 Healthy Dietary Patterns ..................................................110 Current Intakes ..................................................................113 Special Considerations ....................................................115 Meeting Nutrient Needs..............................................115 Folate/Folic Acid ..........................................................115 Iron ..................................................................................115 Iodine ..............................................................................116 Choline ............................................................................117 Seafood ..........................................................................117 Alcoholic Beverages ....................................................117 Caffeine ..........................................................................118 Supporting Healthy Eating ..............................................120 Dietary Guidelines for Americans, 2020-2025 — Page ii List of Tables Table I-1: Facts About Nutrition-Related Health Table A1-1: Daily Nutritional Goals, Conditions in the United States .......................................... 5 Ages 6 Through 11 Months and Table 1-1: Healthy U.S.-Style Dietary Pattern at the 12 Through 23 Months .....................................................131 2,000-Calorie Level, With Daily or Weekly Amounts Table A1-2: Daily Nutritional Goals, From Food Groups, Subgroups, and Components ....... 20 Ages 2 and Older ...............................................................133 Table 2-1: Healthy U.S.-Style Dietary Pattern for Table A1-3: Daily Nutritional Goals for Women Toddlers Ages 12 Through 23 Months Who Are No Who Are Pregnant, by Age Group and Trimester ........135 Longer Receiving Human Milk or Infant Formula, With Daily or Weekly Amounts From Food Groups, Table A1-4: Daily Nutritional Goals for Women Subgroups, and Components ........................................... 64 Who Are Lactating, by Age Group and Months Postpartum ..........................................................137 Table 2-2: Signs a Child is Hungry or Full ...................... 67 Table A2-1: Estimated Calorie Needs per Day, Table 3-1: Healthy U.S.-Style Dietary Pattern for by Age and Sex, Ages 12 Through 23 Months .............139 Children Ages 2 Through 8, With Daily or Weekly Amounts From Food Groups, Subgroups, Table A2-2: Estimated Calorie Needs per Day, and Components .................................................................74 by Age, Sex, and Physical Activity Level, Ages 2 and Older ...............................................................141 Table 3-2: Healthy U.S.-Style Dietary Pattern for Children and Adolescents Ages 9 Through 13, Table A2-3: Estimated Change in Calorie Needs With Daily or Weekly Amounts From Food Groups, During Pregnancy and Lactation for Women With a Subgroups, and Components ...........................................81 Healthy Prepregnancy Weight ........................................141 Table 3-3: Healthy U.S.-Style Dietary Pattern for Table A3-1: Healthy U.S.-Style Dietary Pattern for Adolescents Ages 14 Through 18, Toddlers Ages 12 Through 23 Months Who Are No With Daily or Weekly Amounts From Food Groups, Longer Receiving Human Milk or Infant Formula, Subgroups, and Components ...........................................84 With Daily or Weekly Amounts From Food Groups, Subgroups, and Components .........................................143 Table 4-1: Healthy U.S.-Style Dietary Pattern for Adults Ages 19 Through 59, With Daily or Weekly Amounts Table A3-2: Healthy U.S.-Style Dietary Pattern for From Food Groups, Subgroups, and Components ....... 96 Ages 2 and Older, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components .....144 Table 5-1: Healthy U.S.-Style Dietary Pattern for Women Who Are Pregnant or Lactating, Table A3-3: Healthy Vegetarian Dietary Pattern for With Daily or Weekly Amounts From Food Groups, Toddlers Ages 12 Through 23 Months Who Are Subgroups, and Components .........................................111 No Longer Receiving Human Milk or Infant Formula, With Daily or Weekly Amounts From Food Groups, Table 5-2: Estimated Change in Calorie Needs Subgroups, and Components .........................................147 During Pregnancy and Lactation for Women With a Healthy Prepregnancy Weight ............................112 Table A3-4: Healthy Vegetarian Dietary Pattern for Ages 2 and Older, With Daily or Weekly Amounts Table 5-3: Weight Gain Recommendations From Food Groups, Subgroups, and Components .....148 for Pregnancy .....................................................................112 Table A3-5: Healthy Mediterranean-Style Dietary Table 6-1: Healthy U.S.-Style Dietary Pattern for Adults Pattern for Ages 2 and Older, With Daily or Ages 60 and Older, With Daily or Weekly Amounts Weekly Amounts From Food Groups, Subgroups, From Food Groups, Subgroups, and Components .....125 and Components ...............................................................149 Page iii | Dietary Guidelines for Americans, 2020-2025 List of Figures Figure I-1: Adherence of the U.S. Population to the Figure 3-1: Healthy Eating Index Scores Across Dietary Guidelines Over Time, as Measured by the Childhood and Adolescence ..............................................75 Average Total Healthy Eating Index-2015 Scores ........... 4 Figure 3-2: Current Intakes: Figure 1-1: Examples of Calories in Food Choices Ages 2 Through 4 ................................................................77 That Are Not Nutrient Dense and Calories in Nutrient-Dense Forms of These Foods .......................... 21 Figure 3-3: Average Intakes of Subgroups Compared to Recommended Intake Ranges: Figure 1-2: Making Nutrient-Dense Choices: Ages 2 Through 4 ................................................................78 One Food or Beverage At a Time ...................................... 22 Figure 3-4: Current Intakes: Ages 5 Through 8 ............. 79 Figure 1-3: The Science Underlying the Dietary Guidelines Demonstrates That Healthy Eating Figure 3-5: Average Intakes of Subgroups Across the Lifespan Can Promote Health and Compared to Recommended Intake Ranges: Reduce Risk of Chronic Disease ....................................... 24 Ages 5 Through 8 ................................................................80 Figure 1-4: Adherence of the U.S. Population to the Figure 3-6: Current Intakes: Dietary Guidelines Across Life Stages, as Measured Ages 9 Through 13 ..............................................................82 by Average Total Healthy Eating Index-2015 Scores .... 26 Figure 3-7: Average Intakes of Subgroups Figure 1-5: Customizing the Dietary Guidelines Compared to Recommended Intake Ranges: Framework ............................................................................28 Ages 9 Through 13 ..............................................................83 Figure 1-6: Dietary Intakes Compared to Figure 3-8: Current Intakes: Recommendations: Percent of the U.S. Population Ages 14 Through 18 ............................................................85 Ages 1 and Older Who Are Below and At or Above Figure 3-9: Average Intakes of Subgroups Each Dietary Goal ................................................................30 Compared to Recommended Intake Ranges: Figure 1-7: The 85-15 Guide: Percentage of Calories Ages 14 Through 18 ............................................................86 Needed To Meet Food Group Needs With Nutrient- Figure 4-1: Current Intakes: Dense Choices and Percentage Left for Other Uses .... 37 Ages 19 Through 30 ............................................................97 Figure 1-8: Making Nutrient-Dense Choices: Figure 4-2: Average Intakes of Subgroups One Meal At a Time .............................................................38 Compared to Recommended Intake Ranges: Figure 1-9: Making Healthy Choices: Ages 19 Through 30 ............................................................98 One Day At a Time ...............................................................39 Figure 4-3: Current Intakes: Figure 1-10: Top Sources and Average Intakes of Ages 31 Through 59 ............................................................99 Added Sugars: U.S. Population Ages 1 and Older ......... 43 Figure 4-4: Average Intakes of Subgroups Figure 1-11: Top Sources and Average Intakes of Compared to Recommended Intake Ranges: Saturated Fat: U.S. Population Ages 1 and Older .......... 45 Ages 31 Through 59 ..........................................................100 Figure 1-12: Top Sources and Average Intakes of Figure 5-1: Current Intakes: Women Who Are Sodium: U.S. Population Ages 1 and Older .................... 47 Pregnant or Lactating .......................................................113 Figure 2-1: Make Healthy Shifts To Empower Figure 5-2: Average Intakes of Subgroups Toddlers To Eat Nutrient-Dense Foods in Compared to Recommended Intake Ranges: Dietary Patterns ...................................................................63 Women Who Are Pregnant or Lactating .......................114 Figure 2-2: Current Intakes: Figure 6-1: Current Intakes: Ages 12 Through 23 Months .............................................65 Ages 60 and Older .............................................................126 Figure 2-3: Average Intakes of Subgroups Figure 6-2: Average Intakes of Subgroups Compared to Recommended Intake Ranges: Compared to Recommended Intake Ranges: Ages 12 Through 23 Months ............................................. 66 Ages 60 and Older .............................................................127 Dietary Guidelines for Americans, 2020-2025 — Page iv Message From the Secretaries We are pleased to present the Dietary Guidelines for Americans, 2020-2025. This edition marks the first time the Guidelines provide recommendations by life stage, from birth through older adulthood. Each stage of life is distinct and has unique needs that affect health and disease risk. Early food preferences influence food and beverage choices later. And the science has evolved to focus on the importance of a healthy dietary pattern over time. The science also shows it’s never too late to start and maintain a healthy dietary pattern, which can yield health benefits in the short term and cumulatively over years. This new edition of the Dietary Guidelines includes specific recommendations for all life stages, now including infants and toddlers, and pregnant and lactating women. We are excited this is the first edition to provide guidance for every life stage. This edition of the Dietary Guidelines is grounded in robust scientific reviews of the current body of evidence on key nutrition and health topics for each life stage. We thank the 20 distinguished scientists on the 2020 Dietary Guidelines Advisory Committee for their expertise and dedication in conducting an independent scientific review that was characterized by more transparency and public participation throughout the process than ever before. The Committee’s work culminated in a comprehensive scientific report on the current state of nutrition science and provided advice to the Departments for our development of this 9th edition of the Dietary Guidelines. The Committee also included important considerations for future research, such as a need to reconsider the Dietary Reference Intakes. The U.S. and Canadian Dietary Reference Intake Steering Committees are currently developing plans to re-examine energy, protein, fat, and carbohydrate–the timeline for these macronutrient reviews has not been established. USDA and HHS are looking forward to jointly funding the work to help guide our Departments’ research agendas in the coming years. With the science must come practice—that is, making food and beverage choices that align with the Dietary Guidelines. Using the new edition of the Dietary Guidelines, we hope Americans can find ways to “Start Simple” and incorporate modest changes each day that push Americans closer to meeting the recommendations. It’s more important than ever to make healthy eating a priority in the United States. With the release of the Dietary Guidelines for Americans, 2020-2025, we have an important call to action for you as health professionals and policymakers. We are asking you to help the public “make every bite count with the Dietary Guidelines for Americans.” Help people make food and beverage choices that are rich in nutrition—individual choices that can become a healthy routine over time, choices they can enjoy in good health for many years to come. Thank you for all you do to help Americans make strides toward aligning closer to the Dietary Guidelines as we all work together to help the public lead healthier lives. /Sonny Perdue/ /Alex M. Azar II/ Sonny Perdue Alex M. Azar II Secretary, Secretary, U.S. Department of Agriculture U.S. Department of Health and Human Services Page v | Dietary Guidelines for Americans, 2020-2025 Acknowledgments The U.S. Department of Agriculture and U.S. Department of Health and Human Services acknowledge the work of the 2020 Dietary Guidelines Advisory Committee whose recommendations informed the development of this edition of the Dietary Guidelines for Americans. Dietary Guidelines Advisory Committee Members Barbara Schneeman, PhD; Ronald Kleinman, MD; Jamy Ard, MD; Regan Bailey, PhD, MPH, RD; Lydia Bazzano, MD, PhD; Carol Boushey, PhD, MPH, RD; Teresa Davis, PhD; Kathryn Dewey, PhD; Sharon Donovan, PhD, RD; Steven Heymsfield, MD; Heather Leidy, PhD; Richard Mattes, PhD, MPH, RD; Elizabeth Mayer-Davis, PhD, RD; Timothy Naimi, MD, MPH; Rachel Novotny, PhD, RDN, LD; Joan Sabaté, MD, DrPH; Linda Snetselaar, PhD, RDN; Jamie Stang, PhD, MPH, RD; Elsie Taveras, MD, MPH; Linda Van Horn, PhD, RDN, LD. The Departments also acknowledge the work of the scientists, staff, and policy officials responsible for the production of this document. Policy Officials USDA: Secretary Sonny Perdue, DVM; Brandon Lipps; Pamilyn Miller; Jackie Haven, MS, RD. HHS: Secretary Alex M. Azar II, JD; Brett P. Giroir, MD; Paul Reed, MD; Don Wright, MD, MPH (through March 2020). Dietary Guidelines Writing Team USDA: Eve E. Stoody, PhD; Julie Obbagy, PhD, RD; TusaRebecca Pannucci, PhD, MPH, RD; Stephenie L. Fu; Elizabeth Rahavi, RD; Jean Altman, MS; Meghan Adler, MS, RDN; Clarissa (Claire) Brown, MS, MPH, RDN; Kelley S. Scanlon, PhD, RD. HHS: Janet de Jesus, MS, RD; Richard Olson, MD, MPH; Cria Perrine, PhD; Julia Quam, MSPH, RDN; Katrina Piercy, PhD, RD; Ashley Vargas, PhD, MPH, RDN; Jennifer Lerman, MPH, RD; Dana DeSilva, PhD, RD; Dennis Anderson-Villaluz, MBA, RD, LDN. Editorial Support: Anne Brown Rodgers; Jane Fleming. Reviewers The Departments acknowledge the contributions of numerous other internal departmental scientists and external peer reviewers who provided consultation and review during the production of this document. Finally, the Departments would like to acknowledge the important role of the Federal staff who supported the development of this edition of the Dietary Guidelines, and of those who provided public comments throughout the process. Dietary Guidelines for Americans, 2020-2025 — Page vi Executive Summary The foods and beverages that people consume have Research Act, which states that at least every 5 years, a profound impact on their health. The scientific the U.S. Departments of Agriculture (USDA) and of connection between food and health has been well Health and Human Services (HHS) must jointly publish documented for many decades, with substantial and a report containing nutritional and dietary information increasingly robust evidence showing that a healthy and guidelines for the general public. The statute lifestyle—including following a healthy dietary pattern— (Public Law 101-445, 7 United States Code 5341 et can help people achieve and maintain good health seq.) requires that the Dietary Guidelines be based on and reduce the risk of chronic diseases throughout the preponderance of current scientific and medical all stages of the lifespan: infancy and toddlerhood, knowledge. The 2020-2025 edition of the Dietary childhood and adolescence, adulthood, pregnancy and Guidelines builds from the 2015 edition, with revisions lactation, and older adulthood. The core elements of grounded in the Scientific Report of the 2020 Dietary a healthy dietary pattern are remarkably consistent Guidelines Advisory Committee and consideration of across the lifespan and across health outcomes. Federal agency and public comments. Since the first edition was published in 1980, the Dietary The Dietary Guidelines is designed for policymakers Guidelines for Americans have provided science-based and nutrition and health professionals to help all advice on what to eat and drink to promote health, individuals and their families consume a healthy, reduce risk of chronic disease, and meet nutrient needs. nutritionally adequate diet. The information in Publication of the Dietary Guidelines is required under the Dietary Guidelines is used to develop, implement, the 1990 National Nutrition Monitoring and Related and evaluate Federal food, nutrition, and health policies Page vii | Dietary Guidelines for Americans, 2020-2025 | Executive Summary and programs. It also is the basis for Federal nutrition chronic disease. A fundamental premise of the 2020- education materials designed for the public and for 2025 Dietary Guidelines is that just about everyone, the nutrition education components of USDA and no matter their health status, can benefit from shifting HHS nutrition programs. State and local governments, food and beverage choices to better support healthy schools, the food industry, other businesses, dietary patterns. community groups, and media also use Dietary Guidelines information to develop programs, policies, The second is its focus on dietary patterns. and communication for the general public. Researchers and public health experts, including registered dietitians, understand that nutrients and The aim of the Dietary Guidelines is to promote health foods are not consumed in isolation. Rather, people and prevent disease. Because of this public health consume them in various combinations over time—a orientation, the Dietary Guidelines is not intended dietary pattern—and these foods and beverages act to contain clinical guidelines for treating chronic synergistically to affect health. The Dietary Guidelines diseases. Chronic diseases result from a complex for Americans, 2015-2020 puts this understanding mix of genetic, biological, behavioral, socioeconomic, into action by focusing its recommendations on and environmental factors, and people with these consuming a healthy dietary pattern. The 2020-2025 conditions have unique health care requirements that Dietary Guidelines carries forward this emphasis on the require careful oversight by a health professional. The importance of a healthy dietary pattern as a whole— body of scientific evidence on diet and health reviewed rather than on individual nutrients, foods, or food to inform the Dietary Guidelines is representative of the groups in isolation. U.S. population—it includes people who are healthy, people at risk for diet-related chronic conditions and The third is its focus on a lifespan approach. This diseases, such as cardiovascular disease, type 2 edition of the Dietary Guidelines highlights the diabetes, and obesity, and some people who are living importance of encouraging healthy dietary patterns at with one or more of these diet-related chronic illnesses. every life stage from infancy through older adulthood. It At the same time, it is essential that Federal agencies, provides recommendations for healthy dietary patterns medical organizations, and health professionals adapt by life stage, identifying needs specific to each life stage the Dietary Guidelines to meet the specific needs of and considering healthy dietary pattern characteristics their patients as part of an individual, multifaceted that should be carried forward into the next stage of treatment plan for the specific chronic disease. life. For the first time since the 1985 edition, the 2020- 2025 Dietary Guidelines includes recommendations for Consistent healthy dietary patterns for infants and toddlers. and Evolving The Guidelines Although many recommendations have remained The 2020-2025 Dietary Guidelines provides four relatively consistent over time, the Dietary Guidelines overarching Guidelines that encourage healthy eating also has built upon previous editions and evolved as patterns at each stage of life and recognize that scientific knowledge has grown. The Dietary Guidelines individuals will need to make shifts in their food and for Americans, 2020-2025 reflects this in three beverage choices to achieve a healthy pattern. The important ways: Guidelines also explicitly emphasize that a healthy dietary pattern is not a rigid prescription. Rather, the The first is its recognition that diet-related chronic Guidelines are a customizable framework of core diseases, such as cardiovascular disease, type 2 elements within which individuals make tailored and diabetes, obesity, and some types of cancer, are very affordable choices that meet their personal, cultural, prevalent among Americans and pose a major public and traditional preferences. Several examples of health problem. Today, more than half of adults healthy dietary patterns that translate and integrate have one or more diet-related chronic diseases. As a the recommendations in overall healthy ways to eat result, recent editions of the Dietary Guidelines have are provided. The Guidelines are supported by Key focused on healthy individuals, as well as those with Recommendations that provide further guidance on overweight or obesity and those who are at risk of healthy eating across the lifespan. Dietary Guidelines for Americans, 2020-2025 | Executive Summary | Page viii The Guidelines Make every bite count with the Dietary Guidelines for Americans� Here’s how: 1 Follow a healthy dietary pattern at every life stage� At every life stage—infancy, toddlerhood, childhood, adolescence, adulthood, pregnancy, lactation, and older adulthood—it is never too early or too late to eat healthfully. • For about the first 6 months of life, exclusively feed infants human milk. Continue to feed infants human milk through at least the first year of life, and longer if desired. Feed infants iron-fortified infant formula during the first year of life when human milk is unavailable. Provide infants with supplemental vitamin D beginning soon after birth. • At about 6 months, introduce infants to nutrient-dense complementary foods. Introduce infants to potentially allergenic foods along with other complementary foods. Encourage infants and toddlers to consume a variety of foods from all food groups. Include foods rich in iron and zinc, particularly for infants fed human milk. • From 12 months through older adulthood, follow a healthy dietary pattern across the lifespan to meet nutrient needs, help achieve a healthy body weight, and reduce the risk of chronic disease. 2 Customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations� A healthy dietary pattern can benefit all individuals regardless of age, race, or ethnicity, or current health status. The Dietary Guidelines provides a framework intended to be customized to individual needs and preferences, as well as the foodways of the diverse cultures in the United States. 3 Focus on meeting food group needs with nutrient-dense foods and beverages, and stay within calorie limits� An underlying premise of the Dietary Guidelines is that nutritional needs should be met primarily from foods and beverages—specifically, nutrient-dense foods and beverages. Nutrient-dense foods provide vitamins, minerals, and other health-promoting components and have no or little added sugars, saturated fat, and sodium. A healthy dietary pattern consists of nutrient-dense forms of foods and beverages across all food groups, in recommended amounts, and within calorie limits. The core elements that make up a healthy dietary pattern include: • Vegetables of all types—dark green; red and orange; beans, peas, and lentils; starchy; and other vegetables • Fruits, especially whole fruit • Grains, at least half of which are whole grain • Dairy, including fat-free or low-fat milk, yogurt, and cheese, and/or lactose-free versions and fortified soy beverages and yogurt as alternatives • Protein foods, including lean meats, poultry, and eggs; seafood; beans, peas, and lentils; and nuts, seeds, and soy products • Oils, including vegetable oils and oils in food, such as seafood and nuts Page ix | Dietary Guidelines for Americans, 2020-2025 | Executive Summary 4 Limit foods and beverages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages� At every life stage, meeting food group recommendations—even with nutrient-dense choices—requires most of a person’s daily calorie needs and sodium limits. A healthy dietary pattern doesn’t have much room for extra added sugars, saturated fat, or sodium—or for alcoholic beverages. A small amount of added sugars, saturated fat, or sodium can be added to nutrient-dense foods and beverages to help meet food group recommendations, but foods and beverages high in these components should be limited. Limits are: • Added sugars—Less than 10 percent of calories per day starting at age 2. Avoid foods and beverages with added sugars for those younger than age 2. • Saturated fat—Less than 10 percent of calories per day starting at age 2. • Sodium—Less than 2,300 milligrams per day—and even less for children younger than age 14. • Alcoholic beverages—Adults of legal drinking age can choose not to drink, or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed. Drinking less is better for health than drinking more. There are some adults who should not drink alcohol, such as women who are pregnant. For most individuals, no matter their age or health status, Terms to Know achieving a healthy dietary pattern will require changes in Several terms are used throughout food and beverage choices. Some of these changes can the Dietary Guidelines and are be accomplished by making simple substitutions, while essential to understanding the others will require greater effort to accomplish. This edition Guidelines and putting them into of the Dietary Guidelines presents overall guidance on action. These terms are defined here: choosing nutrient-dense foods and beverages in place of less healthy choices and also discusses special nutrition • Dietary pattern: It is the combination of considerations for individuals at each life stage—infants foods and beverages that constitutes and toddlers, children and adolescents, adults, women who an individual’s complete dietary intake are pregnant or lactating, and older adults. over time. This may be a description of a customary way of eating or a description Although individuals ultimately decide what and how much of a combination of foods recommended to consume, their personal relationships; the settings in for consumption. which they live, learn, work, play, and gather; and other contextual factors—including their ability to consistently • Nutrient dense: Nutrient-dense foods access healthy and affordable food—strongly influence and beverages provide vitamins, minerals, their choices. Health professionals, communities, and other health-promoting components businesses and industries, organizations, government, and have little added sugars, saturated and other segments of society all have a role to play in fat, and sodium. Vegetables, fruits, whole supporting individuals and families in making choices grains, seafood, eggs, beans, peas, and that align with the Dietary Guidelines and ensuring that lentils, unsalted nuts and seeds, fat-free all people have access to a healthy and affordable food and low-fat dairy products, and lean meats supply. Resources, including Federal programs that support and poultry—when prepared with no or little households, regardless of size and make-up, in choosing added sugars, saturated fat, and sodium— a healthy diet and improving access to healthy food, are are nutrient-dense foods. highlighted throughout this edition of the Dietary Guidelines for Americans. Dietary Guidelines for Americans, 2020-2025 | Executive Summary | Page x Page 1 Dietary Guidelines for Americans, 2020-2025 | Introduction Introduction Diietary Guiidelliines for Ameriicans,, 2020-2025 | Introduction | Page 2 Setting the Stage The foods and beverages that people consume have a profound impact on their health. The scientific connection between food and health has been well documented for many decades, with substantial evidence showing that healthy dietary patterns can help people achieve and maintain good health and reduce the risk of chronic diseases throughout all stages of the lifespan. Yet, Federal data show that from the first edition of the Dietary Guidelines for Americans in 1980 through today, Americans have fallen far short of meeting its recommendations, and diet-related chronic disease rates have risen to pervasive levels and continue to be a major public health concern. The Dietary Guidelines is an important part of a complex, multifaceted approach to promote health and reduce chronic disease risk. The Dietary Guidelines provides science-based advice on what to eat and drink to promote health, help reduce risk of chronic disease, and meet nutrient needs. The Dietary Guidelines is the foundation of Federal food, nutrition, and health policies and programs. An important audience is health professionals and nutrition program administrators who work with the general public to help them consume a healthy and nutritionally adequate diet and establish policies and services to support these efforts. Comprehensive, coordinated strategies built on the science-based foundation of the Dietary Guidelines—and a commitment to drive these strategies over time across sectors and settings—can help all Americans consume healthy dietary patterns, achieve and maintain good health, and reduce the risk of chronic diseases. Grounded in Science and Focused on Public Health The U.S. Departments of Agriculture (USDA) and of Health and Human Services (HHS) update the Dietary Guidelines at least every 5 years, based on the current science. A fundamental premise of the Dietary Guidelines is that everyone, no matter their age, race, or ethnicity, economic circumstances, or health status, can benefit from shifting food and beverage choices to better support healthy dietary patterns. Page 3 Dietary Guidelines for Americans, 2020-2025 | Introduction To make sure that the dietary advice provided in the 60 percent of adults have one or more diet-related chronic Dietary Guidelines is aimed at improving public health, diseases (Table I-1). Given its aim to prevent further the science used to inform the Guidelines has examined disease incidence by promoting health and reducing diet through a lens of health promotion and disease chronic disease risk, the Dietary Guidelines focuses on prevention and considered various segments of the the general public, including healthy individuals, as well United States population, including ethnic populations as those with overweight or obesity and those who are at who have disproportionately and/or historically been risk of chronic disease. The importance of following the affected by diet-related disparities. This means that Dietary Guidelines across all life stages has been brought priority has been placed on scientific studies that into focus even more with the emergence of COVID-19, examine the relationship between diet and health across as people living with diet-related chronic conditions and all life stages, in men, women, and children from diverse diseases are at an increased risk of severe illness from racial and ethnic backgrounds, who are healthy or at risk the novel coronavirus. of chronic disease. Grounded in the current body of scientific evidence Over time, eating patterns in the United States have on diet and health that is relevant to all Americans, remained far below Dietary Guidelines recommendations the Dietary Guidelines is a critically important tool for (Figure I-1). Concurrently, it has become increasingly health professionals, policymakers, and many other clear that diet-related chronic diseases, such as professionals. It is designed to help people make food cardiovascular disease, type 2 diabetes, obesity, liver and beverage choices all through life that are enjoyable disease, some types of cancer, and dental caries, pose and affordable and that also promote health and help a major public health problem for Americans. Today, prevent chronic disease. Figure I-1 Adherence of the U�S� Population to the Dietary Guidelines Over Time, as Measured by the Average Total Healthy Eating Index-2015 Scores 100 80 60 56 57 59 60 59 59 40 20 0 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 2015-2016 NOTE: HEI-2015 total scores are out of 100 possible points. A score of 100 indicates that recommendations on average were met or exceeded. A higher total score indicates a higher quality diet. Data Source: Analysis of What We Eat in America, National Health and Nutrition Examination Survey (NHANES) data from 2005-2006 through 2015-2016, ages 2 and older, day 1 dietary intake data, weighted. Dietary Guidelines for Americans, 2020-2025 | Introduction | Page 4 Maximum Total Score = 100 Table I-1 Facts About Nutrition-Related Health Conditions in the United States HEALTH CONDITIONS STATISTICS • About 74% of adults are overweight or have obesity. • Adults ages 40 to 59 have the highest rate of obesity (43%) of any age group with adults Overweight and Obesity 60 years and older having a 41% rate of obesity. • About 40% of children and adolescents are overweight or have obesity; the rate of obesity increases throughout childhood and teen years. • Heart disease is the leading cause of death. • About 18.2 million adults have coronary artery disease, the most common type of heart disease. Cardiovascular Disease (CVD) • Stroke is the fifth leading cause of death. and Risk Factors: • Hypertension, high LDL cholesterol, and high total cholesterol are major risk factors in heart disease and stroke. • Coronary artery disease • Rates of hypertension and high total cholesterol are higher in adults with obesity than • Hypertension those who are at a healthy weight. • High LDL and total blood • About 45% of adults have hypertension.a cholesterol • More Black adults (54%) than White adults (46%) have hypertension. • Stroke • More adults ages 60 and older (75%) than adults ages 40 to 59 (55%) have hypertension. • Nearly 4% of adolescents have hypertension.b • More than 11% of adults have high total cholesterol, ≥240 mg/dL. • More women (12%) than men (10%) have high total cholesterol, ≥240 mg/dL. • 7% of children and adolescents have high total cholesterol, ≥200 mg/dL. • Almost 11% of Americans have type 1 or type 2 diabetes. • Almost 35% of American adults have prediabetes, and people 65 years and older have the highest rate (48%) compared to other age groups. Diabetes • Almost 90% of adults with diabetes also are overweight or have obesity. • About 210,000 children and adolescents have diabetes, including 187,000 with type 1 diabetes. • About 6-9% of pregnant women develop gestational diabetes. • Colorectal cancer in men and breast cancer in women are among the most common types of cancer. Cancer c • About 250,520 women will be diagnosed with breast cancer this year. • Breast Cancer • Close to 5% of men and women will be diagnosed with colorectal cancer at some point during their lifetime. • Colorectal Cancer • More than 1.3 million people are living with colorectal cancer. • The incidence and mortality rates are highest among those ages 65 and older for every cancer type. • More women (17%) than men (5%) have osteoporosis. Bone Health and • 20% of older adults have reduced muscle strength. Muscle Strength • Adults over 80 years, non-Hispanic Asians, and women are at the highest risk for reduced bone mass and muscle strength. a For adults, hypertension is defined as systolic blood pressure (SBP) >130 mm Hg and/or a diastolic blood pressure (DBP) >90 mm Hg. b For children, hypertension was defined using the 2017 American Academy of Pediatrics (AAP) Clinical Practice Guideline. c The types of cancer included here are not a complete list of all diet- and physical activity-related cancers. Page 5 Dietary Guidelines for Americans, 2020-2025 | Introduction A Spotlight on Dietary Patterns Although many of its recommendations have remained relatively consistent over time, the Dietary Guidelines has evolved as scientific knowledge has grown. Early Dietary Guidelines editions used evidence that examined the relationships between individual nutrients, foods, and food groups and health outcomes. In recent years, researchers, public health experts, and registered dietitians have acknowledged that nutrients and foods are not consumed in isolation. Rather, people consume them in various combinations over time—a dietary pattern—and these foods and beverages act synergistically to affect health. The 2015-2020 Dietary Guidelines put this understanding into action by focusing its recommendations on consuming a healthy dietary pattern. The 2020-2025 Dietary Guidelines carries forward this emphasis on the importance of a healthy dietary pattern as a whole— rather than on individual nutrients or foods in isolation. Serving as a framework, the Guidelines’ dietary patterns approach enables policymakers, programs, and health professionals to help people personalize their food and beverage choices to accommodate their wants and needs, food preferences, cultural traditions and customs, and budgetary considerations. Healthy Dietary Patterns at Every Life Stage The 2020-2025 Dietary Guidelines takes the dietary patterns approach one step further by focusing on the importance of encouraging healthy dietary patterns at every stage of life, from birth to older adulthood. It provides recommendations for healthy dietary patterns by life stage, identifying needs specific to each life stage and considering healthy dietary pattern characteristics that should be carried forward into the next stage of life. And, for the first time since the 1985 edition, this edition of the Dietary Guidelines includes recommendations for infants and toddlers as well as continuing the emphasis on healthy dietary patterns during pregnancy and lactation. This approach recognizes that each life stage is distinct—nutrient needs vary over the lifespan and each life stage has unique implications for food and beverage choices and disease risk. At the same time, it recognizes an important continuity. Because early food preferences influence later food choices, establishing a healthy dietary pattern early in life may have a beneficial impact on health promotion and disease prevention over the course of decades. Dietary Guidelines for Americans, 2020-2025 | Introduction | Page 6 Dietary Guidelines for population, including healthy individuals and people at risk of diet-related chronic conditions and diseases, Americans: What It Is, such as cardiovascular disease, type 2 diabetes, or obesity, and some people who are living with a diet- What It Is Not related chronic illness. The Dietary Guidelines translates the current science Because of this public health orientation, the Dietary on diet and health into guidance to help people choose Guidelines is not intended to be a clinical guideline foods and beverages that comprise a healthy and for treating chronic diseases. However, the Dietary enjoyable dietary pattern—the “what” and “how much” Guidelines often has served as a reference for Federal, of foods and beverages to consume to achieve good medical, voluntary, and patient care organizations health, reduce risk of diet-related chronic diseases, and as they develop clinical nutrition guidance tailored meet nutrient needs. The Dietary Guidelines is just one for people living with a specific medical condition. piece of the nutrition guidance landscape, however. Chronic diseases result from a complex mix of Other guidance is designed to address requirements for genetic, biological, behavioral, socioeconomic, and the specific nutrients contained in foods and beverages environmental factors, and people with these conditions or to address treatments for individuals who have a have unique health care requirements that require chronic disease. The following section describes the careful oversight by a health professional. Health role of the Dietary Guidelines within this larger nutrition professionals can adapt the Dietary Guidelines to guidance landscape. meet the specific needs of their patients with chronic diseases, as part of a multi-faceted treatment plan. Quantitative Guidance on Foods, Not Nutrient Requirements Nutrient requirements are established and updated Developing the by the National Academies of Sciences, Engineering, and Medicine. At the request of the U.S. and Canadian Dietary Guidelines Federal Governments, the Academies set the for Americans quantitative requirements or limits—known as Dietary Reference Intakes (DRI)—on nutrients, which include The process to develop the Dietary Guidelines has macronutrients (i.e., protein, carbohydrates, and fats), evolved over time, in step with developments in nutrition vitamins and minerals (e.g., vitamin C, iron, and sodium), science, public health, and best practices in scientific and food components (e.g., dietary fiber). review and guidance development. USDA and HHS work together to determine the approach for each edition. Because foods provide an array of nutrients and other components that have benefits for health, nutritional As stipulated by law, USDA and HHS must update the needs should be met primarily through foods. Thus, Dietary Guidelines at least every 5 years. The Guidelines the Dietary Guidelines translates the Academies’ must be grounded in the body of scientific and medical nutrient requirements into food and beverage knowledge available at that time, not in individual recommendations. The Dietary Guidelines recognizes, studies or individual expert opinion. In establishing the though, that in some cases, fortified foods and process for the 2020-2025 Dietary Guidelines, USDA dietary supplements are useful when it is not possible and HHS considered and integrated recommendations otherwise to meet needs for one or more nutrients (e.g., from a comprehensive 2017 National Academies’ during specific life stages such as pregnancy). study, Review of the Process to Update the Dietary Guidelines. Greater transparency figured prominently Health Promotion, Not Disease Treatment in the Academies’ recommendations. As a result, in At its core, the Dietary Guidelines has a public health developing the 2020-2025 process, USDA and HHS mission—that is, health promotion and disease made significant changes to increase transparency and prevention. Medical and nutrition professionals may public participation while maintaining the core element use or adapt the Dietary Guidelines to encourage their of scientific integrity. patients or clients to follow a healthy dietary pattern. The body of current scientific evidence on diet and One of these changes was the addition of a new stage health reviewed to inform the Dietary Guidelines at the beginning of the process. Thus, the 2020-2025 included study participants who represent the U.S. process consisted of four stages: (1) identify the topics Page 7 Dietary Guidelines for Americans, 2020-2025 | Introduction Stage 1: Stage 2: Stage 3: Stage 4: IDENTIFY Topics APPOINT a Dietary DEVELOP the IMPLEMENT the and Supporting Guidelines Advisory Dietary Guidelines Dietary Guidelines Scientific Questions Committee to Review Evidence and supporting scientific questions to be examined; and Federal agencies 30 days to view and provide (2) appoint a Dietary Guidelines Advisory Committee comments. Following review of the comments, USDA to review current scientific evidence; (3) develop the and HHS posted the final topics and questions, along new edition of the Dietary Guidelines; and (4) implement with the public call for nominations to the 2020 the Dietary Guidelines through Federal programs. Committee. Having topics and questions identified The following information provides an overview of upfront helped inform the public’s nominations by the 4-stage process. More details are available at defining which areas of nutrition expertise were needed DietaryGuidelines.gov. on the Committee. Stage 1: Identify Topics and Supporting Stage 2: Appoint a Dietary Guidelines Scientific Questions Advisory Committee To Review Current The Departments added a new step of identifying Scientific Evidence topics and scientific questions to begin the process In the second stage, the Secretaries of USDA and HHS of developing the next Dietary Guidelines. This was appointed the Committee with the single, time-limited done to promote a deliberate and transparent process, task of reviewing the 2015-2020 Dietary Guidelines, better define the expertise needed on the Committee, examining the evidence on the selected nutrition and ensure the scientific review conducted by the and public health topics and scientific questions, Committee would address Federal nutrition policy and and providing independent, science-based advice program needs and help manage resources. and recommendations to USDA and HHS. The 20 nationally recognized scientific experts appointed to In consultation with agencies across the Federal the Committee represented a mix of practitioners, Government, USDA and HHS identified potential epidemiologists, scientists, clinical trialists, and others topics and supporting scientific questions that were of from every region of the United States. greatest importance and relevance to Federal nutrition programs, policies, and consumer education priorities. The use of a Federal advisory committee is a commonly Compared to all previous Dietary Guidelines processes, used best practice to ensure the Federal Government the topic areas for 2020-2025 expanded due to the seeks sound, external scientific advice to inform added focus on infants and toddlers from birth through decisions. The Committee’s work concluded with its age 23 months, as well as women who are pregnant. scientific report submitted to the Secretaries of USDA The Agricultural Act of 2014 mandated that, beginning and HHS in June 2020.1 This report was not a draft of with the 2020-2025 edition, the Dietary Guidelines the Dietary Guidelines; it was a scientific document that should expand to include dietary guidance for these detailed the Committee’s evidence review and provided populations. Thus, the topics and questions—and areas advice to USDA and HHS. of expertise needed on the Committee—reflected this change. The Committee was divided into six subcommittees to conduct its work: Dietary Patterns, Pregnancy and The Departments posted the topics and questions Lactation, Birth to Age 24 Months, Beverages and publicly on DietaryGuidelines.gov, allowing the public Added Sugars, Dietary Fats and Seafood, and Frequency 1 Dietary Guidelines Advisory Committee. 2020. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC. Dietary Guidelines for Americans, 2020-2025 | Introduction | Page 8 of Eating. The Committee also formed one cross-cutting working group—Data Analysis and Food Pattern Modeling— to support work across the subcommittees. The Committee’s work had three defining characteristics: the use of three approaches to examine the evidence, the creation of transparent protocols before the evidence review began, and the development of scientific review conclusion statements for the scientific reviews conducted. THREE APPROACHES TO EXAMINE THE EVIDENCE The 2020 Committee used three state-of-the-art approaches to conduct its robust and rigorous reviews: Data analysis: Using Federal, nationally representative data, this approach provided insights into current eating habits of the U.S. population and current diet-related chronic Food pattern modeling: This type of analysis disease rates in the United States. These data illustrates how changes to the amounts or helped make the Dietary Guidelines practical, types of foods and beverages in a dietary relevant, and achievable. pattern might affect meeting nutrient needs across the U.S. population. The Committee used data analysis to address scientific questions that looked at current dietary The Committee used this method to assess patterns and beverage consumption, current potential changes to the USDA Dietary intakes of food groups and nutrients, dietary Patterns, which help meet the DRIs set by components of public health concern, prevalence the National Academies, while taking into of nutrition-related chronic health conditions, and consideration current consumption in the relationships between eating habits and achieving United States and the conclusions from nutrient and food group recommendations. its systematic reviews. As with all food pattern modeling for the Dietary Guidelines, Nutrition Evidence Systematic Review (NESR): the results of the Committee’s food pattern Systematic reviews are research projects that modeling tests were interpreted in light of follow meticulously defined protocols (i.e., plans) two key assumptions. First, the modeling to answer clearly formulated scientific questions tests were based on nutrient profiles of by searching for, evaluating, and synthesizing nutrient-dense foods in the U.S. food supply all relevant, peer-reviewed studies. Systematic and U.S. population-based dietary data. reviews are considered a gold standard method to Population-based patterns articulate the inform development of evidence-based guidelines evidence on the relationships between diet by ensuring consideration of the strongest, most and health in ways that might be adopted by appropriate body of evidence available on a topic. the U.S. public as a whole. Second, modeling USDA’s Nutrition Evidence Systematic Review is a tests assumed population-wide compliance team of scientists who specializes in conducting with all food intake recommendations. systematic reviews focused on nutrition and As with other types of modeling, the food disease prevention and evaluating scientific pattern modeling is hypothetical and does evidence on nutrition topics relevant to Federal not predict the behaviors of individuals. policy and programs. NESR used its rigorous, protocol-driven methodology to support the Each of these approaches had its own rigorous, Committee in conducting its systematic reviews. protocol-driven methodology, and each had a New to the 2020 process, USDA and HHS added a unique, complementary role in examining the step for peer review of the systematic reviews by science. Additional detailed information is available Federal scientists. at DietaryGuidelines.gov and NESR.usda.gov. Page 9 Dietary Guidelines for Americans, 2020-2025 | Introduction TRANSPARENT PROTOCOLS FIRST, THEN REVIEW To answer each scientific question, the Committee Health Status of Participants in first created a protocol that described how the Studies Included in Nutrition Committee would apply one of the three approaches Evidence Systematic Reviews to examine the evidence related to that specific To ensure that the Dietary Guidelines promotes question. The Committee created each protocol the health of and reduce risk of disease among before examining any evidence, and, for the first time, all Americans, the evidence base that informs the protocols were posted online for the public as the Dietary Guidelines must comprise studies they were being developed. This enabled the public conducted with people who are representative of to understand how a specific scientific question the general public and must examine diet through would be answered and to have the opportunity to a health promotion and disease prevention lens. submit public comments before the Committee completed the protocols and conducted its reviews As outlined in the Committee’s systematic review of the scientific evidence. Detailed information on the protocols, the Committee’s reviews included Committee’s review is documented in its scientific studies with participants who were healthy and/ report, which is available on DietaryGuidelines.gov. or who were at risk of a chronic disease, including participants with obesity, as well as studies that enrolled some participants with a disease. Because the Dietary Guidelines is not intended to be a clinical guideline for treating chronic diseases, the Committee excluded studies that enrolled only patients with a disease with the intention to treat those individuals. In general, the majority of the reviews conducted to inform the Dietary Guidelines included trials that exclusively enrolled participants with overweight or obesity, or who were at high risk of cardiovascular disease or type 2 diabetes, and observational studies that enrolled participants from a wide range of health and weight status, including those with healthy weight, overweight, or obesity. The reviews included few studies that enrolled only healthy participants. Thus, the Dietary Guidelines are applicable to the overall U.S. population, including healthy individuals and people at risk of diet-related chronic conditions and diseases, such as cardiovascular disease, type 2 diabetes, and obesity. In addition, people living with a diet- related chronic illness can benefit from a healthy dietary pattern. The Dietary Guidelines can serve as a reference for Federal, medical, voluntary, and patient care organizations as they develop nutrition guidance tailored for people living with a specific medical condition. Health professionals can adapt the Dietary Guidelines to meet the specific needs of their patients with chronic diseases, as part of a multifaceted treatment plan. Dietary Guidelines for Americans, 2020-2025 | Introduction | Page 10 CONCLUSION STATEMENTS FOR THE SCIENTIFIC Grading the strength of the evidence applied only to REVIEWS CONDUCTED questions answered using NESR systematic reviews; For all topics and questions, regardless of the it did not apply to questions answered using data approach used to identify and evaluate the scientific analysis or food pattern modeling. Therefore, data evidence, the Committee developed conclusion analysis and food pattern modeling conclusion statements. Each conclusion statement provided a statements were not graded. succinct answer to the specific question posed. The Committee took the strengths and limitations of the As it completed its work, the Committee looked evidence base into consideration when formulating across all of the conclusion statements to develop conclusion statements. overarching advice for USDA and HHS to consider as the Departments developed the next edition of the For questions answered using NESR systematic Dietary Guidelines. reviews, the conclusion statements included a grade to indicate the strength of the evidence supporting Using these three approaches, the Committee worked the conclusion statement. The grades were Strong, collaboratively for 16 months and deliberated on the Moderate, Limited, or Grade Not Assignable. scientific reviews in six meetings, all of which were open to the public. Two of the six meetings included an opportunity for the public to provide oral comments to the Committee. An ongoing period for written public comments to the Committee spanned 15 months of its work. And, for the first time, a final public meeting was included for the Committee to discuss its draft scientific report 1 month before the final report was posted for public comment. In addition to documenting its rigorous review of the evidence to answer the scientific questions from USDA and HHS and providing advice for the Departments’ development of the next Dietary Guidelines edition, the Committee provided recommendations for future research. These research recommendations reflected an acknowledgment that science in nutrition, diet, and health associations continues to evolve, and that new findings build on and enhance existing evidence. Upon submitting its final scientific report to the USDA and HHS Secretaries, the Committee disbanded. The Departments then posted the scientific report and asked the public for comments. The Departments received written comments on the report over a 30-day period and also held an online meeting to hear oral comments. Stage 3: Develop the Dietary Guidelines Each edition of the Dietary Guidelines builds on the preceding edition, with the scientific justification for revisions informed by the Committee’s scientific report and consideration of public and Federal agency comments. As with previous editions, development of the 2020-2025 Dietary Guidelines involved a step-by- step process of writing, review, and revision conducted by a writing team of Federal staff from USDA and HHS. Page 11 Dietary Guidelines for Americans, 2020-2025 | Introduction The writing team included Federal nutrition scientists This process culminated with approval by the with expertise in the Dietary Guidelines and related Secretaries of USDA and HHS. After approval by the research and programs as well as specialists with Secretaries, the Departments released the Dietary expertise in communicating nutrition information. Guidelines to Federal agencies and the public for implementation across programs and through Key tenets of writing the Dietary Guidelines are that educational activities. it must: Stage 4: Implement the Dietary Guidelines • Represent the totality of the evidence examined The U.S. Government uses the Dietary Guidelines as the basis of its food assistance and meal programs, • Address the needs of Federal programs nutrition education efforts, and decisions about national health objectives. For example, the National School • Reduce unintended consequences Lunch Program and the Older Americans Act Nutrition Program incorporate the Dietary Guidelines in menu • Follow best practices for developing guidelines planning; the Special Supplemental Nutrition Program for Women, Infants, and Children applies the Dietary • Use plain language Guidelines in its program and educational materials; and the Healthy People objectives for the Nation include The draft Dietary Guidelines went through internal and objectives based on the Dietary Guidelines. external review. Ultimately, the document was reviewed by all Agencies with nutrition policies and programs The Dietary Guidelines also provides a critical structure across USDA and HHS, such as USDA’s Food and for State and local public health promotion and Nutrition Service and its Food Safety and Inspection disease prevention initiatives. In addition, it provides Service, and HHS’ National Institutes of Health, Food and foundational, evidence-based nutrition guidance for Drug Administration, and Centers for Disease Control use by individuals and those who serve them in public and Prevention. The draft Dietary Guidelines also went and private settings, including health professionals, through an external expert peer review to ensure that it public health and social service agencies, health care accurately reflected the body of evidence documented in and educational institutions, researchers, agricultural the Committee’s scientific report. producers, food and beverage manufacturers, and more. Dietary Guidelines for Americans, 2020-2025 | Introduction | Page 12 Implementation of the Dietary Guidelines Through MyPlate Using MyPlate as a Guide To Support Healthy Dietary Patterns The Dietary Guidelines for Americans is developed and written for a professional audience. Therefore, its translation into actionable consumer messages and resources is crucial to help individuals, families, and communities achieve healthy dietary patterns. MyPlate is one example of consumer translation. Created to be used in various settings and adaptable to meeting personal preferences, cultural foodways, traditions, and budget needs, MyPlate is used by professionals across sectors to help people become more aware of and informed about making healthy food and beverage choices over time. More information is available at MyPlate.gov. Following a healthy dietary pattern from birth through older adulthood can have a profound impact on a person’s lifelong health. The Dietary Guidelines provides the framework for following such a pattern. However, broad and multisector collaboration is needed to help people achieve that goal. Action on many fronts is needed to ensure that healthy dietary choices at home, school, work, and play are the affordable, accessible norm. Everyone has a role to play in helping all Americans shift to a healthy dietary pattern and achieve better health. Try the MyPlate Plan A healthy eating routine is important at every stage of life and can have positive effects that add up over time. It’s important to eat a variety of fruits, vegetables, grains, dairy or fortified soy alternatives, and protein foods. When deciding what to eat or drink, choose options that are full of nutrients. Make every bite count. Think about how the following recommendations can come together over the course of your day or week to help you create a healthy eating routine: Make half your plate Move to low-fat or fruits & vegetables. fat-free dairy milk or yogurt (or lactose- free dairy or fortified Focus Make half soy versions). on whole your grains fruits. whole grains. To learn what the right amounts are for you, try Vary your Vary your the personalized veggies. protein MyPlate Plan.2 routine. Based on decades of solid science, MyPlate advice can help you day to day and over time. Choose foods and beverages with less added sugars, saturated fat, and sodium. The benefits of healthy eating add up over time, bite by bite. Small changes matter. Start Simple with MyPlate. with MyPlate 2 Available at: MyPlate.gov/myplate-plan Page 13 Dietary Guidelines for Americans, 2020-2025 | Introduction A Roadmap to the Dietary Guidelines 1 for Americans, 2020-2025 Reflecting the accumulating body of evidence Patterns for this age group, about the relationships between diet and health explains how current intakes outcomes, the 2020-2025 Dietary Guidelines presents compare to recommendations, its recommendations with a primary emphasis on and discusses special dietary encouraging the consumption of a healthy overall guidance considerations for 2 dietary pattern at every stage of life, from birth adults. The chapter concludes with through older adulthood. This edition of the Dietary suggestions for how to support healthy Guidelines consists of an Executive Summary, this dietary patterns among adults and a look Introduction, six chapters, and three appendixes. toward two important adult life stages—Women Who Are Pregnant or Lactating and Older Adults. • Chapter 1: Nutrition and Health Across the Lifespan: The Guidelines and Key • Chapter 5: Women Who Are Pregnant 3 Recommendations discusses the health or Lactating opens with a discussion of benefits of lifelong healthy dietary choices and selected nutrition issues important to this explains the four Guidelines and supporting Key stage of adult life. It then presents Recommendations. This chapter is the basis for the recommended Healthy Dietary all the succeeding chapters. Chapters 2 through 6 Patterns for this life stage, should be read in tandem with Chapter 1. explains how current intakes compare to recommendations, • Chapter 2: Infants and Toddlers is the first of five and discusses special dietary 4 chapters that focus on healthy dietary patterns guidance considerations for for a specific life stage. This edition of the Dietary women who are pregnant Guidelines is the first since the 1985 edition to or lactating. The chapter provide guidance for infants and toddlers (birth concludes with suggestions through age 23 months). The chapter provides for how to support healthy specific key recommendations for this age dietary patterns among this group, along with guidance on how to put these population group. recommendations into action. The chapter closes 5 with a Healthy Dietary Pattern during the second • Chapter 6: Older Adults opens with a year of life and a look toward the next life stage— discussion of selected nutrition issues that Children and Adolescents. are important for older adults, ages 60 and older. It then presents the recommended • Chapter 3: Children and Adolescents first sets Healthy Dietary Patterns for this life the stage by describing nutrition issues specific stage, explains how current intakes to children and adolescents ages 2 through 18. It compare to recommendations, and then presents the recommended Healthy Dietary discusses special dietary guidance 6 Patterns for this age group, explains how current considerations for this age group. intakes compare to recommendations, and The chapter concludes with discusses special dietary guidance considerations suggestions for how to support for this life stage. The chapter concludes with healthy dietary patterns among a discussion of ways to support healthy dietary older adults. patterns among children and adolescents and a look toward the next life stage—Adults. • Appendixes include a table summarizing nutritional goals for A • Chapter 4: Adults opens with a discussion of age-sex groups, estimated calorie selected nutrition issues that characterize the needs for all ages and at three adult life stage (ages 19 through 59). It then physical activity levels, and the USDA presents the recommended Healthy Dietary Dietary Patterns. Dietary Guidelines for Americans, 2020-2025 | Introduction | Page 14 Page 15 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan CHAPTER1 Nutrition and Health Across the Lifespan: The Guidelines and Key Recommendations Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 16 The Guidelines Make every bite count with the Dietary Guidelines for Americans� Here’s how: Follow a healthy dietary pattern at every life stage� 1 Customize and enjoy nutrient- dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary Limit foods and bev 4 2 considerations� erages higher in added sugars, saturated fat, and sodium, and limit alcoholic beverages� 3 Focus on meeting food group needs with nutrient-dense foods and beverages, and stay within calorie limits� Page 17 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Key Recommendations Follow a healthy dietary pattern at forms of foods and beverages across all food groups, in Guideline every life stage� recommended amounts, and within calorie limits. At every life stage—infancy, toddlerhood, 1 childhood, adolescence, adulthood, The core elements that make up a healthy dietary pregnancy, lactation, and older pattern include: adulthood—it is never too early or too late • Vegetables of all types—dark green; red and orange; to eat healthfully. beans, peas, and lentils; starchy; and other vegetables • For about the first 6 months of life, exclusively feed • Fruits, especially whole fruit infants human milk. Continue to feed infants human milk through at least the first year of life, and longer • Grains, at least half of which are whole grain if desired. Feed infants iron-fortified infant formula • Dairy, including fat-free or low-fat milk, yogurt, and during the first year of life when human milk is cheese, and/or lactose-free versions and fortified soy unavailable. Provide infants with supplemental vitamin beverages and yogurt as alternatives D beginning soon after birth. • Protein foods, including lean meats, poultry, and eggs; • At about 6 months, introduce infants to nutrient-dense seafood; beans, peas, and lentils; and nuts, seeds, and complementary foods. Introduce infants to potentially soy products allergenic foods along with other complementary foods. Encourage infants and toddlers to consume a • Oils, including vegetable oils and oils in food, such as variety of foods from all food groups. Include foods rich seafood and nuts in iron and zinc, particularly for infants fed human milk. Limit foods and beverages higher • From 12 months through older adulthood, follow a Guideline in added sugars, saturated fat, healthy dietary pattern across the lifespan to meet and sodium, and limit alcoholic nutrient needs, help achieve a healthy body weight, 4 beverages� and reduce the risk of chronic disease. At every life stage, meeting food group recommendations—even with nutrient- Customize and enjoy nutrient- dense choices—requires most of a person’s Guideline dense food and beverage choices daily calorie needs and sodium limits. A healthy to reflect personal preferences, dietary pattern doesn’t have much room for extra 2 cultural traditions, and budgetary added sugars, saturated fat, or sodium—or for alcoholic considerations� beverages. A small amount of added sugars, saturated A healthy dietary pattern can benefit fat, or sodium can be added to nutrient-dense foods and all individuals regardless of age, race, or beverages to help meet food group recommendations, ethnicity, or current health status. The Dietary but foods and beverages high in these components Guidelines provides a framework intended to be should be limited. Limits are: customized to individual needs and preferences, as well as the foodways of the diverse cultures in the • Added sugars—Less than 10 percent of calories per United States. day starting at age 2. Avoid foods and beverages with added sugars for those younger than age 2. Focus on meeting food group • Saturated fat—Less than 10 percent of calories per Guideline needs with nutrient-dense foods day starting at age 2. and beverages, and stay within • Sodium—Less than 2,300 milligrams per day—and calorie limits� even less for children younger than age 14. 3 An underlying premise of the Dietary Guidelines is that nutritional needs • Alcoholic beverages—Adults of legal drinking age can should be met primarily from foods and choose not to drink or to drink in moderation by limiting beverages—specifically, nutrient-dense foods intake to 2 drinks or less in a day for men and 1 drink and beverages. Nutrient-dense foods provide vitamins, or less in a day for women, when alcohol is consumed. minerals, and other health-promoting components and Drinking less is better for health than drinking more. have no or little added sugars, saturated fat, and sodium. There are some adults who should not drink alcohol, A healthy dietary pattern consists of nutrient-dense such as women who are pregnant. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 18 Guideline 1 Guideline 1 Follow a Healthy Dietary Pattern at Every Life Stage A fundamental premise of the Dietary Guidelines is forms of foods and beverages across all food groups, that almost everyone, no matter an individual’s age, in recommended amounts, and within calorie limits. race, or ethnicity, or health status, can benefit from Achieving a healthy dietary pattern at each life stage shifting food and beverage choices to better support not only supports health at that point in time, but also healthy dietary patterns. supports health in the next life stage and possibly for future generations. If healthy dietary patterns can be Healthy eating starts at birth with the exclusive established early in life and sustained thereafter, the consumption of human milk, if possible, for about the impact on health could be significant. Establishing first 6 months. If human milk is unavailable, infants and maintaining a healthy dietary pattern can help should be fed an iron-fortified commercial infant minimize diet-related chronic disease risk. Conversely, formula (i.e., labeled “with iron”) regulated by the consuming foods and beverages that are not nutrient- U.S. Food and Drug Administration (FDA), which are dense may lead to disease expression in later years. based on standards that ensure nutrient content and High intakes of such foods (i.e., an unhealthy dietary safety. Healthy eating continues with the introduction pattern) throughout the lifespan can increase the risk of of complementary foods and beverages at about developing chronic diseases. 6 months of age. By 12 months, infants should maintain their healthy eating as they transition to The good news is that at any stage of life, individuals developmentally appropriate foods and beverages. can make efforts to adopt a healthy dietary pattern Healthy eating continues in each life stage thereafter. and improve their health. The Healthy U.S.-Style Dietary Even though nutrient needs vary across life stages, the Pattern, USDA’s primary Dietary Pattern, provides a foods and beverages that individuals should eat over framework for healthy eating that all Americans can the lifespan are remarkably consistent. follow. It is based on the types and proportions of foods Americans of all ages, genders, races, and ethnicities This chapter provides foundational guidance about typically consume, but in nutrient-dense forms and maintaining a healthy dietary pattern across each life appropriate amounts. stage—infancy, toddlerhood, childhood, adolescence, adulthood, pregnancy, lactation, and older adulthood. The Healthy U.S.-Style Dietary Pattern is carried forward Because the nutritional needs and transition of infants from the 2015-2020 Dietary Guidelines for Americans. and toddlers are unique, Chapter 2 provides a focused The 2,000-calorie level of the pattern is shown in discussion on this age group. Chapters 3, 4, 5, and 6 Table 1-1. The Healthy Mediterranean-Style Dietary then provide tailored nutrition information specific Pattern and the Healthy Vegetarian Dietary Pattern— to children and adolescents, adults, women who are also carried forward from the 2015-2020 Dietary pregnant or lactating, and older adults, respectively. Guidelines for Americans—are variations of the Healthy U.S.-Style Dietary Pattern that have the same core What Is a Dietary Pattern? elements. The USDA Dietary Patterns are described in Over the course of any given day, week, or year, Appendix 3. USDA Dietary Patterns and are meant to individuals consume foods and beverages1 in be tailored to meet cultural and personal preferences combination—a dietary pattern. A dietary pattern and used as guides to plan and serve meals for represents the totality of what individuals habitually individuals, households, and in a variety of institutions eat and drink, and the parts of the pattern act and other settings. The Dietary Approaches to Stop synergistically to affect health. As a result, the dietary Hypertension (DASH) dietary pattern is an example of pattern may better predict overall health status and a healthy dietary pattern and has many of the same disease risk than individual foods or nutrients. characteristics as the Healthy U.S.-Style Dietary Pattern. Additional details on DASH are available at nhlbi.nih. A healthy dietary pattern consists of nutrient-dense gov/health-topics/dash-eating-plan. 1 If not specified explicitly, references to “foods” refer to “foods and beverages.” Page 19 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 1 Table 1-1 Healthy U�S�-Style Dietary Pattern at the 2,000-Calorie Level, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components FOOD GROUP OR SUBGROUPa Daily Amountb of Food From Each Group (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 2 ½ Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) 1 ½ Red and Orange Vegetables (cup eq/wk) 5 ½ Beans, Peas, Lentils (cup eq/wk) 1 ½ Starchy Vegetables (cup eq/wk) 5 Other Vegetables (cup eq/wk) 4 Fruits (cup eq/day) 2 Grains (ounce eq/day) 6 Whole Grains (ounce eq/day) ≥ 3 Refined Grains (ounce eq/day) < 3 Dairy (cup eq/day) 3 Protein Foods (ounce eq/day) 5 ½ Protein Foods Subgroups in Weekly Amounts Meats, Poultry, Eggs (ounce eq/wk) 26 Seafood (ounce eq/wk) 8 Nuts, Seeds, Soy Products (ounce eq/wk) 5 Oils (grams/day) 27 Limit on Calories for Other Uses (kcal/day)c 240 Limit on Calories for Other Uses (%/day) 12% a Definitions for each food group and subgroup are provided throughout the chapter and are compiled in Appendix 3. b Food group amounts shown in cup or ounce equivalents (eq). Oils are shown in grams. Quantity equivalents for each food group are defined in Appendix 3. Amounts will vary for those who need <2,000 or >2,000 calories per day. c Foods are assumed to be in nutrient-dense forms, lean or low-fat and prepared with minimal added sugars, refined starches, saturated fat, or sodium. If all food choices to meet food group recommendations are in nutrient-dense forms, a small number of calories remain within the overall limit of the pattern (i.e., limit on calories for other uses). The amount of calories depends on the total calorie level of the pattern and the amounts of food from each food group required to meet nutritional goals. Calories up to the specified limit can be used for added sugars, saturated fat, and/or alcohol, or to eat more than the recommended amount of food in a food group. NOTE: The total dietary pattern should not exceed Dietary Guidelines limits for added sugars, saturated fat, and alcohol; be within the Acceptable Macronutrient Distribution Ranges for protein, carbohydrate, and total fats; and stay within calorie limits. Values are rounded. See Appendix 3 for all calorie levels of the pattern. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 20 Guideline 1 Figure 1-1 Examples of Calories in Food Choices That Are Not Nutrient Dense and Calories in Nutrient-Dense Forms of These Foods Calories in Nutrient-Dense Form of the Food Additional Calories in Food as Consumed 97% Lean Beef Beef Fat 80% Lean Ground 122 87 209 Total Beef Patty, 3 ounces Baked Cod Breading & Frying Oil Breaded, Fried 99 131 230 Total Cod, 4 ounces Fat-Free Milk Milk Fat Whole Milk, 83 63 146 Total 1 cup Movie Air-Popped Popcorn Butter Theater-Style Popcorn 62 122 184 Total With Butter, 2 cups Espresso & Fat-Free Milk Milk Fat Chocolate Syrup Full-Fat Mocha, 110 79 101 290 Total 12 ounces Unsweetened Applesauce Added Sugars Sweetened Applesauce, 103 67 170 Total 1 cup 0 50 100 150 200 250 300 CALORIES Data Source: U.S. Department of Agriculture, Agricultural Research Service. FoodData Central, 2019. fdc.nal.usda.gov. Page 21 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 1 Figure 1-2 Making Nutrient-Dense Choices: One Food or Beverage At a Time Every food and beverage choice is an opportunity to move toward a healthy dietary pattern. Small changes in single choices add up and can make a big difference. These are a few examples of realistic, small changes to nutrient- dense choices that can help people adopt healthy dietary patterns. Plain Shredded Plain, Low-Fat Low-Sodium Wheat Yogurt With Fruit Black Beans Vegetable Oil Sparkling Water NUTRIENT- DENSE TYPICAL Frosted Full-Fat Yogurt With Regular Canned Shredded Wheat Added Sugars Black Beans Butter Soda Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 22 Guideline 1 The Health Benefits of a Healthy low- or non-fat dairy, lean meats and poultry, Dietary Pattern seafood, nuts, and unsaturated vegetable Science is the foundation of the Dietary Guidelines oils, and relatively lower consumption of red recommendations on what Americans should eat and processed meats, sugar-sweetened foods and and drink to promote health, reduce risk of chronic beverages, and refined grains. The evidence examined disease, and meet nutrient needs. The science shows showed broad representation across a number of that consuming a healthy dietary pattern, meeting food populations and demographic groups. This suggests a group and nutrient needs with nutrient-dense foods and consistent association no matter the region or cultural beverages, and limiting intake of foods and beverages context in which a healthy dietary pattern is consumed. that are not nutrient-dense is related to many health In addition, dietary patterns characterized by higher benefits. Science also supports the idea that every life intake of red and processed meats, sugar-sweetened stage provides an opportunity to make food choices foods and beverages, and refined grains are, in and that promote health and well-being, achieve and of themselves, associated with detrimental health maintain appropriate weight status, and reduce risk of outcomes. These findings are consistent with—and diet-related chronic disease. build on—the evidence base that informed the 2015- 2020 Dietary Guidelines. The science supporting the Dietary Guidelines is extensively documented in the Scientific Report of the A Healthy Dietary Pattern Supports 2020 Dietary Guidelines Advisory Committee, which Appropriate Calorie Levels describes the state of the science on key topics related The total number of calories a person needs each day to diet and health. Outcomes with Strong or Moderate varies depending on a number of factors, namely the evidence are provided in Figure 1-3. The report is person’s age, sex, height, weight, level of physical activity, available at DietaryGuidelines.gov. and pregnancy or lactation status. Due to reductions in basal metabolic rate that occur with aging, calorie Evidence on the association between dietary needs generally decrease for adults as they age. In patterns and reduced risk of diet-related chronic addition, a need to lose, maintain, or gain weight affects diseases has expanded in recent years and supports how many calories should be consumed. Estimated the use of dietary patterns as a foundation for amounts of calories needed based on age, sex, and the recommendations in the Dietary Guidelines level of physical activity are provided in Appendix 2. for Americans, 2020-2025. Consistent evidence Estimated Calorie Needs, and estimated calorie needs demonstrates that a healthy dietary pattern is relevant for different ages are provided in each life stage associated with beneficial outcomes for all-cause chapter. These estimates are based on the Estimated mortality, cardiovascular disease, overweight and Energy Requirement (EER) equations established by obesity, type 2 diabetes, bone health, and certain types the National Academies of Sciences, Engineering, and of cancer (breast and colorectal). Medicine (National Academies) using reference heights (average) and reference weights (healthy) for each Common characteristics of dietary patterns associated age-sex group. These amounts are estimates. The best with positive health outcomes include relatively higher way to evaluate calorie intake, in comparison to calorie intake of vegetables, fruits, legumes, whole grains, needs, is by measuring body weight status. Rather than focus on weight status at any one point in life, the Dietary Guidelines supports healthy weight trajectories at each stage of life—appropriate weight gain during pregnancy and postpartum weight loss, healthy growth and development from infancy through adolescence, weight stability during mid-life, and healthy body composition late in life. Meeting the Dietary Guidelines recommendations within calorie needs can help prevent excess weight gain at every life stage and support overall good health. Page 23 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 1 Figure 1-3 The Science Underlying the Dietary Guidelines Demonstrates That Healthy Eating Across the Lifespan Can Promote Health and Reduce Risk of Chronic Disease Birth Through 23 Months • Lower risk of overweight and obesity • Lower risk of type 1 diabetes • Adequate iron status and lower risk of iron deficiency • Lower risk of peanut allergy • Lower risk Children and of asthma Adolescents • Lower adiposity • Lower total and low-density lipoprotein (LDL) cholesterol Women Who Are Pregnant or Lactating Adults, Including Older Adults • Favorable cognitive development in • Lower risk of the child all-cause mortality • Favorable folate • Lower risk of status in women cardiovascular disease during pregnancy • Lower risk of cardiovascular and lactation disease mortality • Lower total and LDL cholesterol • Lower blood pressure • Lower risk of obesity • Lower body mass index, waist circumference, and body fat • Lower risk of type 2 diabetes • Lower risk of cancers of the breast, colon, and rectum • Favorable bone health, including lower risk of hip fracture NOTE: The 2020 Dietary Guidelines Advisory Committee examined the evidence on diet and health across the lifespan. Evidence is not available for all combinations of exposures and outcomes for the population subgroups presented in this figure. The Committee rated the evidence on diet and health as Strong, Moderate, Limited, or Grade Not Assignable. Only outcomes with Strong or Moderate evidence are included in this table. See the Committee’s Report for specific graded conclusion statements. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 24 Guideline 1 Key Dietary Principles To help people meet the Guidelines and Key Recommendations, the following are important principles when making decisions about nutrient- dense food and beverage choices to achieve a healthy dietary pattern. MEET NUTRITIONAL NEEDS PRIMARILY FROM FOODS AND BEVERAGES The Dietary Guidelines are designed to meet the Recommended Dietary Allowances and Adequate Intakes for essential nutrients, as well as Acceptable Macronutrient Distribution Ranges, all set by the National Academies. An underlying premise of the Dietary Guidelines is that nutritional needs should be met primarily from foods and beverages— specifically, nutrient-dense foods and beverages. In some cases, when meeting nutrient needs is not otherwise possible, fortified foods and nutrient-containing dietary supplements are useful. It is important to note that the nutrient density and healthfulness of what people eat and drink often is determined ultimately by how a food item, dish, or meal is prepared, at home and away from home or produced by a manufacturer. Based on the U.S. food supply and marketplace, the examples of healthy dietary patterns in this edition are achievable through thoughtful, informed choices one decision, one meal, one day at a time—and consistently over time. CHOOSE A VARIETY OF OPTIONS FROM EACH FOOD GROUP Enjoy different foods and beverages within each food group. This can help meet nutrient needs—and also allows for flexibility so that the Dietary Guidelines can be tailored to meet cultural and personal preferences. All forms of foods, including fresh, canned, dried, frozen, and 100% juices, in nutrient-dense forms, can be included in healthy dietary patterns. PAY ATTENTION TO PORTION SIZE Portion size is a term often used to describe the amount of a food or beverage served or consumed in one eating occasion. It is important to pay attention to portion size when making food and beverage choices, particularly for foods and beverages that are not nutrient-dense. A concept that can help people choose appropriate portions is serving size. This term is included on the Nutrition Facts label and refers to the amount of a food or beverage that is customarily consumed—it is not a recommendation of how much to eat or drink. Consuming less than the stated serving size results in consuming fewer calories and other nutrients or food components. Some products may have multiple servings per package. Page 25 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 1 Most Americans Do Not Follow a Healthy Dietary Pattern The typical dietary patterns currently consumed by many in the United States do not align with the Dietary Guidelines (Figure 1-4). The Healthy Eating Index (HEI) is a measure of diet quality that can be used to assess compliance with the Dietary Guidelines. For Americans ages 2 and older, HEI-2015 scores indicate that intakes are not consistent with recommendations for a healthy dietary pattern. Average diet quality has slightly improved in the past 10 years, but the average score of 59 (on a scale from 0 to 100) indicates that people have much room for improvement. Differences in overall HEI scores are seen across age, sex, race-ethnic, and income subgroups and by pregnancy and lactation status, though poor diet quality is observed across all groups. With each step closer to a diet that aligns with the core elements of a healthy dietary pattern, HEI scores will increase and risk for chronic disease will decrease. Figure 1-4 Adherence of the U�S� Population to the Dietary Guidelines Across Life Stages, as Measured by Average Total Healthy Eating Index-2015 Scores 100 80 61 60 59 63 55 52 56 51 40 20 0 Ages 2-4 Ages 5-8 Ages 9-13 Ages 14-18 Ages 19-30 Ages 31-59 Ages 60+ NOTE: HEI-2015 total scores are out of 100 possible points. A score of 100 indicates that recommendations on average were met or exceeded. A higher total score indicates a higher quality diet. Data Source: Analysis of What We Eat in America, NHANES 2015-2016, ages 2 and older, day 1 dietary intake data, weighted. In addition, the high percentage of the population with overweight or obesity suggests that many people in the United States consume foods and beverages that contribute to a calorie imbalance, a situation more likely to occur with low physical activity. As shown in the Introduction, Table I-1, 74 percent of all adults and 40 percent of all children and youth in the United States have either overweight or obesity. Even from the youngest ages, almost all Americans should shift to healthier food and beverage choices and consume smaller portions to achieve a healthy dietary pattern within an appropriate number of calories. It is never too early or too late to improve intake and establish a healthy dietary pattern. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 26 Maximum Total Score = 100 Guideline 2 Guideline 2 Customize and Enjoy Food and Beverage Choices to Reflect Personal Preferences, Cultural Traditions, and Budgetary Considerations Eating should be enjoyed, and Start with Personal Preferences a healthy dietary pattern can be Exposure to different types of food is important enjoyable, from early life to older early in life to better develop a child’s interest and adulthood. The science reviewed willingness to eat and enjoy a variety of foods. to inform the Dietary Guidelines Through each life stage that follows, a key starting represents the diversity of point for establishing and maintaining a healthy Americans, including all ages and dietary pattern is to ensure that individual and/or life stages, different racial family preferences—in nutrient-dense forms—are and ethnic backgrounds, and a built into day-to-day choices. range of socioeconomic statuses. A healthy dietary pattern can Incorporate Cultural Traditions benefit all individuals regardless Cultural background can have significant influence of age, race or ethnicity, or current on food and beverage choices. Customizing the health status. Dietary Guidelines framework to reflect specific cultures and traditions is an important strategy The Dietary Guidelines provides to help communities across the country eat and a framework intended to be enjoy a healthy dietary pattern. Nutrient-dense customized to fit individual, culturally relevant foods and beverages are part household, and Federal program of all of the food groups. Spices and herbs can participants’ preferences, as well help flavor foods when reducing added sugars, as the foodways of the diverse saturated fat, and sodium, and they also can add cultures in the United States. The to the enjoyment of nutrient-dense foods, dishes, U.S. population is diverse in myriad and meals that reflect specific cultures. Relying on ways. The Dietary Guidelines the expertise of professionals in nutrition and in framework purposely provides specific cultural foodways can help people prepare recommendations by food groups foods healthfully while retaining heritage. and subgroups—not specific foods and beverages—to avoid Consider Budget being prescriptive. This framework Despite a common perception that eating approach ensures that people can healthfully is expensive, a healthy dietary pattern “make it their own” by selecting can be affordable and fit within budgetary healthy foods, beverages, meals, constraints. There are a range of strategies that and snacks specific to their needs can be used to help individuals and families follow and preferences. a healthy dietary pattern including advanced planning; considering regional and seasonal food The food groups include a broad availability; and incorporating a variety of fresh, variety of nutrient-dense food and frozen, dried, and canned options. The USDA beverage choices. In every setting, Food Plans—Thrifty, Low-Cost, Moderate-Cost, across all cultures, and at any age and Liberal-Cost food plans—each represent or budget, there are foods and a nutritious diet at a different cost level. These beverages that can fit within the plans are scheduled to be revised, with an updated Dietary Guidelines framework. Thrifty Food Plan published by the end of 2022 to reflect this edition of the Dietary Guidelines and updated food availability and food cost data. Page 27 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 2 Figure 1-5 Customizing the Dietary Guidelines Framework The Dietary Guidelines approach of providing a framework–not prescriptive details–ensures that its recommendations can “meet people where they are,” from personal preferences to cultural foodways, and including budgetary considerations. The examples below are a sample of the range of options in each food group—to be eaten in nutrient- dense forms. Additional examples are listed under Table A3-2 in Appendix 3. Vegetables • Dark-Green Vegetables: All fresh, frozen, and canned dark- green leafy vegetables and broccoli, cooked or raw: for example, amaranth leaves, bok choy, broccoli, chamnamul, chard, collards, kale, mustard greens, poke greens, romaine lettuce, spinach, taro leaves, turnip greens, and watercress. • Red and Orange Vegetables: All fresh, frozen, and canned red and orange vegetables or juice, cooked or raw: for example, calabaza, carrots, red or orange bell peppers, sweet potatoes, tomatoes, 100% tomato juice, and winter squash. • Beans, Peas, Lentils: All cooked from dry or canned beans, peas, chickpeas, and lentils: for example, black beans, black-eyed peas, bayo beans, chickpeas (garbanzo beans), edamame, kidney beans, lentils, lima beans, mung beans, pigeon peas, pinto beans, and split peas. Does not include green beans or green peas. • Starchy Vegetables: All fresh, frozen, and canned starchy vegetables: for example, breadfruit, burdock root, cassava, corn, jicama, lotus root, lima beans, plantains, white potatoes, salsify, taro root (dasheen or yautia), water chestnuts, yam, and yucca. • Other Vegetables: All other fresh, frozen, and canned vegetables, cooked or raw: for example, asparagus, avocado, bamboo shoots, beets, bitter melon, Brussels sprouts, cabbage (green, red, napa, savoy), cactus pads (nopales), cauliflower, celery, chayote (mirliton), cucumber, eggplant, green beans, kohlrabi, luffa, mushrooms, okra, onions, radish, rutabaga, seaweed, snow peas, summer squash, tomatillos, and turnips. Fruits • All fresh, frozen, canned, and dried fruits and 100% fruit juices: for example, apples, Asian pears, bananas, berries (e.g., blackberries, blueberries, currants, huckleberries, kiwifruit, mulberries, raspberries, and strawberries); citrus fruit (e.g., calamondin, grapefruit, lemons, limes, oranges, and pomelos); cherries, dates, figs, grapes, guava, jackfruit, lychee, mangoes, melons (e.g., cantaloupe, casaba, honeydew, and watermelon); nectarines, papaya, peaches, pears, persimmons, pineapple, plums, pomegranates, raisins, rhubarb, sapote, and soursop. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 28 Figure 1-5 Customizing the Dietary Guidelines Framework (continued) Grains • Whole grains: All whole-grain products and whole grains used as ingredients: for example, amaranth, barley (not pearled), brown rice, buckwheat, bulgur, millet, oats, popcorn, quinoa, dark rye, whole-grain cornmeal, whole-wheat bread, whole-wheat chapati, whole-grain cereals and crackers, and wild rice. • Refined grains: All refined-grain products and refined grains used as ingredients: for example, white breads, refined-grain cereals and crackers, corn grits, cream of rice, cream of wheat, barley (pearled), masa, pasta, and white rice. Refined- grain choices should be enriched. Dairy and Fortified Soy Alternatives • All fluid, dry, or evaporated milk, including lactose-free and lactose-reduced products and fortified soy beverages (soy milk), buttermilk, yogurt, kefir, frozen yogurt, dairy desserts, and cheeses. Most choices should be fat-free or low-fat. Cream, sour cream, and cream cheese are not included due to their low calcium content. Protein Foods • Meats, Poultry, Eggs: Meats include beef, goat, lamb, pork, and game meat (e.g., bison, moose, elk, deer). Poultry includes chicken, Cornish hens, duck, game birds (e.g., ostrich, pheasant, and quail), goose, and turkey. Organ meats include chitterlings, giblets, gizzard, liver, sweetbreads, tongue, and tripe. Eggs include chicken eggs and other birds’ eggs. Meats and poultry should be lean or low-fat. • Seafood: Seafood examples that are lower in methylmercury include: anchovy, black sea bass, catfish, clams, cod, crab, crawfish, flounder, haddock, hake, herring, lobster, mullet, oyster, perch, pollock, salmon, sardine, scallop, shrimp, sole, squid, tilapia, freshwater trout, light tuna, and whiting. • Nuts, Seeds, Soy Products: Nuts and seeds include all nuts (tree nuts and peanuts), nut butters, seeds (e.g., chia, flax, pumpkin, sesame, and sunflower), and seed butters (e.g., sesame or tahini and sunflower). Soy includes tofu, tempeh, and products made from soy flour, soy protein isolate, and soy concentrate. Nuts should be unsalted. Page 29 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline Guideline 3 3 Focus on Meeting Food Group Needs With Nutrient-Dense Foods and Beverages, and Stay Within Calorie Limits The Dietary Guidelines include recommendations for food groups—vegetables, fruits, grains, dairy, and protein foods— eaten at an appropriate calorie level and in forms with limited amounts of added sugars, saturated fat, and sodium. Science shows that these same core elements of a healthy dietary pattern are consistent across each life stage. However, as shown in Figure 1-6, when compared to the Healthy U.S.-Style Dietary Pattern, most Americans have substantial room for improvement: • More than 80 percent have dietary patterns that are low in vegetables, fruits, and dairy. • More than half of the population is meeting or exceeding total grain and total protein foods recommendations, but are not meeting the recommendations for the subgroups within each of these food groups. Figure 1-6 Dietary Intakes Compared to Recommendations: Percent of the U�S� Population Ages 1 and Older Who Are Below and At or Above Each Dietary Goal Intake At/Above Recommendation Intake Below Recommendation 100 90 80 70 60 50 40 The center (0) line is the 30 goal or limit. 20 For most, those 10 represented by the dark blue 0 section of the 10 bars can improve their 20 dietary pattern 30 by shifting toward the 40 center line. 50 60 70 80 90 100 es es les tils es s ains ains ains iry s cts tabl tabl tables Fruit Gr Gr Da od gs Fo , E g food ge ge etab en tabl s, L ge ge Ve Veg tal ole d Gr ulty Sea Produ r V e To Wh fin e otein oy tal n Ve ge s, Pea y V e e To ee an *R e Pr ts, Po tal s, S k-G r Or an ch Star Oth Be To Mea ed Se Dar d & Re ts, Nu *NOTE: Recommended daily intake of whole grains is to be at least half of total grain consumption, and the limit for refined grains is to be no more than half of total grain consumption. Data Source: Analysis of What We Eat in America, NHANES 2013-2016, ages 1 and older, 2 days dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 30 Percent of Population Percent of Population Below Recommendation At or Above Recommendation Guideline Learn More: The following sections use the Healthy U.S.-Style 3 Table A3-2 in Appendix Dietary Pattern to show how people can make shifts 3 provides the food in their choices to achieve a healthy dietary pattern. group-based Healthy Information on the amounts to consume—in cup and ounce U.S.-Style Dietary equivalents—for each life stage is discussed in the subsequent Pattern as a sample life stage chapters and Appendix 3. USDA Dietary Patterns. framework. Information on what counts as a Eating an appropriate mix of foods from the food groups and cup- or ounce-equivalent subgroups—within an appropriate calorie level—is important is also provided under to promote health at each life stage. Each of the food groups this table in footnote c. and their subgroups provides an array of nutrients, and the amounts recommended reflect eating patterns that have been associated with positive health outcomes. Foods from all of the food groups should be eaten in nutrient-dense forms. The following sections describe special considerations related to each food group. Vegetables About Beans, Peas, and Lentils Healthy dietary patterns include a variety of vegetables “Beans, peas, and lentils” is a new name for the from all five vegetable subgroups—dark green; red and orange; vegetable subgroup formerly called “legumes beans, peas, and lentils; starchy; and other. These include (beans and peas).” Beans, peas, and lentils, which all fresh, frozen, canned, and dried options in cooked or raw also are known as pulses, include the dried edible forms, including 100% vegetable juices. Vegetables in their seeds of legumes. The foods in this vegetable nutrient-dense forms have limited additions such as salt, subgroup have not changed. However, the new butter, or creamy sauces. Examples of vegetables in each of name of the subgroup more accurately reflects the subgroups are available in Appendix 3. the category of foods included. Beans include varieties such as kidney beans, pinto beans, white Almost 90 percent of the U.S. population does not meet beans, black beans, lima beans, and fava beans. the recommendation for vegetables. In addition, with Also included are dried peas (e.g., chickpeas, few exceptions, the U.S. population does not meet intake black-eyed peas, pigeon peas, and split peas) and recommendations for any of the vegetable subgroups. About lentils. Edamame, which is the soybean in the pod, 45 percent of all vegetables are eaten as a separate food item; is counted in the beans, peas, and lentils subgroup about 40 percent as part of a mixed dish; and the remainder even though it is eaten fresh and not dried. are mostly consumed as snack foods and condiments. Vegetables, when consumed on their own, are generally Because beans, peas, and lentils have a similar consumed in forms with additional sodium either from salt nutrient profile to foods in both the vegetable added in cooking or added sauces such as soy sauce or group and the protein foods group, they may be bottled stir-fry sauces. Many vegetables are consumed as part thought of as either a vegetable or a protein food of mixed dishes like sandwiches, pasta with a tomato-based when aiming to meet recommended intakes. sauce, or casseroles that may have other ingredients that are sources of saturated fat and/or sodium. Green peas and green (string) beans are not counted in the beans, peas, and lentils For most individuals, following a healthy eating pattern will subgroup because the nutrient content of these require an increase in total vegetable intake and from all vegetables is more similar to vegetables in other vegetable subgroups, shifting to nutrient-dense forms, and subgroups. Green peas, which are not dried before an increase in the variety of different vegetables consumed consumption, are grouped with starchy vegetables over time. Vegetables can be part of many types of mixed and green beans are in the other vegetables dishes, from burgers, sandwiches, and tacos, to pizza, stews, subgroup, which includes onions, iceberg lettuce, pasta dishes, grain-based casseroles, and soups. Strategies celery, and cabbage. Generally, foods made from to increase vegetable intake include increasing the vegetable processed soybeans are a part of the nuts, seeds content of mixed dishes or eating less of a main dish to and soy products protein foods subgroup. allow for more vegetables as side dishes—keeping these nutrient dense. Page 31 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline Fruits 3 The fruit food group includes whole fruits and 100% fruit juice. Whole fruits include fresh, canned, frozen, and dried forms. Whole fruits can be eaten in various forms, such as cut, sliced, diced, or cubed. At least half of the recommended amount of fruit should come from whole fruit, rather than 100% juice. When juices are consumed, they should be 100% juice and always pasteurized or 100% juice diluted with water (without added sugars). Also, when selecting canned fruit, choose options that are canned with 100% juice or options lowest in added sugars. About 80 percent of the U.S. population does not meet fruit recommendations. Over 60 percent of all fruit intake comes from whole forms—fresh, canned, frozen, or dried—or 100% juice. Fruit is generally consumed in • Choose products with at least 50 percent of the total nutrient-dense forms such as plain bananas, apples, weight as whole-grain ingredients. If a food has at least oranges, or grapes. However, some fruit is consumed as 8 grams of whole grains per ounce-equivalent then half part of foods that may not be nutrient-dense, such as fruit of the grains are whole-grain ingredients. pie or similar desserts. Most Americans meet recommendations for total grain intakes, although 98 percent fall below recommendations Most people would benefit from increasing their intake for whole grains and 74 percent exceed limits for refined of fruit, mostly as whole fruits in nutrient-dense forms. A grains. Almost half of all intake of refined grains is from wide variety of fruits are available in the U.S. marketplace, mixed dishes, such as sandwiches, burgers, tacos, pizza, some year-round and others seasonally. Strategies to macaroni and cheese, and spaghetti with meatballs. help achieve this shift include choosing more whole fruits About 20 percent of intake of refined grains comes from as snacks and including them in meals. snacks and sweets, including crackers, pretzels, cakes, cookies, and other grain desserts. The remaining refined Grains grains are generally eaten as separate food items, such Healthy dietary patterns include whole grains and limit as pancakes, cereals, breads, tortillas, pasta, or rice. the intake of refined grains. At least half of total grains About 60 percent of whole-grain intake in the United should be whole grains. Individuals who eat refined grains States is from individual food items, mostly cereals and should choose enriched grains. Individuals who consume crackers, rather than mixed dishes. Grains are generally all of their grains as whole grains should include some consumed in forms with higher amounts of sodium (e.g., that have been fortified with folic acid. Grain-based foods breads, tortillas, crackers) and added sugars (e.g., grain- in nutrient-dense forms limit the additions of added based desserts, many ready-to-eat breakfast cereals) sugars, saturated fat, and sodium. rather than the nutrient-dense forms. Further, grains are often consumed as part of mixed dishes, such as pasta A food is a 100% whole-grain food if the only grains dishes, casseroles, and sandwiches that may have other it contains are whole grains. A 1 ounce-equivalent of ingredients that are not in nutrient-dense forms. 100% whole grains has 16 grams of whole grains. The recommendation to consume at least half of total grains Shifting from refined to whole-grain versions of as whole grains can be met in a number of ways. commonly consumed foods—such as from white to 100% whole-wheat breads, and white to brown rice • Choose 100% whole-grain foods for at least half of all where culturally appropriate—would increase whole-grain grains consumed. The relative amount of whole grain in intakes and lower refined grain intakes to help meet the food can be inferred by the placement of the grain recommendations. Additionally, shifting to more nutrient- in the ingredient list. The whole grain should be the first dense forms of grains, such as ready-to-eat breakfast ingredient—or the second ingredient after water. For cereals with less sugar, will help meet healthy dietary foods with multiple whole-grain ingredients, they should patterns. With careful planning, limited amounts of salt, appear near the beginning of the ingredient list. butter, or sources of added sugars can be used to make Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 32 Guideline 3 some grain-based foods more palatable while staying (including lactose-free milk), yogurt, and cheese, or within calorie and nutrient limits, but most grains should from fortified soy beverages or soy yogurt. Strategies be eaten in their most nutrient-dense forms. Reducing to increase dairy intake include drinking fat-free or intakes of cakes, cookies, and other grain desserts will low-fat milk or a fortified soy beverage with meals or also support reducing refined grain intakes and staying incorporating unsweetened fat-free or low-fat yogurt into within calorie needs. breakfast or snacks. Dairy and Fortified Soy Alternatives Protein Foods Healthy dietary patterns feature dairy, including fat-free Healthy dietary patterns include a variety of protein and low-fat (1%) milk, yogurt, and cheese. Individuals foods in nutrient-dense forms. The protein foods group who are lactose intolerant can choose low-lactose and comprises a broad group of foods from both animal and lactose-free dairy products. For individuals who choose plant sources, and includes several subgroups: meats, dairy alternatives, fortified soy beverages (commonly poultry, and eggs; seafood; and nuts, seeds, and soy known as “soy milk”) and soy yogurt—which are fortified products. As noted previously, beans, peas, and lentils with calcium, vitamin A, and vitamin D—are included as may be considered a part of the protein foods group part of the dairy group because they are similar to milk as well as the vegetable group. Protein also is found and yogurt based on nutrient composition and in their in some foods from other food groups, such as dairy. use in meals. Meats and poultry vary in fat content and include both fresh and processed forms. Most intake of meats and Other products sold as “milks” but made from plants poultry should be from fresh, frozen, or canned, and (e.g., almond, rice, coconut, oat, and hemp “milks”) in lean forms (e.g., chicken breast or ground turkey) may contain calcium and be consumed as a source versus processed meats (e.g., hot dogs, sausages, ham, of calcium, but they are not included as part of the luncheon meats). dairy group because their overall nutritional content is not similar to dairy milk and fortified soy beverages. A healthy vegetarian dietary pattern can be achieved Therefore, consuming these beverages does not by incorporating protein foods from plants. Compared contribute to meeting the dairy group recommendation. with the Healthy U.S.-Style Dietary Pattern, the Healthy Vegetarian Dietary Pattern is higher in soy products About 90 percent of the U.S. population does not meet (particularly tofu and other processed soy products); dairy recommendations. The percent of Americans who beans, peas, and lentils; nuts and seeds; and whole drink milk as a beverage on a given day is 65 percent grains. Inclusion of dairy and eggs make this an among young children, 34 percent in adolescents, and example of a lacto-ovo vegetarian pattern. Meats, about 20 percent for adults. Dairy is generally consumed poultry, and seafood are not included. in forms with higher amounts of sodium (e.g., cheeses as part of mixed dishes such as sandwiches, pizza, and Seafood, which includes fish and shellfish, is a protein pasta dishes) and saturated fat (e.g., higher fat milks and foods subgroup that provides beneficial fatty acids (e.g., yogurts) and can be a source of added sugars such as eicosapentaenoic acid [EPA] and docosahexaenoic flavored milk, ice cream, and sweetened yogurts. acid [DHA]). In addition, mercury, in the form of methylmercury, is found in seafood in varying levels. Most individuals would benefit by increasing intake of The U.S. Food and Drug Administration (FDA) and the dairy in fat-free or low-fat forms, whether from milk U.S. Environmental Protection Agency (EPA) provide Page 33 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline joint advice regarding seafood consumption to limit filet, or peanuts. About the same proportion are 3 methylmercury exposure for women who might become consumed as part of a mixed dish (48%), with or are pregnant or lactating and young children.2 the largest amount from sandwiches including Seafood choices higher in EPA and DHA and lower burgers and tacos. Protein foods are generally consumed in methylmercury are encouraged. Seafood varieties in forms with higher amounts of saturated fat or sodium commonly consumed in the United States that are higher and often part of mixed dishes (e.g., sandwiches, in EPA and DHA and lower in methylmercury include casseroles, pasta dishes) that include other ingredients salmon, anchovies, sardines, Pacific oysters, and trout. that are not in nutrient-dense forms. Tilapia, shrimp, catfish, crab, and flounder are commonly consumed varieties that also are lower in methylmercury. Shifts are needed within the protein foods group to add variety to subgroup intakes. Selecting from the Intakes of protein foods are close to the target amounts, seafood subgroup or the beans, peas, and lentils but many Americans do not meet recommendations subgroup more often could help meet recommendations for specific protein subgroups. About three-quarters while still ensuring adequate protein consumption. of Americans meet or exceed the recommendation for Replacing processed or high-fat meats (e.g., hot dogs, meats, poultry, and eggs. However, almost 90 percent sausages, bacon) with seafood could help lower intake do not meet the recommendation for seafood and more of saturated fat and sodium, nutrients that are often than half do not meet the recommendation for nuts, consumed in excess of recommended limits. Replacing seeds, and soy products. Slightly less than half (43%) processed or high-fat meats with beans, peas, and lentils of all protein foods are consumed as a separate food would have similar benefits, as well as increasing dietary item, such as a chicken breast, a steak, an egg, a fish fiber, a dietary component of public health concern. 2 Available at FDA.gov/fishadvice and EPA.gov/fishadvice. Follow Food Safety Recommendations An important part of healthy eating is keeping food safe. Individuals in their own homes can help keep food safe by following safe food handling practices. Four basic food safety principles work together to reduce the risk of foodborne illness—Clean, Separate, Cook, and Chill. 1: Clean 2: Separate 3: Cook 4: Chill Wash hands and Separate raw meats Cook food to safe Refrigerate foods surfaces often. from other foods. internal temperatures. promptly. Some eating behaviors, such as consuming raw, undercooked, or unpasteurized food products, increase the risk of contracting a foodborne illness. Populations at increased risk of foodborne illness, or those preparing food for them, should use extra caution. These include women who are pregnant, young children, and older adults. Specific guidance for these life stages is discussed in subsequent chapters. Individuals with weakened immune systems are also at increased risk for foodborne illness. More information about food safety is available at: • Your Gateway to Food Safety: foodsafety.gov • USDA Food Safety Education campaigns: fsis.usda.gov/wps/portal/fsis/topics/food-safety-education/teach- others/fsis-educational-campaigns • Fight BAC!®: fightbac.org and for Babies and Toddlers: fightbac.org/kids/ • CDC 4 Steps to Food Safety: cdc.gov/foodsafety • FDA: Buy, Store & Serve Safe Food at fda.gov/food/consumers/buy-store-serve-safe-food Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 34 Guideline 3 Oils Oils are important to consider as part of a healthy dietary pattern as they provide essential fatty acids. Commonly consumed oils include canola, corn, olive, peanut, safflower, soybean, and sunflower oils. Oils also are naturally present in nuts, seeds, seafood, olives, and avocados. The fat in some tropical plants, such as coconut oil, palm kernel oil, and palm oil, are not included in the oils category because they contain a higher percentage of saturated fat than do other oils. Strategies to shift intake include cooking with vegetable oil in place of fats high in saturated fat, including butter, shortening, lard, or coconut oil. However, some foods, such as desserts and sweet snacks, that are prepared with oils instead of fats high in saturated fat are still high in added sugars, and are thus not a nutrient-dense food choice. Beverages When choosing beverages in a healthy dietary pattern, both the calories and nutrients that they provide are important considerations. Beverages that are calorie-free—especially water—or that contribute beneficial nutrients, such as fat-free and low-fat milk and 100% juice, should be the primary beverages consumed. Coffee, tea, and flavored waters also are options, but the most nutrient-dense options for these beverages include little, if any, sweeteners or cream. For discussion on sugar-sweetened beverages or alcohol, see “Added Sugars” and “Alcoholic Beverages,” respectively. CAFFEINE Caffeine is a dietary component that functions in the body as a stimulant. Most intake of caffeine in the United States comes from coffee, tea, and soda. Caffeine is a substance that is Generally Recognized as Safe (GRAS) in cola-type beverages by the Food and Drug Administration (FDA). For healthy adults, the FDA has cited 400 milligrams per day of caffeine as an amount not generally associated with dangerous, negative effects. Additional information related to caffeine is provided in subsequent life stage chapters. Page 35 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline Beverages and Added Sugars 3 Examples of beverages that often have added sugars are regular soda (i.e., not sugar-free), fruit drinks, sports drinks, energy drinks, sweetened waters, and coffee and tea beverages with added sugars. Coffee and tea beverages from restaurants can contain many extra calories because of the addition of cream or milk and sugar. See below for examples of 12-ounce beverages showing the added sugars and total calories. Drink (12-ounce Total Added Added Calories Sugars Sugars serving) (Grams) (Tea- spoons) Plain Water 0 0 0 Unsweetened Tea 0 0 0 Sports Drinks 97 20 5 Cafe Mocha 290 21 5 Chai Tea Latte 180 23 5 ½ Dietary Components of Public Health Concern for Underconsumption Sweetened Tea 115 29 7 Current inadequate intake of nutrient-dense foods Regular Soda 156 37 9 and beverages across food groups has resulted in underconsumption of some nutrients and dietary Lemonade 171 43 10 components. Calcium, potassium, dietary fiber, and Fruit Drinks 238 59 14 vitamin D are considered dietary components of Data Source: U.S. Department of Agriculture, Agricultural public health concern for the general U.S. population Research Service. 2020. USDA Food and Nutrient Database for because low intakes are associated with health Dietary Studies and USDA Food Patterns Equivalents Database concerns. Additional dietary components that are 2017-2018. Food Surveys Research Group Home Page, ars.usda. gov/nea/bhnrc/fsrg. underconsumed during specific life stages are highlighted in subsequent chapters. If a healthy dietary pattern is consumed, amounts of calcium, potassium, and dietary fiber can meet recommendations. Individuals should be encouraged to make shifts to increase the intake of vegetables, fruits, beans, whole grains, and dairy to move intakes of these underconsumed dietary components closer to recommendations. In some cases, fortified foods and dietary supplements may be useful in providing one or more nutrients that otherwise may be consumed in less than recommended amounts. Vitamin D recommendations are harder to achieve through natural sources from diet alone and would require consuming foods and beverages fortified with vitamin D. In many cases, taking a vitamin D supplement may be appropriate especially when sunlight exposure is limited due to climate or the use of sunscreen. Lists of dietary sources of calcium, potassium, dietary fiber, and vitamin D are available at DietaryGuidelines.gov. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 36 Guideline 4 Guideline 4 Limit Foods and Beverages Higher in Added Sugars, Saturated Fat, and Sodium, and Limit Alcoholic Beverages A healthy dietary pattern is designed to meet food group and nutrient recommendations while staying within calorie needs. Additionally, a healthy dietary pattern is designed to not exceed the Tolerable Upper Intake Level (UL) or Chronic Disease Risk Reduction (CDRR) level for nutrients. To achieve these goals, the pattern is based on consuming foods and beverages in their nutrient-dense forms—forms with the least amounts of added sugars, saturated fat, and sodium. Most of the calories a person needs to eat each day—around 85 percent—are needed to meet food group recommendations healthfully, in nutrient-dense forms. The remaining calories—around 15 percent—are calories available for other uses, including for added sugars or saturated fat beyond the small amounts found in nutrient- dense forms of foods and beverages within the pattern, to consume more than the recommended amount of a food group, or for alcoholic beverages. This equates to 250 to 350 remaining calories for calorie patterns appropriate for most Americans. Figure 1-7 The 85-15 Guide: Percentage of Calories Needed To Meet Food Group Needs With Nutrient-Dense Choices and Percentage Left for Other Uses Total Calories Per Day 85% of calories are needed per day to meet of remaining food group recommendations healthfully, in nutrient-dense forms 15% calories are available for other uses (including added sugars and saturated fat) Page 37 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 4 Figure 1-8 Making Nutrient-Dense Choices: One Meal At a Time Slight changes to individual parts of a meal can make a big difference. This meal shows examples of small shifts to more nutrient-dense choices that significantly improve the nutritional profile of the meal overall while delivering on taste and satisfaction. Typical Burrito Bowl Nutrient-Dense Burrito Bowl Total Calories = 1,120 Total Calories = 715 White rice (1½ cups) Brown rice (1 cup) + Romaine lettuce (½ cup) Black beans (⅓ cup) Black beans, reduced sodium (⅓ cup) Chicken cooked with sauce (2 ounces) Grilled chicken with spice rub (2 ounces) No grilled vegetables Added grilled vegetables (⅓ cup) Guacamole (½ cup) Sliced avocado (5 slices) Jarred salsa (¼ cup) Fresh salsa/pico de gallo (¼ cup) Sour cream (¼ cup) No sour cream Cheese (⅓ cup) Reduced-fat cheese (⅓ cup) Jalapeño (5 slices) Jalapeño (5 slices) Iced tea with sugar (16 ounces) Iced tea, no sugar (16 ounces) Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 38 Guideline 4 Figure 1-9 Making Healthy Choices: One Day At a Time Small changes to more nutrient-dense, single food and beverage choices that, when combined, become a nutrient- dense meal, can lead to a whole day made up of nutrient-dense meals and snacks. The following example, which comes in under 2,000 calories, shows how people can make thoughtful choices that meet their food group needs, stay within limits, and, importantly, that they can enjoy. BREAKFAST Total calories: 375 • Banana-Walnut Overnight Oats (350 calories): » Oats (½ cup raw) » Low-fat, plain Greek yogurt (¼ cup) » Fat-free milk (¼ cup) » Banana (½ banana) » Walnuts (4 nuts) » Honey (1 tsp) • Coffee (25 calories): » Coffee (1 cup) » Fat-free milk (¼ cup) LUNCH Total calories: 715 • Chicken Burrito Bowl (710 calories) » Brown rice (1 cup) » Romaine lettuce (½ cup) » Black beans, low sodium (⅓ cup) » Grilled chicken with spice rub (2 ounces) » Grilled vegetables (⅓ cup) » Sliced avocado (5 slices) » Fresh salsa/pico de gallo (¼ cup) » Reduced-fat cheese (⅓ cup) » Jalapeño (5 slices) • Iced Tea, No Sugar (16 ounces) (5 calories) Page 39 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 4 The nutrient density and healthfulness of what people eat and drink often is determined ultimately by how a food item, dish or meal is prepared, at home and away from home, or produced by a manufacturer. Based on the U.S. food supply and marketplace, the examples of healthy dietary patterns in this edition are achievable through thoughtful, informed choices one decision, one meal, one day at a time—and consistently over time. DINNER Total calories: 585 • Oven-Roasted Tilapia and Vegetables With Pasta (510 calories) » Tilapia (4 ounces) » Broccoli (½ cup) » Carrots (⅓ cup) » Summer squash (⅓ cup) » Pasta (¾ cup cooked) » Garlic-herb oil (1 Tbsp) • Orange (1 medium) (75 calories) • Sparkling Water (8 ounces) (0 calories) SNACKS Total calories: 300 • Air-Popped Popcorn (2 cups) (60 calories) • Yogurt and Peaches (240 calories) » Plain, low-fat Greek yogurt (1 cup yogurt) » Canned peaches packed in 100% juice (½ cup) TOTAL CALORIES FOR THE DAY: 2,000 Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 40 Guideline 4 As such, a nutrient-dense diet, where most nutritional to support a healthy dietary pattern over needs are met by 85% of the calories consumed, offers time. Additionally, if alcoholic beverages a small amount of leeway to add minimal amounts are consumed, intakes should be within the of added sugars or saturated fat to the diet. For limits described in this chapter, and calories should example, one way to use remaining calories is to add be accounted for to keep total calorie intake at an small amounts of added sugars or saturated fat to appropriate level. some nutrient-dense foods to help make some foods more palatable while working towards meeting food Added Sugars group recommendations—for example, oatmeal with a A healthy dietary pattern limits added sugars to less small amount of brown sugar or vegetables prepared than 10 percent of calories per day. Added sugars with small amounts of butter. However, to achieve a can help with preservation; contribute to functional healthy dietary pattern, all (or mostly all) food group attributes such as viscosity, texture, body, color, and recommendations should be met with foods and browning capability, and/or help improve the palatability beverages that are in nutrient-dense forms. of some nutrient-dense foods. In fact, the nutrient- dense choices included in the Healthy U.S.-Style Dietary A healthy dietary pattern has little room available for Pattern are based on availability in the U.S. food supply foods and beverages high in added sugars, saturated and include 17-50 calories from added sugars, or fat, and/or sodium. Intakes of foods and beverages 1.5-2 percent of total calories. high in these components should be limited. These foods and beverages should be occasional choices— Foods and beverages high in calories from added sugars consumed in small portions. should be limited to help achieve healthy dietary patterns within calorie limits. When added sugars in foods and While intakes of added sugars, saturated fat, and beverages exceed 10 percent of calories, a healthy sodium should be limited, the guidance below is dietary pattern within calories limits is very difficult to intended to allow programs and individuals to have achieve. Most Americans have less than 8 percent of some flexibility to choose a healthy dietary pattern calories available for added sugars, including the added within calorie limits that fits personal preferences and sugars inherent to a healthy dietary pattern. The limit for cultural traditions—and allows day-to-day flexibility added sugars is based on the following assumptions: Page 41 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 4 • Most calorie levels have less than 15 percent less than the allotted amount of calories for saturated of calories remaining after meeting food group fat, 10 percent of added sugars may fit in a healthy recommendations through nutrient-dense choices. dietary pattern. • Approximately half of remaining calories are Added sugars account on average for almost 270 consumed as saturated fat and half consumed as calories—or more than 13 percent of total calories—per added sugars. day in the U.S. population. As shown in Figure 1-10, the major sources of added sugars in typical U.S. diets • Total saturated fat intakes meet the recommendation are sugar-sweetened beverages, desserts and sweet for less than 10 percent of total calorie intake. snacks, sweetened coffee and tea, and candy. Together, these food categories make up more than half of the • No alcoholic beverages are consumed. intake of all added sugars while contributing very little to food group recommendations. • Overall calorie intake does not exceed intake needs to maintain or achieve a healthy weight. Individuals have many potential options for reducing the intake of added sugars, including reducing the intake Based on the assumptions above, an individual who of major sources of added sugars. Strategies include needs 2,000 calories per day (based on age, sex, reducing portions, consuming these items less often, and physical activity level) has less than 7 percent and selecting options low in added sugars. For those of calories available for added sugars. Individuals with a weight loss goal, limiting intake of foods and who need 2,800 calories per day or less have less beverages high in added sugars is a strategy to help than 8 percent of calories available for added sugars. reduce calorie intake. Individuals who need more than 3,000 calories may have a total of 9 to 10 percent of calories available for It should be noted that replacing added sugars with added sugars. In this portion of the population that low- and no-calorie sweeteners may reduce calorie requires high calorie intake, an upper limit of 10 percent intake in the short-term and aid in weight management, of calories from added sugars may be consumed while yet questions remain about their effectiveness as a still meeting food group recommendations in nutrient- long-term weight management strategy. For additional dense forms. The 10 percent added sugar limit allows information about high-intensity sweeteners permitted for flexibility in food choices over time but also requires for use in food in the United States, see fda.gov/food/ careful planning. For example, if one chooses to eat food-additives-petitions/high-intensity-sweeteners. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 42 Guideline 4 Figure 1-10 Top Sources and Average Intakes of Added Sugars: U�S� Population Ages 1 and Older Breakfast Cereals & Bars Candy & 7% Sugars Higher Fat Milk & Yogurt 9% 4% Added Sugars Average Intake: 266 kcal/day Sugar-Sweetened Desserts & Beverages Sweet Snacks 24% 19% Other Sources Coffee & Tea Sandwiches 19% 7% 11% Within Sugar-Sweetened Within Desserts & Beverages: Sweet Snacks: Other Sources Doughnuts, 1 Other Sources Sweet Rolls, % 1 & Pastries % 3% Soft Drinks CCooookkiieess && IIccee C Crreeaam & & Fruit Drinks BBrroowwnniieess FroFzroezne Dnairy 16% 5% DairDye Dsessesrtesrts 6 S %% 5%% CCaakkeess && PPiieess2% Sport & Energy Drinks 4%% Data Source: Analysis of What We Eat in America, NHANES, 2013-2016, ages 1 and older, 2 days dietary intake data, weighted. Page 43 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 4 Saturated Fat Strategies to lower saturated fat intake include reducing For those 2 years and older, intake of saturated fat intakes of dessert and sweet snacks by consuming should be limited to less than 10 percent of calories per smaller portion sizes and eating these foods less often. day by replacing them with unsaturated fats, particularly Additional strategies include reading food labels to polyunsaturated fats. Although some saturated fat is choose packaged foods lower in saturated fats and inherent in foods (e.g., high-fat meat), some sources are choosing lower fat forms of foods and beverages added (e.g., butter on toast). Similar to added sugars, (e.g., fat-free or low-fat milk instead of 2 percent or some of the nutrient-dense choices included in the whole milk; lean rather than fatty cuts of meat). When Healthy U.S.-Style Dietary Pattern include saturated fat. cooking and purchasing meals, select lean meat and Approximately 5 percent of total calories inherent to the lower fat cheese in place of high-fat meats and regular nutrient-dense foods in the Healthy U.S.-Style Dietary cheese—or replace them with ingredients with oils, Pattern are from saturated fat from sources such as such as nuts, seeds, or avocado. Cook and purchase lean meat, poultry, and eggs; nuts and seeds; grains; products made with oils higher in polyunsaturated and and saturated fatty acids in oils. As such, there is little monounsaturated fat (e.g., canola, corn, olive, peanut, room to include additional saturated fat in a healthy safflower, soybean, and sunflower) rather than butter, dietary pattern while staying within limits for saturated shortening, or coconut or palm oils. fat and total calories. A note on trans fats and dietary cholesterol: The Current average intakes of saturated fat are 11 percent National Academies recommends that trans fat of calories. Only 23 percent of individuals consume and dietary cholesterol consumption to be as low amounts of saturated fat consistent with the limit of as possible without compromising the nutritional less than 10 percent of calories. The main sources adequacy of the diet. The USDA Dietary Patterns are of saturated fat in the U.S. diet include sandwiches, limited in trans fats and low in dietary cholesterol. including burgers, tacos, and burritos; desserts and Cholesterol and a small amount of trans fat occur sweet snacks; and rice, pasta, and other grain-based naturally in some animal source foods. As of June mixed dishes (Figure 1-11). Saturated fat is commonly 2018, partially hydrogenated oils (PHOs), the major found in higher amounts in high-fat meat, full-fat dairy source of artificial trans fat in the food supply, are no products (e.g., whole milk, ice cream, cheese), butter, longer Generally Recognized as Safe (GRAS). Therefore, coconut oil, and palm kernel and palm oil. PHOs are no longer added to foods. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 44 Guideline 4 Figure 1-11 Top Sources and Average Intakes of Saturated Fat: U�S� Population Ages 1 and Older Eggs 3% Pizza Poultry, Excluding Deli & 5% Higher Fat Meat, Poultry & Mixed Dishes Milk & Yogurt Seafood Mixed Dishes 4% 6% 4% Spreads Saturated Fat Average Intake: 3% 239 calories/day Sandwiches Desserts & Sweet Snacks 19 % 11% Meats, Excluding Deli & Mixed Dishes 3% Rice, Pasta & Other Chips, Crackers Cheese Grain-Based & Savory 4% Vegetables, Mixed Dishes Snacks Excluding Starchy 7% 4 4% % Other Sources Starchy Vegetables 20% 3% Within Within Desserts & Sandwiches: Sweet Snacks: Breakfast Sandwiches Chicken & Turkey Cakes & Pies 2 Sandwiches % 3% 2% Cookies & Brownies Other Burritos & Sandwiches Tacos Ice Cream & 6 Frozen Dairy % % 4% Desserts 4% 3 Burgers 2% 1% 3% Hotdog Doughnuts, Sandwiches Sweet Rolls & Pastries Data Source: Analysis of What We Eat in America, NHANES, 2013-2016, ages 1 and older, 2 days dietary intake data, weighted. Page 45 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 4 Sodium Sodium is an essential nutrient primarily consumed as salt (sodium chloride). Healthy eating patterns limit sodium to the Chronic Disease Risk Reduction (CDRR) levels defined by the National Academies— 1,200 mg/day for ages 1 through 3; 1,500 mg/day for ages 4 through 8; 1,800 mg/day for ages 9 through 13; and 2,300 mg/day for all other age groups. The CDRR for sodium was established using evidence of the benefit of reducing sodium intake on cardiovascular risk and hypertension risk. As a food ingredient, sodium is used in multiple ways, including curing meat, baking, as a thickening agent, as a flavor enhancer, as a preservative, and to retain moisture. The nutrient-dense choices in the Healthy U.S.-Style Dietary Pattern provide approximately 60-100 percent of the age-specific CDRR for sodium across calorie levels with amounts ranging from about 1,000 to 2,200 mg. For most calorie levels and at most ages, there is very little room for food choices that are high in sodium. Average intakes of sodium are high across the U.S. population compared to the CDRRs. Average intakes for those ages 1 and older is 3,393 milligrams per day, with a range of about 2,000 to 5,000 mg per day. Only a small proportion of total sodium intake is from sodium inherent in foods or from salt added in home cooking or at the table. Most sodium consumed in the United States comes from salt added during commercial food processing and preparation, including foods prepared at restaurants. Sodium is found in foods from almost all food categories across the food supply (Figure 1-12), including mixed dishes such as sandwiches, burgers, and tacos; rice, pasta, and grain dishes; pizza; meat, poultry, and seafood dishes; and soups. Calorie intake is highly associated with sodium intake (i.e., the more foods and beverages people consume, the more sodium they tend to consume). Because sodium is found in so many foods, multiple strategies should be implemented to reduce sodium intake to the recommended limits. Careful choices are needed in all food groups to reduce intake. Strategies to lower sodium intake include cooking at home more often; using the Nutrition Facts label to choose products with less sodium, reduced sodium, or no-salt-added, etc.; and flavoring foods with herbs and spices instead of salt based on personal and cultural foodways. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 46 Guideline 4 Figure 1-12 Top Sources and Average Intakes of Sodium: U�S� Population Ages 1 and Older Yeast Breads & Tortillas Deli & Cured Poultry, Excluding Deli & 3 Products % Starchy Mixed Dishes 3% Vegetables 4% 5% Pizza Chips, Crackers 5 & Savory Snacks % Eggs Sodium 4% Average Intake: 3% Breakfast Cereals & Bars 3,393 mg/day Sandwiches Rice, Pasta & Other Grain-Based 21 Mixed Dishes 3% % 8% Desserts & Vegetables, Sweet Snacks Excluding Starchy Soups 4% 4% Meat, Poultry & Seafood Mixed Dishes 7% Other Sources 5% Condiments 19% & Gravies 3% Within Within Rice, Pasta & Sandwiches: Other Grain-Based Hotdog Mixed Dishes: Sandwiches 2 Breakfast % Sandwiches 2 Other Sources % 3 Other % Mexican Dishes, Other Chicken & Turkey Excludes Sandwiches Sandwiches Tacos & Burritos 7 4% % 3% 1% Other Sources 2% 1% 1% 3% Rice Mixed Dishes Pasta Mixed Dishes, PBJ Excludes Sandwiches Burritos & Macaroni & Cheese Tacos Data Source: Analysis of What We Eat in America, NHANES, 2013-2016, ages 1 and older, 2 days dietary intake data, weighted. Page 47 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 4 Nutrition Facts Label The Nutrition Facts label on packaged foods and beverages is a tool for making informed and healthy food choices. For the first time in more than 20 years, the U.S. Food and Drug Administration (FDA) has updated the Nutrition Facts label. There are a number of key changes to the label including: The serving size information is now in Along with the updated large, bold font and has been updated design, the Nutrition Facts to better reflect the amount that people typically eat and drink. label helps support healthy dietary patterns by providing Calories are displayed in larger, bolder font. information on nutrients of Some Daily Values have been updated. public health concern—dietary The percent Daily Value (%DV) shows fiber, vitamin D, calcium, how much a nutrient in a serving of food iron, and potassium—and contributes to a total daily diet. Five on dietary components to percent or less is low; 20 percent or more is high. limit, such as added sugars, saturated fat, and sodium. More information on the Nutrition Facts label is Added sugars, vitamin D, and available at: fda.gov/ potassium are now listed. NewNutritionFactsLabel. Menu Nutrition Labeling Americans eat and drink about one-third of their calories from foods prepared away from home. Usually, these foods provide more calories, saturated fat, and sodium than meals prepared at home. To help individuals make informed and healthy decisions, many food establishments and chain restaurants list calories in foods or beverages on menus or menu boards and additional nutrition information is available upon request. More information is available at fda.gov/CaloriesOnTheMenu. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 48 Guideline 4 Alcoholic Beverages the typical adult female in about 2 hours, should The Dietary Guidelines does not recommend that be avoided. Emerging evidence suggests that individuals who do not drink alcohol start drinking for any even drinking within the recommended limits reason. There are also some people who should not drink may increase the overall risk of death from various at all, such as if they are pregnant or might be pregnant; causes, such as from several types of cancer and some under the legal age for drinking; if they have certain forms of cardiovascular disease. Alcohol has been medical conditions or are taking certain medications that found to increase risk for cancer, and for some types of can interact with alcohol; and if they are recovering from cancer, the risk increases even at low levels of alcohol an alcohol use disorder or if they are unable to control consumption (less than 1 drink in a day). Caution, the amount they drink. If adults age 21 years and older therefore, is recommended. choose to drink alcoholic beverages, drinking less is better for health than drinking more. Alcoholic beverages are not a component of the USDA Dietary Patterns. The amount of alcohol and Evidence indicates that, among those who drink, higher calories in beverages varies and should be accounted average alcohol consumption is associated with an for within the limits of healthy dietary patterns, so increased risk of death from all causes compared with that calorie limits are not exceeded (see “Calories in lower average alcohol consumption. Alcohol misuse Alcoholic Beverages”). or consuming alcohol in excess of recommendations increases risk of several other conditions such as liver Approximately 60 percent of adults report alcoholic disease, cardiovascular disease, injuries, and alcohol beverage consumption in the past month. Of those, use disorders. approximately 30 percent binge drink, sometimes multiple times per month. During days when men and For the purposes of evaluating amounts of alcohol that women consume alcohol, their consumption typically may be consumed, the Dietary Guidelines defines drink exceeds current guidance. Among adults, including equivalents. One alcoholic drink equivalent is defined as those who do not drink, alcoholic beverages contribute containing 14 grams (0.6 fl oz) of pure alcohol. approximately 5 percent of calorie intake (3 to 4% of The following count as one alcoholic drink equivalent: calories for women and 5 to 7% for men); this translates 12 fluid ounces of regular beer (5% alcohol), 5 fluid into approximately 9 percent of calories among those ounces of wine (12% alcohol), or 1.5 fluid ounces of who drink. As such, among those who drink, alcoholic 80 proof distilled spirits (40% alcohol). To help Americans beverages, alone, account for most of the calories that move toward a healthy dietary pattern and minimize remain after meeting food group recommendations risks associated with drinking, adults of legal drinking in nutrient-dense forms—leaving very few calories for age can choose not to drink or to drink in moderation added sugars or saturated fat. by limiting intakes to 2 drinks or less in a day for men and 1 drink or less in a day for women, on days when Adults who choose to drink, and are not among the alcohol is consumed. This is not intended as an average individuals listed above who should not drink, are over several days, but rather the amount consumed on encouraged to limit daily intakes to align with the Dietary any single day. Binge drinking,3 defined as 5 or more Guidelines—and to consider calories from alcoholic drinks for the typical adult male or 4 or more drinks for beverages so as not to exceed daily calorie limits. 3 More information is available at niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking. Calories in Alcoholic Beverages Alcoholic beverages supply calories but few nutrients, 12 fluid ounces of regular 5 fluid ounces of wine and calories from alcoholic beverages should be beer (5% alcohol): (12% alcohol): about 150 calories about 120 calories accounted for to keep total calorie intake at an appropriate level. Alcoholic beverages may contain 1.5 fluid ounces of 7 fluid ounces of a calories from both alcohol and other ingredients, such 80 proof distilled spirits rum (40% alcohol) and as soda, juice, and added sugars. It is important to (40% alcohol): about 100 calories cola: about 190 calories consider ingredients and portion size. The range of More information on calories in alcoholic beverages is calories in cocktails varies widely depending on serving available at rethinkingdrinking.niaaa.nih.gov/Tools/ size and ingredients. Examples of calories contained in Calculators/calorie-calculator.aspx. alcoholic beverages include: Page 49 | Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan Guideline 4 Support Healthy types of stores in an area), ability to prepare one’s own meals or eat independently, and the Dietary Patterns for availability of personal or public transportation. The underlying socioeconomic characteristics of a All Americans neighborhood also may influence an individual’s ability to access foods to support healthy eating patterns. Everyone has a role to play to support access to healthy foods and beverages in multiple settings nationwide In 2019, 10.5 percent of households were food insecure where people live, learn, work, play, and gather. Having at least some time during the year. Food insecurity access to healthy, safe, and affordable food is crucial occurs when access to nutritionally adequate and for an individual to achieve a healthy dietary pattern. safe food is limited or uncertain. Food insecurity can Concerted efforts within communities, businesses be temporary or persist over time, preventing and industries, organizations, government, and other individuals and families from following a healthy segments of society are needed to support individuals dietary pattern that aligns with the Dietary Guidelines. and families in making lifestyle choices that align with The prevalence of food insecurity typically rises during the Dietary Guidelines. times of economic downturn as households experience greater hardship. Government and nongovernment Food manufacturers and retail establishments can nutrition assistance programs help alleviate food support Americans in achieving a healthy dietary insecurity and play an essential role by providing food, pattern by providing healthy options in all the places meals, and educational resources so that participants where foods and beverages are purchased. During can make healthy food choices within their budget. the past few decades, food products and menus have Chapters 2, 3, 4, 5, and 6 highlight examples of these evolved substantially in response to consumer demand resources at each life stage. and public health concerns. Food reformulation and menu and retail modification opportunities include As discussed in subsequent chapters, everyone has offering more vegetables, fruits, whole grains, low-fat an important role in leading disease prevention efforts and fat-free dairy, and a greater variety of protein foods within their organizations and communities to make that are nutrient dense, while also reducing sodium healthy eating an organizational and societal norm. and added sugars, reducing saturated fat and replacing Changes at multiple levels of society are needed, and it with unsaturated fats, and reducing added refined these changes, in combination and over time, can starches. Portion sizes also can be reduced to help have a meaningful impact on the health of current and individuals make choices that better fit within their future generations. calorie needs. Food manufacturers are encouraged to consider the entire composition of the food or beverage, and not just individual nutrients or ingredients when developing or reformulating products. Looking Toward Similarly, when developing or modifying menus, the Life Stages establishments can consider the range of offerings both within and across food groups and other dietary This chapter has provided guidance about the components to determine whether the healthy options fundamentals of a healthy dietary pattern. These offered reflect the proportions in healthy dietary fundamentals are remarkably consistent across life patterns. In taking these actions, care should be taken stages, even though each stage also has its own to assess any potential unintended consequences so specific nutrition considerations. The following chapters that as changes are made to better align with the Dietary build on this chapter and take a closer look at each of Guidelines, undesirable changes are not introduced. For the life stages: Chapter 2 provides a focused discussion example, a change made to reduce the amount of added of the unique nutritional needs of infants and toddlers. sugars in a product should not come at the expense of Chapters 3, 4, 5, and 6 present recommended dietary increasing the amount of saturated fat or sodium. patterns, describe current nutrition intakes, and provide tailored nutrition information specific to children and Food access is influenced by diverse factors, such as adolescents, adults, women who are pregnant or proximity to food retail outlets (e.g., the number and lactating, and older adults, respectively. Dietary Guidelines for Americans, 2020-2025 | Chapter 1: Nutrition and Health Across the Lifespan | Page 50 BIRTH THROUGH 23 MONTHS Page 51 | Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers BIRTH THROUGH 23 MONTHS CHAPTER2 Infants and Toddlers Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 52 BIRTH THROUGH 23 MONTHS Introduction Key Recommendations • For about the first 6 months The time from birth until a child’s of life, exclusively feed infants human milk. Continue to feed second birthday is a critically infants human milk through at least the first year of life, and important period for proper growth longer if desired. Feed infants iron-fortified infant formula during and development. It also is key for the first year of life when human milk is unavailable. establishing healthy dietary patterns that may influence the trajectory of • Provide infants with supplemental vitamin D beginning soon eating behaviors and health throughout after birth. the life course. During this period, • At about 6 months, introduce infants to nutrient-dense nutrients critical for brain development complementary foods. and growth must be provided in • Introduce infants to potentially allergenic foods along with other adequate amounts. Children in this complementary foods. age group consume small quantities • Encourage infants and toddlers to consume a variety of foods from of foods, so it’s important to make all food groups. Include foods rich in iron and zinc, particularly for every bite count! infants fed human milk. • Avoid foods and beverages with added sugars. • Limit foods and beverages higher in sodium. • As infants wean from human milk or infant formula, transition to a healthy dietary pattern. Page 53 | Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers BIRTH THROUGH 23 MONTHS Human milk feeding alone is the ideal form of nutrition from birth through about age 6 months. Human milk provides necessary nutrients, protective factors against disease, and other unique immunological benefits. If human milk is unavailable, infants should be fed an iron- fortified commercial infant formula. Once an infant is developmentally ready, foods and beverages should be introduced to complement human milk feeding. These complementary foods and beverages are essential to meet the nutrient requirements of infants starting at about age 6 months and should be selected carefully to help meet these needs. As an infant becomes a toddler, and learns to eat a variety of foods, flavors, and textures, the goal of complementary feeding becomes establishing a healthy dietary pattern and transitioning to immunologic properties that support infant health and a healthy family diet by age 2. growth and development. U.S. data show that about 84 percent of infants born in 2017 were ever fed human milk, with only 25 percent fed Putting the Key human milk exclusively through age 6 months, and 35 percent continuing to be fed any human milk at age 12 Recommendations months. Nearly one-quarter of infants were fed some human milk beyond age 12 months, with about 15 percent Into Action of toddlers being fed human milk at age 18 months. Families may have a number of reasons for not having Feed Infants Human Milk for the First human milk for their infant. For example, a family may 6 Months, If Possible choose not to breastfeed, a child may be adopted, or the Exclusive human milk feeding is one of the best ways to mother may be unable to produce a full milk supply or start an infant off on the path of lifelong healthy nutrition. may be unable to pump and store milk safely due to family Exclusive human milk feeding, commonly referred to as or workplace pressures. If human milk is unavailable, exclusive breastfeeding, refers to an infant consuming infants should be fed an iron-fortified commercial infant only human milk, and not in combination with infant formula (i.e., labeled “with iron”) regulated by the U.S. formula and/or complementary foods or beverages Food and Drug Administration (FDA), which is based on (including water), except for medications or vitamin and standards that ensure nutrient content and safety. Infant mineral supplementation. formulas are designed to meet the nutritional needs of infants and are not needed beyond age 12 months. It is Human milk can support an infant’s nutrient needs for important to take precautions to ensure that expressed about the first 6 months of life, with the exception of human milk and prepared infant formula are handled vitamin D and potentially iron. In addition to nutrients, and stored safely (see “Proper Handling and Storage of human milk includes bioactive substances and Human Milk and Infant Formula”). Donor Human Milk If families do not have sufficient human milk for their infant but want to feed their infant human milk, they may look for alternative ways to obtain it. It is important for the family to obtain pasteurized donor human milk from a source, such as an accredited human milk bank, that has screened its donors and taken appropriate safety precautions. When human milk is obtained directly from individuals or through the internet, the donor is unlikely to have been screened for infectious diseases, and it is unknown whether the human milk has been collected or stored in a way to reduce possible safety risks to the baby. More information is available at fda.gov/science-research/ pediatrics/use-donor-human-milk. Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 54 BIRTH THROUGH 23 MONTHS Proper Handling and Storage of Human Milk and Infant Formula • Wash hands thoroughly before expressing human milk or preparing to feed human milk or infant formula. • If expressing human milk, ensure pump parts are thoroughly cleaned before use. • If preparing powdered infant formula, use a safe water source and follow instructions on the label. • Refrigerate freshly expressed human milk within 4 hours for up to 4 days. Previously frozen and thawed human milk should be used within 24 hours. Thawed human milk should never be refrozen. Refrigerate prepared infant formula for up to 24 hours. • Do not use a microwave to warm human milk or infant formula. Warm safely by placing the sealed container of human milk or infant formula in a bowl of warm water or under warm, running tap water. • Once it has been offered to the infant, use or discard leftovers quickly (within 2 hours for human milk or 1 hour for infant formula). • Thoroughly wash all infant feeding items, such as bottles and nipples. Consider sanitizing feeding items for infants younger than 3 months of age, infants born prematurely, or infants with a compromised immune system. More information on storing and handling human milk is available at cdc.gov/ breastfeeding/recommendations/handling_breastmilk.htm. More information on storing and preparing powdered infant formula is available at cdc.gov/ nutrition/downloads/prepare-store-powered-infant-formula-508.pdf. Additional information on how to clean, sanitize, and store infant feeding items is available at cdc.gov/healthywater/hygiene/healthychildcare/infantfeeding/ cleansanitize.html. Page 55 | Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers BIRTH THROUGH 23 MONTHS Homemade infant formulas and those that are improperly and illegally imported into the United States without mandated FDA review and supervision should not be used. Toddler milks or toddler formulas should not be fed to infants, as they are not designed to meet the nutritional needs of infants. Supplemental Vitamin B12 Provide Infants Supplemental Vitamin D Beginning Human milk has sufficient vitamin Soon After Birth B12 to meet infant needs unless All infants who are fed human milk exclusively or who receive both the mother’s vitamin B12 status human milk and infant formula (mixed fed) will need a vitamin D is inadequate. This can occur for supplement of 400 IU per day beginning soon after birth. Infant formula different reasons, including when is fortified with vitamin D, thus, when an infant is receiving full feeds the mother eats a strictly vegan of infant formula, vitamin D supplementation is not needed. Families diet without any animal source who do not wish to provide a supplement directly to their infant should foods. When the mother is at risk discuss with a healthcare provider the risks and benefits of maternal of vitamin B12 deficiency, human high dose supplementation options. Even when consuming a varied milk may not provide sufficient diet, achieving adequate vitamin D from foods and beverages (natural vitamin B12. In these cases, the sources) alone is challenging, suggesting that young children may mother and/or infant fed human need to continue taking a vitamin D supplement after age 12 months. milk may require a vitamin B12 Parents, caregivers, and guardians should consult with a healthcare supplement. Parents, caregivers, provider to determine how long supplementation is necessary. and guardians should consult with a healthcare provider to determine Introduce Infants To Nutrient-Dense Complementary whether supplementation is Foods at About 6 Months Old necessary. At about age 6 months, infants should be introduced to nutrient-dense, developmentally appropriate foods to complement human milk or infant formula feedings. Some infants may show developmental signs of readiness before age 6 months (see “Developmental Readiness for Beginning to Eat Solid Foods”), but introducing complementary foods before age 4 months is not recommended. Waiting until after age 6 months to introduce foods also is not recommended. Starting around that time, complementary foods are necessary to ensure adequate nutrition and exposure to flavors, textures, and different types of foods. Infants should be given age- and developmentally appropriate foods to help prevent choking. It is important to introduce potentially allergenic foods along with other complementary foods. For infants fed human milk, it is particularly important to include complementary foods that are rich in iron and zinc when starting complementary foods (see Appendix 1: Nutritional Goals for Age-Sex Groups). About one-third (32%) of infants in the United States are introduced to complementary foods and beverages before age 4 months, highlighting the importance of providing guidance and support to parents, guardians, and caregivers on the timing of introduction to complementary foods. Early introduction of complementary foods and beverages is higher among infants receiving infant formula (42%) or a combination of infant formula and human milk (32%) than among infants exclusively fed human milk (19%). Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 56 BIRTH THROUGH 23 MONTHS Developmental Readiness for Beginning To Eat Solid Foods The age at which infants reach different developmental stages will vary. Typically between age 4 and 6 months, infants develop the gross motor, oral, and fine motor skills necessary to begin to eat complementary foods. As an infant’s oral skills develop, the thickness and texture of foods can gradually be varied. Signs that an infant is ready for complementary foods include: • Being able to control head and neck. • Sitting up alone or with support. • Bringing objects to the mouth. • Trying to grasp small objects, such as toys or food. • Swallowing food rather than pushing it back out onto the chin. Infants and young children should be given age- and developmentally appropriate foods to help prevent choking. Foods such as hot dogs, candy, nuts and seeds, raw carrots, grapes, popcorn, and chunks of peanut butter are some of the foods that can be a choking risk for young children. Parents, guardians, and caregivers are encouraged to take steps to decrease choking risks, including: • Offering foods in the appropriate size, consistency, and shape that will allow an infant or young child to eat and swallow easily. • Making sure the infant or young child is sitting up in a high chair or other safe, supervised place. • Ensuring an adult is supervising feeding during mealtimes. • Not putting infant cereal or other solid foods in an infant’s bottle. This could increase the risk of choking and will not make the infant sleep longer. More information on foods that can present choking hazards is available from USDA at wicworks.fns. usda.gov/resources/reducing-risk-choking-young- children-mealtimes. Page 57 | Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers BIRTH THROUGH 23 MONTHS Introduce Infants to Potentially Allergenic Foods Along With Other Complementary Foods Potentially allergenic foods (e.g., peanuts, egg, cow milk products, tree nuts, wheat, crustacean shellfish, fish, and soy) should be introduced when other complementary foods are introduced to an infant’s diet. Introducing peanut-containing foods in the first year reduces the risk that an infant will develop a food allergy to peanuts. Cow milk, as a beverage, should be introduced at age 12 months or later (see “Establish a Healthy Beverage Pattern”). There is no evidence that delaying introduction of allergenic foods, beyond For Infants at High Risk of when other complementary foods are introduced, helps to prevent Peanut Allergy, Introduce food allergy. For more information, see “For Infants at High Risk Peanut-Containing Foods of Peanut Allergy, Introduce Peanut-Containing Foods at Age at Age 4 to 6 Months 4 to 6 Months.” If an infant has severe eczema, egg allergy, or both (conditions that increase the risk of peanut allergy), age-appropriate, peanut- containing foods should be introduced into the diet as early as age 4 to 6 months. This will reduce the risk of developing peanut allergy. Caregivers should check with the infant’s healthcare provider before feeding the infant peanut- containing foods. A blood test or skin prick may be recommended to determine whether peanut should be introduced to the infant, and, if so, the safest way to introduce it. More information is available in the Addendum Guidelines for the Prevention of Peanut Allergy in the United States at niaid.nih.gov/ sites/default/files/addendum- peanut-allergy-prevention- guidelines.pdf. Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 58 BIRTH THROUGH 23 MONTHS Encourage Infants and Toddlers To iron, calcium, potassium, dietary fiber, and vitamin D are Consume a Variety of Complementary available at DietaryGuidelines.gov. Foods and Beverages To Meet Energy and Nutrient Needs Parents, caregivers, and guardians are encouraged INTRODUCE IRON-RICH FOODS TO INFANTS to introduce foods across all the food groups—as STARTING AT ABOUT 6 MONTHS OLD described below and carrying forward the principles Iron-rich foods (e.g., meats and seafood rich in heme in Chapter 1—including items that fit within a iron and iron-fortified infant cereals) are important family’s preferences, cultural traditions, and budget. components of the infant’s diet from age 6 through Complementary foods and beverages should be rich in 11 months to maintain adequate iron status, which nutrients, meet calorie and nutrient requirements during supports neurologic development and immune function. this critical period of growth and development, and Infants are typically born with body stores of iron stay within limits of dietary components such as added adequate for about the first 6 months of life, depending sugars and sodium. Although the Dietary Guidelines does on gestational age, maternal iron status, and timing of not provide a recommended dietary pattern for infants umbilical cord clamping. By age 6 months, however, ages 6 through 11 months, infants should be on the infants require an external source of iron apart from path to a healthy dietary pattern that is recommended human milk. for those ages 12 through 23 months (see Appendix 3: USDA Dietary Patterns). Caregivers of infants exclusively fed human milk should talk with their pediatric care provider about whether In the United States, some dietary components are there may be a need for infants supplementation with of public health concern for infants and toddlers. Iron iron before age 6 months. A complementary food source is a dietary component of public health concern for of iron beginning at about 6 months is particularly underconsumption among older infants ages 6 through important for infants fed human milk because the iron 11 months who are fed primarily human milk and content of human milk is low and maternal iron intake consume inadequate iron from complementary foods. during lactation does not increase its content. In the Older infants who are fed primarily human milk also United States, an estimated 77 percent of infants fed underconsume zinc and protein from complementary human milk have inadequate iron intake during the foods, and vitamin D, choline, and potassium are notably second half of infancy, highlighting the importance of underconsumed by all older infants. During the second introducing iron-rich foods starting at age 6 months. year of life, the dietary components of public health concern for underconsumption are vitamin D, calcium, Infants receiving most of their milk feeds as iron- dietary fiber, and potassium and for overconsumption fortified infant formula are likely to need less iron from are added sugars and sodium. Lists of dietary sources of complementary foods beginning at 6 months of age. After Page 59 | Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers BIRTH THROUGH 23 MONTHS age 12 months, children have a lower iron requirement, but good food sources of iron are still needed to maintain adequate iron status and prevent deficiency. INTRODUCE ZINC-RICH FOODS TO INFANTS STARTING AT ABOUT 6 MONTHS OLD Zinc-rich complementary foods (e.g., meats, beans, zinc- fortified infant cereals) are important from age 6 months onwards to support adequate zinc status, which supports growth and immune function. Although the zinc content of human milk is initially high and efficiently absorbed, the concentration declines over the first 6 months of lactation and is not affected by maternal zinc intake. During the second half of infancy, approximately half (54%) of U.S. infants fed human milk have inadequate zinc intake. Prioritizing zinc-rich foods starting at 6 months of age to complement human milk feedings will help infants meet their requirement for zinc. • Vegetables and fruits, especially those rich in potassium, vitamin A, and vitamin C, should be offered ENCOURAGE A VARIETY OF FOODS FROM ALL to infants and toddlers age 6 through 23 months. The FOOD GROUPS TO INFANTS STARTING AT ABOUT vegetable subgroup of beans, peas, and lentils also 6 MONTHS OLD provides a good source of protein and dietary fiber. To support nutrient adequacy, foster acceptance of healthy foods, and set intakes on a path toward a healthy • For dairy, families can introduce yogurt and cheese, pattern, it is important to encourage foods from all food including soy-based yogurt, before 12 months. groups. Because very young children are being exposed However, infants should not consume cow milk, as to new textures and flavors for the first time, it may take a beverage, or fortified soy beverage, before age 12 up to 8 to 10 exposures for an infant to accept a new type months as a replacement for human milk or infant of food. Repeated offering of foods such as fruits and formula (see “Cow Milk and Fortified Soy Beverages”). vegetables increases the likelihood of an infant accepting In the second year of life, when calcium requirements them. A nutrient-dense, diverse diet from age 6 through increase, dairy products, including milk, yogurt, 23 months of life includes a variety of food sources from cheese, and fortified soy beverages and soy yogurt each food group. provide a good source of calcium. Vitamin D-fortified milk and soy beverages also provide a good source of • Protein foods, including meats, poultry, eggs, vitamin D. For those younger than the age of 2, offer seafood, nuts, seeds, and soy products, are important dairy products without added sugar (see “Avoid sources of iron, zinc, protein, choline, and long Added Sugars”). chain polyunsaturated fatty acids. The long-chain polyunsaturated fatty acids, specifically the essential • Grains, including iron-fortified infant cereal, play an omega-3 and omega-6 fatty acids supplied through important role in meeting nutrient needs during this seafood, nuts, seeds, and oils, influence the infant’s life stage. Infant cereals fortified with iron include oat, fatty acid status and are among the key nutrients barley, multigrain, and rice cereals. Rice cereal fortified needed for the rapid brain development that occurs with iron is a good source of nutrients for infants, but through the infant’s first 2 years of life. Some types of rice cereal shouldn’t be the only type of cereal given fish such as salmon and trout are also natural sources to infants. Offering young children whole grains more of vitamin D. To limit exposure to methylmercury from often than refined grains will increase dietary fiber as seafood, the U.S. Food and Drug Administration and well as potassium intake during the second year the U.S. Environmental Protection Agency issued joint of life and help young children establish healthy guidance regarding the types of seafood to choose.1 dietary practices. 1 U.S. Food and Drug Administration and U.S. Environmental Protection Agency. Advice About Eating Fish. Available at FDA.gov/fishadvice; EPA.gov/fishadvice. Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 60 BIRTH THROUGH 23 MONTHS DIETARY COMPONENTS TO LIMIT While encouraging intake from each food group, some dietary components should be limited. Avoid Added Sugars Infants and young children have virtually no room in their diet for added sugars. This is because the nutrient requirements for infants and young children are quite high relative to their size, but the amount of complementary foods they consume is small. Complementary foods need to be nutrient-dense and not contain additional calories from added sugars. In addition, low- and no-calorie sweeteners, which can also be called high-intensity sweeteners, are not recommended for children younger than age 2. Taste preferences are being formed during this time period, and infants and young children may develop preferences for overly sweet foods if introduced to very sweet foods during this timeframe. For more information on added sugars, see Chapter 1. Avoid Foods Higher in Sodium Sodium is found in a number of foods, including some salty snacks, commercial toddler foods, and processed meats. In addition to keeping sodium intake within limits for toddlers (see Appendix 1), another reason to avoid high-sodium foods is that taste preferences for salty food may be established early in life. Choose fresh or low-sodium frozen foods, when available, and low-sodium canned foods to minimize sodium content. For more information on sodium, see Chapter 1. Avoid Honey and Unpasteurized Foods and Beverages Infants should not be given any foods containing raw or cooked honey. Honey can contain the Clostridium botulinum organism that could cause serious illness or death among infants. Infants and young children also should not be given any unpasteurized foods or beverages, such as unpasteurized juices, milk, yogurt, or cheeses, as they could contain harmful bacteria. Establish a Healthy Beverage Pattern An important part of establishing an overall healthy dietary pattern is careful consideration of beverages. Guidance for different beverage categories is provided below. WATER For healthy infants with adequate intake of human milk or infant formula, supplemental water is typically not needed in the first 6 months. Small amounts (up to 4 to 8 ounces per day) of plain, fluoridated drinking water can be given to infants with the introduction of complementary foods. Plain, fluoridated drinking water intake can slowly be increased after age 1 to meet hydration and fluoride needs. Page 61 | Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers BIRTH THROUGH 23 MONTHS COW MILK AND FORTIFIED SOY BEVERAGES Infants should not consume cow milk or fortified soy beverages before age 12 months to replace human milk or infant formula. Cow milk does not have the correct amount of nutrients for infants, and its higher protein and mineral content are hard for an infant’s kidneys and digestive system to process. Plain cow milk (whole milk) or fortified unsweetened soy beverage can be offered beginning around 12 months of age to help meet calcium, potassium, vitamin D, and protein needs. Flavored milks for children age 12 through 23 months should be avoided because they contain added sugars. PLANT-BASED MILK ALTERNATIVES Plant-based milk alternatives, which are sometimes referred to as milk alternatives, include beverages made from plants, such as soy, oat, rice, coconut, and almond. These beverages should not be used in the first year of life to replace human milk or infant formula. They may come in different flavors and some forms have added sugars. Unsweetened versions of these beverages may be accommodated in small amounts in the diet during the second year of life, but most have significantly less protein than cow milk and are not always fortified with calcium and vitamin D. Among plant-based milk alternatives, only fortified soy beverage is currently SUGAR-SWEETENED BEVERAGES considered a dairy equivalent. Thus, consuming other Sugar-sweetened beverages (e.g., regular soda, juice plant-based beverages does not contribute to meeting drinks [not 100% fruit juice], sports drinks, and flavored dairy recommendations. water with sugar) should not be given to children younger than age 2. Drinks labeled as fruit drinks or fruit-flavored drinks are not the same as 100% fruit juice 100% FRUIT JUICE and contain added sugars. These beverages displace Before age 12 months, 100% fruit or vegetable juices nutrient-dense beverages and foods in the diet of young should not be given to infants. In the second year of children. Infants and toddlers do not have room in their life, fruit juice is not necessary, and most fruit intake diets for the additional calories from added sugars should come from eating whole fruit. If 100% fruit juice found in these beverages. In addition, sugar-sweetened is provided, up to 4 ounces per day can fit in a healthy beverage intake in infancy and early childhood may dietary pattern. Juices that contain added sugars should predispose children to consume more of these be avoided. beverages later in life. TODDLER MILK AND TODDLER DRINKS CAFFEINATED BEVERAGES There are no clear needs for toddler milks or drinks. Concerns exist about potential negative health effects of Needed nutrients can be obtained from cow milk caffeine for young children, and no safe limits of caffeine or fortified soy beverage and appropriate solid have been established for this age group. Caffeine foods. Toddler milks and toddler drinks are drinks is a stimulant that can occur naturally in foods and supplemented with nutrients, and typically contain added beverages or as an additive. Major sources of caffeine sugars. A variety of nutrient-dense complementary for Americans include beverages such as soft drinks, tea, foods and beverages without added sugars should be coffee, and sports drinks. Beverages containing caffeine emphasized for achieving nutrient recommendations. should be avoided for children younger than age 2. Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 62 BIRTH THROUGH 23 MONTHS Healthy Dietary pattern includes a variety of nutrient-dense fruits, vegetables, grains, protein foods (including lean Pattern During a meats, poultry, eggs, seafood, nuts, and seeds), dairy (including milk, yogurt, and cheese), and oils. Based on Toddler’s Second FDA and EPA’s joint “Advice About Eating Fish,” young children should eat seafood lowest in methylmercury, Year of Life and certain species of seafood should be avoided.2 If young children are lower in body weight, they should eat In the second year of life, toddlers consume less less seafood than the amounts in the Healthy U.S.-Style human milk, and infant formula is not recommended. Dietary Pattern. More information is available on the FDA Calories and nutrients should predominantly be met or EPA websites at FDA.gov/fishadvice and EPA.gov/ from a healthy dietary pattern of age-appropriate foods fishadvice. and beverages. The Healthy U.S.-Style Dietary Pattern presented here is intended for toddlers ages 12 through After food group and subgroup recommendations are 23 months who no longer consume human milk or met, a small number of calories are allocated to oils. infant formula. The pattern represents the types and The recommendation to limit saturated fat to less than amounts of foods needed to meet energy and nutrition 10 percent of calories per day does not apply to those requirements for this period (Table 2-1). For toddlers who younger than age 2, and the inclusion of higher fat are still consuming human milk (approximately one-third versions of dairy is a notable difference in the pattern at 12 months and 15 percent at 18 months), a healthy for toddlers ages 12 through 23 months compared dietary pattern should include a similar combination of to patterns for ages 2 and older. However, no calories nutrient-dense complementary foods and beverages. remain in the pattern for additional saturated fat or for added sugars. To illustrate the concept of nutrient Table 2-1 displays the Healthy U.S.-Style Dietary density, Figure 2-1 shows examples of foods and Pattern to illustrate the specific amounts and limits beverages appropriate for this life stage in forms for food groups and other dietary components that that are not in nutrient-dense forms compared to those make up healthy dietary patterns. The pattern is that are in nutrient-dense forms. This dietary pattern provided at calorie levels ranging from 700 to 1,000 requires careful choices of foods and beverages but calories per day, which are appropriate for most does not require inclusion of fortified products toddlers ages 12 through 23 months (see Appendix 2. specifically formulated for infants or toddlers to meet Estimated Calorie Needs). A healthy dietary nutrient recommendations. Figure 2-1 Make Healthy Shifts To Empower Toddlers To Eat Nutrient-Dense Foods in Dietary Patterns Science shows that early food preferences influence later food choices. Make the first choice the healthiest choices that set the toddlers on a path of making nutrient-dense choices in the years to come. Examples of shifts in common choices to healthier, more nutrient-dense food choices include: Cereal with Added Cereal with Minimal Fruit Products with Fruit (e.g., canned in Fried Vegetables Roasted Vegetables Sugars Added Sugars Added Sugars 100% juice) High-sodium Snacks Vegetables High-sodium Meats Ground Lean Meats Beverages with Added Unsweetened Sugars Beverages 2If consuming up to 2 ounces of seafood per week, children should only be fed cooked varieties from the “Best Choices” list in the FDA/EPA joint “Advice About Eating Fish,” available at FDA.gov/fishadvice and EPA.gov/fishadvice. If consuming up to 3 ounces of seafood per week, children should only be fed cooked varieties from the “Best Choices” list that contain even lower methylmercury: flatfish (e.g., flounder), salmon, tilapia, shrimp, catfish, crab, trout, haddock, oysters, sardines, squid, pollock, anchovies, crawfish, mullet, scallops, whiting, clams, shad, and Atlantic mackerel. If consuming up to 3 ounces of seafood per week, many commonly consumed varieties of seafood should be avoided because they cannot be consumed at 3 ounces per week by children without the potential of exceeding safe methylmercury limits; examples that should not be consumed include: canned light tuna or white (albacore) tuna, cod, perch, black sea bass. For a complete list please see: FDA.gov/fishadvice and EPA.gov/fishadvice. Page 63 | Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers BIRTH THROUGH 23 MONTHS Table 2-1 Healthy U�S�-Style Dietary Pattern for Toddlers Ages 12 Through 23 Months Who Are No Longer Receiving Human Milk or Infant Formula, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 700 800 900 1,000 FOOD GROUP OR SUBGROUPb,c Daily Amount of Food From Each Groupd (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) ⅔ ¾ 1 1 Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) 1 ⅓ ½ ½ Red and Orange Vegetables (cup eq/wk) 1 1 ¾ 2 ½ 2 ½ Beans, Peas, Lentils (cup eq/wk) ¾ ⅓ ½ ½ Starchy Vegetables (cup eq/wk) 1 1 ½ 2 2 Other Vegetables (cup eq/wk) ¾ 1 ¼ 1 ½ 1 ½ Fruits (cup eq/day) ½ ¾ 1 1 Grains (ounce eq/day) 1 ¾ 2 ¼ 2 ½ 3 Whole Grains (ounce eq/day) 1 ½ 2 2 2 Refined Grains (ounce eq/day) ¼ ¼ ½ 1 Dairy (cup eq/day) 1 ⅔ 1 ¾ 2 2 Protein Foods (ounce eq/day) 2 2 2 2 Protein Foods Subgroups in Weekly Amounts Meats, Poultry (ounce eq/wk) 8 ¾ 7 7 7 ¾ Eggs (ounce eq/wk) 2 2 ¾ 2 ½ 2 ½ Seafood (ounce eq/wk)e 2-3 2-3 2-3 2-3 Nuts, Seeds, Soy Products (ounce eq/wk) 1 1 1 ¼ 1 ¼ Oils (grams/day) 9 9 8 13 a Calorie level ranges: Energy levels are calculated based on median length and body weight reference individuals. Calorie needs vary based on many factors. The DRI Calculator for Healthcare Professionals, available at usda.gov/fnic/dri-calculator, can be used to estimate calorie needs based on age, sex, and weight. b Definitions for each food group and subgroup and quantity (i.e., cup or ounce equivalents) are provided in Chapter 1 and are compiled in Appendix 3. c All foods are assumed to be in nutrient-dense forms and prepared with minimal added sugars, refined starches, or sodium. Foods are also lean or in low-fat forms with the exception of dairy, which includes whole-fat fluid milk, reduced-fat plain yogurts, and reduced-fat cheese. There are no calories available for additional added sugars, saturated fat, or to eat more than the recommended amount of food in a food group. d In some cases, food subgroup amounts are greatest at the lower calorie levels to help achieve nutrient adequacy when relatively small number of calories are required. e If consuming up to 2 ounces of seafood per week, children should only be fed cooked varieties from the “Best Choices” list in the FDA/EPA joint “Advice About Eating Fish,” available at FDA.gov/fishadvice and EPA.gov/fishadvice. If consuming up to 3 ounces of seafood per week, children should only be fed cooked varieties from the “Best Choices” list that contain even lower methylmercury: flatfish (e.g., flounder), salmon, tilapia, shrimp, catfish, crab, trout, haddock, oysters, sardines, squid, pollock, anchovies, crawfish, mullet, scallops, whiting, clams, shad, and Atlantic mackerel. If consuming up to 3 ounces of seafood per week, many commonly consumed varieties of seafood should be avoided because they cannot be consumed at 3 ounces per week by children without the potential of exceeding safe methylmercury limits; examples that should not be consumed include: canned light tuna or white (albacore) tuna, cod, perch, black sea bass. For a complete list please see: FDA.gov/fishadvice and EPA.gov/fishadvice. Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 64 BIRTH THROUGH 23 MONTHS Current Intakes Figure 2-2 and 2-3 highlight the dietary intakes of toddlers during the second year of life. Average intakes of the food groups are compared to the range of recommended intakes at the calorie levels most relevant to males and females in this age group (Figure 2-2). Additionally, the average intakes and range of intakes of added sugars, saturated fat, and sodium are displayed. Average intakes compared to recommended intake ranges of the subgroups for grains are represented in daily amounts; subgroups for vegetables and protein foods are represented in weekly amounts (Figure 2-3). Figure 2-2 Current Intakes: Ages 12 Through 23 Months Average Daily Food Group Intakes Compared to Recommended Intake Ranges Recommended I n take Ranges Average Intakes 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 Total Total Total Total Total Vegetables Fruits Grains Dairy Protein Foods cup eq/day cup eq/day oz eq/day cup eq/day oz eq/day FOOD GROUPS Average Intakes of Added Sugars, Saturated Fat, and Sodium Added Sugars Saturated Fat Sodium Limit: Avoid Limit: N/A Limit: 1,200 mg Average Intakes Average Intakes Average Intakes 104 kcals 167 kcals 1,586 mg Data Sources: Average Intakes: Analysis of What We Eat in America, NHANES 2007-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). PAaggee 6s5 1| D2i-e2ta3ry mGuiodenlitnhess for Americans, 2020-2025 | Chapter 2: Infants and Toddlers CUP or OZ EQUIVALENT BIRTH THROUGH 23 MONTHS Figure 2-3 Approximately 60 percent of toddlers meet or exceed Average Intakes of Subgroups Compared to recommended intakes for fruit. A majority of fruit Recommended Intake Ranges: Ages 12 Through is consumed as whole fruit (fresh, canned, puréed, 23 Months frozen) or as 100% fruit juice. Average intake of total vegetables is below the range of recommended Recommended Intake Ranges Average Intakes amounts, with nearly 90 percent of toddlers falling short Vegetables of recommendations. About one-half of vegetables are 3.0 consumed on their own, one-quarter are consumed as 2.5 part of a mixed dish, and nearly 5 percent are consumed as savory snacks (e.g., potato chips). 2.0 Total grains, particularly refined grains, are consumed 1.5 in amounts that exceed recommendations. Conversely, 1.0 intakes of whole grains fall short of recommended amounts for more than 95 percent of toddlers. A 0.5 majority of grains are consumed through breads, rolls, tortillas, or other bread products or as part of a mixed 0 dish. Ten percent of grains come from sweet bakery Total Dark- Red & Beans, Starchy Other Vegetables Green Orange Peas, products and approximately 15 percent come from cup eq/day Lentils crackers and savory snacks. Many of these categories cup eq/week are top sources of sodium or added sugars in this Grains age group. 3.5 3.0 Average intakes of dairy foods, most of which is consumed as milk, generally exceed recommended 2.5 amounts in this age group. Intakes of yogurt and cheese 2.0 account for about 10 percent of dairy intakes. Plant- based beverages and flavored milks each make up 1.5 about 2 percent of dairy intakes among toddlers. 1.0 Protein foods intakes fall within recommended range, 0.5 on average. Intakes of meats, poultry, and eggs make 0 up a majority of protein foods intakes, however seafood Total Whole Grains Refined Grains Grains intakes in this age group is low. Children in this age oz eq/day group can reduce sodium intake by eating less cured or processed meats including hot dogs, deli meats, Protein Foods and sausages. 12 10 Due to the relatively high nutrient needs of toddlers, a healthy dietary pattern has virtually no room for added 8 sugars. Toddlers consume an average of more than 100 calories from added sugars each day, ranging from 40 to 6 250 calories a day (about 2.5 to 16 teaspoons). Sugar- 4 sweetened beverages, particularly fruit drinks, contribute more than 25 percent of total added sugars intakes and 2 sweet bakery products contribute about 15 percent. Other food category sources contribute a smaller 0 Total Meats, Eggs Seafood Nuts, Seeds, proportion of total added sugars on their own, but the Protein Foods Poultry Soy Products wide variety of sources, which include yogurts, ready-to- oz eq/day oz eq/week eat cereals, candy, fruits, flavored milk, milk substitutes, Data Sources: Average Intakes: Analysis of What We Eat in baby food products, and breads, points to the need to America, NHANES 2007-2016, day 1 dietary intake data, weighted. make careful choices across all foods. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 66 OZ EQUIVALENT OZ EQUIVALENT CUP EQUIVALENT BIRTH THROUGH 23 MONTHS Vegetarian Dietary Pattern During the Second Year of Life A Healthy Vegetarian Dietary Pattern for young children ages 12 through 23 months who are not fed human milk or infant formula is included in Appendix 3. This pattern describes a lacto-ovo vegetarian diet that includes regular consumption of eggs, dairy products, soy products, and nuts or seeds, in addition to vegetables including beans, peas, and lentils, fruits, grains, and oils. Iron may be of particular concern because plant source foods contain only non-heme iron, which is less bioavailable than is heme iron. Food source lists for both heme and non-heme iron are available at DietaryGuidelines.gov. Vitamin B12 also may be of concern because it is present only in animal source foods. When feeding infants and toddlers a lacto-ovo vegetarian diet, parents, caregivers, and guardians should consult with a healthcare provider to determine whether supplementation of iron, vitamin B12, and/or other nutrients is necessary and if so, appropriate levels to meet their unique needs. Supporting Healthy Eating Parents, guardians, and caregivers play an important role in nutrition during this life stage because infants and toddlers are fully reliant on them for their needs. In addition to “what” to feed children, “how” to feed young children also is critical. As noted above, repeated exposure to foods can increase acceptance of new foods. Another important concept is responsive feeding, a feeding style that emphasizes recognizing and responding to the hunger or fullness cues of an infant or young child (see “Responsive Feeding”). Responsive Feeding Table 2-2 Responsive feeding is a term Signs a Child is Hungry or Full used to describe a feeding style that emphasizes recognizing Birth Through Age 5 Months and responding to the hunger or fullness cues of an infant or young A child may be hungry if he or she: A child may be full if he or she: child. Responsive feeding helps • Puts hands to mouth. • Closes mouth. young children learn how to self- • Turns head toward breast or bottle. • Turns head away from breast or bottle. regulate their intake. • Puckers, smacks, or licks lips. • Relaxes hands. • Has clenched hands. See Table 2-2 for some examples of signs a child may show for Age 6 Through 23 Months hunger and fullness when he or she is a newborn through age 5 A child may be hungry if he or she: A child may be full if he or she: months, and signs a child may • Reaches for or points to food. • Pushes food away. • Opens his or her mouth when offered a • Closes his or her mouth when food is start to show between age 6 spoon or food. offered. through 23 months. • Gets excited when he or she sees food. • Turns his or her head away from food. • Uses hand motions or makes sounds to • Uses hand motions or makes sounds to It is important to listen to the let you know he or she is still hungry. let you know he or she is still full. child’s hunger and fullness cues to build healthy eating habits during this critical age. If parents, guardians, or caregivers have questions or concerns, a conversation with a healthcare provider will be helpful. For more information on signs a child is hungry or full, see: cdc.gov/nutritioninfantandtoddlernutrition/mealtime/ signs-your-child-is-hungry-or-full.html. More information on infant development skills, hunger and satiety cues, and typical daily portion sizes is available at wicworks.fns.usda.gov/sites/default/files/media/document/Infant_Nutrition_ and_Feeding_Guide.pdf. Page 67 | Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers BIRTH THROUGH 23 MONTHS Accessing a Healthy Dietary Pattern Many resources exist to support healthy growth and development during infancy and toddlerhood. These include the following Government programs that aim to support a healthy dietary pattern for infants and toddlers living in households with limited incomes: • The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) supports infant and early childhood nutrition through supplementing the diets of women who are pregnant or lactating and by providing breastfeeding support and iron-fortified infant formula when human milk is unavailable or fed only partially. WIC accommodates the transition to solid foods by providing nutrient-dense foods in the supplemental food packages offered to older infants and toddlers. Nutrition education and counseling and referrals to healthcare and social services are other important resources offered to income-eligible WIC participants. • The Child and Adult Care Food Program (CACFP) provides reimbursement for nutrient-dense meals and snacks served to infants and toddlers in participating child care centers, including at Head Start programs, and day care homes where infants and toddlers also have access to health screenings and families can be connected to health services to support their overall well-being. • The Supplemental Nutrition Assistance Program (SNAP) is the largest food assistance program in the United States. SNAP helps meet the nutritional needs of infants and toddlers living in low-income households by providing temporary monthly benefits that can be used to access a healthy dietary pattern. These Government nutrition programs are especially important for the 14 percent3 of families with children who experience food insecurity and may struggle to access the foods needed to support a healthy dietary pattern. Professionals can use these, and additional Government and non-Government resources that exist within communities, to support healthy eating during infancy and toddlerhood. Looking Toward Chapter 3: Children and Adolescents This chapter focused on nutrition issues important to infants and toddlers— exclusive human milk feeding, if possible; introducing nutrient-dense complementary foods at about age 6 months; and encouraging infants and toddlers to sample and consume a variety of nutrient-dense foods and beverages to meet their needs. As toddlers grow and their dietary patterns become more integrated with the family’s food patterns, new issues arise. These issues, and how to accommodate them within a lifelong healthy dietary pattern, are discussed in the next chapter, which focuses on children and adolescents. 3 More information on food insecurity is available at ers.usda.gov/data-products/ag-and- food-statistics-charting-the-essentials/food-security-and-nutrition-assistance. Dietary Guidelines for Americans, 2020-2025 | Chapter 2: Infants and Toddlers | Page 68 AGES 2-18 Page 69 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents AGES 2-18 CHAPTER3 Children and Adolescents Dietary Guidelines for Americans,, 2020-2025 | Chapter 3: Children and Adolescents | Page 70 AGES 2-18 Introduction Children and adolescents include individuals ages 2 through 18— a life stage characterized by transitions and the formation of dietary patterns. Suboptimal current intake patterns among children and adolescents and inadequate physical activity contribute to overweight and obesity in this life stage and risk of chronic disease (e.g., type 2 diabetes, cardiovascular disease) later in life. Changing this trajectory is crucial because dietary patterns established during this life stage tend to continue into adult years. Healthy eating throughout this life stage involves the child or adolescent, families and caregivers, and institutions and settings where food is provided and consumed. Young children are fully reliant on others to provide their meals and snacks. As children transition to school-age and through adolescence, they are exposed to new food choices and begin to have more autonomy in the foods that are selected. New influences on eating behavior also emerge, such as peer pressure, which can create opportunities or challenges for establishing dietary patterns consistent with health and longevity. Adolescents acquire ever-greater independence in their food choices as they mature, with more time spent on their own with peers and more foods and beverages frequently consumed in social settings. Other factors that influence eating behavior include social supports, exposure to food marketing and promotion, and policies that determine community design. Youth have diverse calorie and nutrient needs based on age and patterns of growth, development, and physical activity. Current intake data of young children show some components of a healthy dietary pattern that continue from the infant and toddler life stages. Before these components of a healthy dietary pattern are established, however, diet quality worsens through childhood and into adolescence and intake patterns drift further from recommendations in the Dietary Guidelines. Active community support is needed to help youth meet food group and nutrient goals with nutrient- dense foods and beverages. Page 71 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents AGES 2-18 Childhood Overweight and Obesity In the United States, 41 percent of children and adolescents are overweight or have obesity, and the prevalence is higher among Hispanic and non-Hispanic Black children and adolescents as compared to non-Hispanic Asians and Whites. Overweight and obesity put youth at high risk of serious health concerns. Youth with obesity are more likely to have immediate health risks, including high blood pressure, high cholesterol, and impaired glucose tolerance. They also are at increased risk of cardiovascular disease and type 2 diabetes beginning as soon as the teenage years and into adulthood. Psychological (e.g., anxiety, depression) and social concerns (e.g., bullying, stigma) also are more likely in children and adolescents with overweight or obesity. The causes of childhood obesity are complex and interconnected. Behaviors (e.g., eating habits, level of physical activity, sedentary time) and the community in which a child or adolescent resides can influence risk of obesity. Genetics and the fetal environment also play a role in the development of obesity. However, many opportunities exist to help prevent or manage overweight and obesity as children transition through these life stages. The goal for children and adolescents with overweight or obesity is to reduce the rate of weight gain while allowing normal growth and development. This can primarily be done by emphasizing nutrient-dense food and beverage choices, minimizing calories from sources that do not contribute to a healthy dietary pattern, and encouraging regular physical activity. Healthy Dietary Patterns than do males, with variations based on size and level of Children and adolescents are encouraged to follow the physical activity. During adolescence, the range of calorie recommendations on the types of foods and beverages intakes widens to support diverse growth trajectories. that make up a healthy dietary pattern described in More information on the calorie estimates is provided in Chapter 1. Nutrition and Health Across the Lifespan: Tables 3-1 to 3-3 (see footnote a) and in Appendix 2. The Guidelines and Key Recommendations. Tables 3-1 Estimated Calorie Needs. to 3-3 display the Healthy U.S.-Style Dietary Pattern to illustrate the specific amounts and limits for food groups The USDA Dietary Patterns, including the Healthy and other dietary components that make up healthy U.S.-Style Dietary Pattern, provide a framework dietary patterns at the calorie levels appropriate for most to help children and adolescents follow a healthy children and adolescents across four age ranges: one dietary pattern and meet the Guidelines and their table combining patterns relevant for ages 2 through Key Recommendations. The USDA Foods Patterns 4 and ages 5 through 8, and single tables for ages 9 can be customized based on dietary needs, personal through 13 and for ages 14 through 18. Tables 3-1 to preferences, and budgetary constraints. A variety of 3-3 also show the calories remaining for other uses— nutrient-dense foods and beverages can be selected about 10-15 percent of the total available—after meeting across the food group and subgroups as part of an food group and nutrient goals through the selection of overall healthy dietary pattern. For more information nutrient-dense foods and beverages. about the USDA Food Patterns, see Chapter 1 and Appendix 3. USDA Dietary Patterns. For this age group, Calorie needs generally increase throughout this life as for all the others, a figure comparing current intakes to stage to support growth and development. Child and recommendations is presented. See “Current Intakes” for adolescent females generally have lower calorie needs more information. Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 72 AGES 2-18 Children Ages 2 Through 8 In early childhood (ages 2 through 4), females require about 1,000 to 1,400 calories per day and males require about 1,000 to 1,600 calories per day. With the transition to school-age (ages 5 through 8), females require about 1,200 to 1,800 calories per day and males require about 1,200 to 2,000 calories per day. Physical Activity Childhood and adolescence is a critical period for developing movement skills, learning healthy habits, and establishing a firm foundation for lifelong health and well-being. For youth, regular physical activity can improve bone health, cardiorespiratory and muscular fitness, and cognition (including academic achievement), and reduce the symptoms of depression. Preschool-aged children should be active throughout the day to enhance growth and development. Adults caring for children during this age should encourage active play that includes a variety of activity types (light, moderate, or vigorous intensity) and aim for at least 3 hours per day. School-aged children and adolescents need at least 60 minutes of moderate- to-vigorous activity daily to attain the most health benefits from physical activity. Most activity can be aerobic, like walking, running, or anything that makes their heart beat faster. They also need muscle-strengthening and bone-strengthening activities that make their muscles and bones strong, like climbing on playground equipment, playing basketball, and jumping rope. The U.S. Department of Health and Human Service’s Physical Activity Guidelines for Americans and related Move Your Way® resources have more information about the benefits of physical activity and tips on how to get started. Available at health.gov/paguidelines. Nutrient-Dense Foods and Beverages Nutrient-dense foods and beverages provide vitamins, minerals, and other health- promoting components and have little added sugars, saturated fat, and sodium. Vegetables, fruits, whole grains, seafood, eggs, beans, peas, and lentils, unsalted nuts and seeds, fat-free and low-fat dairy products, and lean meats and poultry—when prepared with no or little added sugars, saturated fat, and sodium—are nutrient- dense foods. Page 73 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents AGES 2-18 Table 3-1 Healthy U�S�-Style Dietary Pattern for Children Ages 2 Through 8, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 1,000 1,200 1,400 1,600 1,800 2,000 FOOD GROUP OR SUBGROUPb Daily Amount of Food From Each Group (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 1 1 ½ 1 ½ 2 2 ½ 2 ½ Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) ½ 1 1 1 ½ 1 ½ 1 ½ Red and Orange Vegetables (cup eq/wk) 2 ½ 3 3 4 5 ½ 5 ½ Beans, Peas, Lentils (cup eq/wk) ½ ½ ½ 1 1 ½ 1 ½ Starchy Vegetables (cup eq/wk) 2 3 ½ 3 ½ 4 5 5 Other Vegetables (cup eq/wk) 1 ½ 2 ½ 2 ½ 3 ½ 4 4 Fruits (cup eq/day) 1 1 1 ½ 1 ½ 1 ½ 2 Grains (ounce eq/day) 3 4 5 5 6 6 Whole Grains (ounce eq/day) 1 ½ 2 2 ½ 3 3 3 Refined Grains (ounce eq/day) 1 ½ 2 2 ½ 2 3 3 Dairy (cup eq/day) 2 2 ½ 2 ½ 2 ½ 2 ½ 2 ½ Protein Foods (ounce eq/day) 2 3 4 5 5 5 ½ Protein Foods Subgroups in Weekly Amounts Meats, Poultry, Eggs (ounce eq/wk) 10 14 19 23 23 26 Seafood (ounce eq/wk)c 2-3d 4 6 8 8 8 Nuts, Seeds, Soy Products (ounce eq/wk) 2 2 3 4 4 5 Oils (grams/day) 15 17 17 22 22 24 Limit on Calories for Other Uses (kcal/day)e 130 80 90 150 190 280 Limit on Calories for Other Uses (%/day) 13% 7% 6% 9% 10% 14% a Calorie level ranges: Ages 2 through 4, Females: 1,000-1,400 calories; Choices” list that contain even lower methylmercury: flatfish (e.g., Males: 1,000-1,600 calories. Ages 5 through 8, Females: 1,200-1,800 flounder), salmon, tilapia, shrimp, catfish, crab, trout, haddock, oysters, calories; Males: 1,200-2,000 calories. Energy levels are calculated sardines, squid, pollock, anchovies, crawfish, mullet, scallops, whiting, based on reference height (median) and reference weight (healthy) clams, shad, and Atlantic mackerel. If consuming up to 3 ounces of corresponding with a healthy body mass index (BMI). Calorie needs seafood per week, many commonly consumed varieties of seafood vary based on many factors. The DRI Calculator for Healthcare should be avoided because they cannot be consumed at 3 ounces per Professionals, available at nal.usda.gov/fnic/dri-calculator, can be week by children without the potential of exceeding safe methylmercury used to estimate calorie needs based on age, sex, height, weight, and limits; examples that should not be consumed include: canned light activity level. tuna or white (albacore) tuna, cod, perch, black sea bass. For a complete list please see: FDA.gov/fishadvice and EPA.gov/fishadvice. b Definitions for each food group and subgroup and quantity (i.e., cup or ounce equivalents) are provided in Chapter 1 and are compiled in e Foods are assumed to be in nutrient-dense forms; lean or low-fat; and Appendix 3. prepared with minimal added sugars, refined starches, saturated fat, or sodium. If all food choices to meet food group recommendations c The U.S. Food and Drug Administration (FDA) and the U.S. are in nutrient-dense forms, a small number of calories remain within Environmental Protection Agency (EPA) provide joint advice regarding the overall limit of the pattern (i.e., limit on calories for other uses). The seafood consumption to limit methylmercury exposure for children. number of calories depends on the total calorie level of the pattern and Depending on body weight, some children should choose seafood the amounts of food from each food group required to meet nutritional lowest in methylmercury or eat less seafood than the amounts in the goals. Calories up to the specified limit can be used for added sugars Healthy US-Style Dietary Pattern. More information is available on the and/or saturated fat, or to eat more than the recommended amount of FDA and EPA websites at FDA.gov/fishadvice and EPA.gov/fishadvice. food in a food group. d If consuming up to 2 ounces of seafood per week, children should NOTE: The total dietary pattern should not exceed Dietary Guidelines only be fed cooked varieties from the “Best Choices” list in the FDA/ limits for added sugars and saturated fat; be within the Acceptable EPA joint “Advice About Eating Fish,” available at FDA.gov/fishadvice Macronutrient Distribution Ranges for protein, carbohydrate, and total and EPA.gov/fishadvice. If consuming up to 3 ounces of seafood fats; and stay within calorie limits. Values are rounded. See Appendix 3 per week, children should only be fed cooked varieties from the “Best for all calorie levels of the pattern. Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 74 AGES 2-18 Current Intakes quality is poor. Notably, HEI Scores decline throughout childhood and adolescence, with scores for adolescents Figures 3-2 to 3-9 highlight the dietary intakes of approximately 10 points lower than those for young children and adolescents, including the Healthy Eating children (Figure 3-1). Index-2015 score, which is an overall measure of how intakes align with the Dietary Guidelines, as well as Among children ages 2 through 4, consumption of information on the components of a healthy diet— total fruit is generally adequate for about 60 percent specifically, the food groups. Figures 3-1, 3-3, 3-5, of children. Compared to other age groups, a higher and 3-7 display the average intakes of the food groups percentage of young children also have intakes of compared to the range of recommended intakes at the total vegetables at or above recommended levels. calorie levels most relevant to males and females in The difference between recommended and actual these age groups. Additionally, the percent of children intakes of total fruit and total vegetables emerges and and adolescents exceeding the recommended limits expands as children age. By late adolescence, average for added sugars, saturated fat, and sodium are shown, fruit and vegetable consumption is about half of the along with average intakes of these components. recommended range of intake. Throughout youth, Average intakes compared to recommended intake starchy vegetables (e.g., white potatoes, corn)—often in ranges of the subgroups for grains are represented in forms that are fried or prepared with additions such as daily amounts; subgroups for vegetables and protein butter and salt—are more frequently consumed than the foods are represented in weekly amounts (see Figures red and orange; dark green; or beans, peas, and lentils 3-2, 3-4, 3-6, and 3-8). vegetable subgroups. For fruit, about 70 percent of intake comes from whole forms—fresh, canned, frozen, Current intakes show that from an early age, dietary or dried—and 100% juice, which are often nutrient-dense patterns are not aligned with the Dietary Guidelines. forms. Some fruit is consumed through sources that are The Healthy Eating Index score of 61 out of 100 for not nutrient-dense; for example, fruit as part of a baked children ages 2 through 4 indicates that overall diet dessert or juice drink. Figure 3-1 Healthy Eating Index Scores Across Childhood and Adolescence 100 80 61 60 55 52 51 40 20 0 Ages 2-4 Ages 5-8 Ages 9-13 Ages 14-18 Data Source: Analysis of What We Eat in America, NHANES 2015-2016, ages 2 through 18, day 1 dietary intake, weighted. Page 75 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents Maximum Total Score = 100 AGES 2-18 The amount of dairy foods consumed by children and total grains trend toward overconsumption due to the adolescents is relatively stable across age groups. contribution of refined grains. Beginning at age 9 the amount of dairy foods in a healthy dietary pattern increases from 2 ½ to 3 cup Total protein intake generally meets targets except for equivalents per day to support an increase in calcium adolescent females ages 14 through 18. Youth typically intake that is needed during these life stages. As a meet or exceed recommendations for meats, poultry, result, average intake of dairy foods is close to or at and eggs. Seafood, a protein subgroup that can support recommended levels for children younger than age intakes of beneficial fatty acids, is consumed at levels 9 while consumption among adolescents is typically far below the lower end of the recommended intakes below recommended intake levels. range. When seafood is consumed, it is typically as part of a mixed dish rather than as an individual Although the gaps between recommended and current food item. intakes widen throughout these life stages for some dietary components, others, principally whole grains Children and adolescents can improve intake patterns and seafood, are infrequently consumed by any youth. by maintaining the components of a healthy diet that Whole grains are consumed below recommended levels are evident in early childhood, particularly total fruit even by young children. As the difference between and dairy foods, while increasing consumption of food recommended and current intakes widens across age groups that are underconsumed across all age groups, groups, the types of refined and whole-grain foods specifically total vegetables and vegetable subgroups, consumed remains consistent. Mixed dishes, such as whole grains, and seafood. Reducing intakes of added pizza, pasta, sandwiches, burgers, and tacos, contribute sugars, saturated fat, and sodium—components of about 50 percent of total grains intake, and snacks and a dietary pattern that are often consumed above sweets, such as chips, crackers, and cookies, about 20 recommended limits beginning at an early age—also percent. Breakfast cereals and bars, including ready- will support youth in achieving a healthy dietary pattern, to-eat and cooked varieties, are the top contributor to particularly when considering the very limited amount of whole-grains intake during these life stages. Despite calories available outside of those needed for meeting the underconsumption of whole grains, intakes of food group and nutrient goals. Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 76 AGES 2-18 Current Intakes Figure 3-2 Current Intakes: Ages 2 Through 4 Average Daily Food Group Intakes Compared to Recommended Intake Ranges Recommended Intake Ranges Average Intakes Healthy Eating Index Score (on a scale of 0-100) 6 5 61 4 3 2 1 0 M F M F M F M F M F Total Total Total Total Total Vegetables Fruits Grains Dairy Protein Foods cup eq/day cup eq/day oz eq/day cup eq/day oz eq/day FOOD GROUPS Percent Exceeding Limits of Added Sugars, Saturated Fat, and Sodium Exceeding Limit Within Recommended Limit Added Sugars Saturated Fat Sodium Limit: 10% of total energy Limit: 10% of total energy Limit: 1,200 mg* Males Females Males Females Males Females 61% 57% 87% 88% 97% 95% Average Intakes Average Intakes Average Intakes Males Females Males Females Males Females 173 kcal 158 kcal 191 kcal 177 kcal 2,274 mg 2,061 mg *NOTE: Children ages 2 through 3 should reduce sodium intake if above 1,200 mg/d and those age 4 should reduce intake if above 1,500 mg/d. Data Sources: Average Intakes and HEI-2015 Scores: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, wAegigehtsed 2. R-4ecommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Percent Exceeding Limits: What We Eat in America, NHANES 2013-2016, 2 days dietary intake data, weighted. Page 77 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents CUP or OZ EQUIVALENT AGES 2-18 Figure 3-3 Average Intakes of Subgroups Compared to Recommended Intake Ranges: Ages 2 Through 4 Recommended Intake Ranges Average Intakes Vegetables 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 M F M* F* M F M F M F M F Total Dark- Red & Beans, Starchy Other Vegetables Green Orange Peas, cup eq/day Lentils cup eq/week Grains 6 5 4 3 2 1 0 M F M F M F Total Whole Grains Refined Grains Grains oz eq/day Protein Foods 25 20 15 10 5 0 M F M F M* F* M F Total Meats, Poultry, Seafood Nuts, Seeds, Protein Foods Eggs Soy Products oz eq/day oz eq/week *NOTE: Estimates may be less precise than others due to small sample size and/or large relative standard error. Data Sources: Average Intakes: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 78 OZ EQUIVALENT OZ EQUIVALENT CUP EQUIVALENT AGES 2-18 Current Intakes Figure 3-4 Current Intakes: Ages 5 Through 8 Average Daily Food Group Intakes Compared to Recommended Intake Ranges Recommended Intake Ranges Average Intakes Healthy Eating Index Score (on a scale of 0-100) 8 7 6 55 5 4 3 2 1 0 M F M F M F M F M F Total Total Total Total Total Vegetables Fruits Grains Dairy Protein Foods cup eq/day cup eq/day oz eq/day cup eq/day oz eq/day FOOD GROUPS Percent Exceeding Limits of Added Sugars, Saturated Fat, and Sodium Exceeding Limit Within Recommended Limit Added Sugars Saturated Fat Sodium Limit: 10% of total energy Limit: 10% of total energy Limit: 1,500 mg Males Females Males Females Males Females 80% 77% 84% 82% 97% 97% Average Intakes Average Intakes Average Intakes Males Females Males Females Males Females 266 kcal 238 kcal 218 kcal 195 kcal 2,785 mg 2,525 mg Data Sources: Average Intakes and HEI-2015 Scores: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Percent Exceeding Limits: What We Eat in AAmgeericsa , 5N-H8ANES 2013-2016, 2 days dietary intake data, weighted. Page 79 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents CUP or OZ EQUIVALENT AGES 2-18 Figure 3-5 Average Intakes of Subgroups Compared to Recommended Intake Ranges: Ages 5 Through 8 Recommended Intake Ranges Average Intakes Vegetables 6 5 4 3 2 1 0 M F M F* M F M F M F M F Total Dark- Red & Beans, Starchy Other Vegetables Green Orange Peas, cup eq/day Lentils cup eq/week 8 Grains 7 6 5 4 3 2 1 0 M F M F M F Total Whole Grains Refined Grains Grains oz eq/day Protein Foods 30 25 20 15 10 5 0 M F M F M* F* M F Total Meats, Poultry, Seafood Nuts, Seeds, Protein Foods Eggs Soy Products oz eq/day oz eq/week *NOTE: Estimates may be less precise than others due to small sample size and/or large relative standard error. Data Sources: Average Intake: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 80 OZ EQUIVALENT OZ EQUIVALENT CUP EQUIVALENT AGES 2-18 Children and Adolescents Ages 9 Through 13 In the late childhood and early adolescence stage, females require about 1,400 to 2,200 calories per day and males require about 1,600 to 2,600 calories per day. Table 3-2 Healthy U�S�-Style Dietary Pattern for Children and Adolescents Ages 9 Through 13, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 1,400 1,600 1,800 2,000 2,200 2,400 2,600 FOOD GROUP OR SUBGROUPb Daily Amount of Food From Each Group (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 1 ½ 2 2 ½ 2 ½ 3 3 3 ½ Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) 1 1 ½ 1 ½ 1 ½ 2 2 2 ½ Red & Orange Vegetables (cup eq/wk) 3 4 5 ½ 5 ½ 6 6 7 Beans, Peas, Lentils (cup eq/wk) ½ 1 1 ½ 1 ½ 2 2 2 ½ Starchy Vegetables (cup eq/wk) 3 ½ 4 5 5 6 6 7 Other Vegetables (cup eq/wk) 2 ½ 3 ½ 4 4 5 5 5 ½ Fruits (cup eq/day) 1 ½ 1 ½ 1 ½ 2 2 2 2 Grains (ounce eq/day) 5 5 6 6 7 8 9 Whole Grains (ounce eq/day) 2 ½ 3 3 3 3 ½ 4 4 ½ Refined Grains (ounce eq/day) 2 ½ 2 3 3 3 ½ 4 4 ½ Dairy (cup eq/day) 3 3 3 3 3 3 3 Protein Foods (ounce eq/day) 4 5 5 5 ½ 6 6 ½ 6 ½ Protein Foods Subgroups in Weekly Amounts Meats, Poultry, Eggs (ounce eq/wk) 19 23 23 26 28 31 31 Seafood (ounce eq/wk)c 6 8 8 8 9 10 10 Nuts, Seeds, Soy Products (ounce eq/wk) 3 4 4 5 5 5 5 Oils (grams/day) 17 22 24 27 29 31 34 Limit on Calories for Other Uses (kcal/day)d 50 100 140 240 250 320 350 Limit on Calories for Other Uses (%/day) 4% 6% 8% 12% 11% 13% 13% a Calorie level ranges: Females: 1,400-2,200; Males: 1,600-2,600. d All foods are assumed to be in nutrient-dense forms; lean or Energy levels are calculated based on reference height (median) and low-fat; and prepared with minimal added sugars, saturated fat, reference weight (healthy) corresponding with a healthy body mass refined starches, or sodium. If all food choices to meet food group index (BMI). Calorie needs vary based on many factors. The DRI recommendations are in nutrient-dense forms, a small number of Calculator for Healthcare Professionals, available at nal.usda.gov/ calories remain within the overall limit of the pattern (i.e., limit on fnic/dri-calculator, can be used to estimate calorie needs based on calories for other uses). The number of calories depends on the age, sex, height, weight, and activity level. total calorie level of the pattern and the amounts of food from each b food group required to meet nutritional goals. Calories up to the Definitions for each food group and subgroup and quantity (i.e., specified limit can be used for added sugars and/or saturated cup or ounce equivalents) are provided in Chapter 1 and are compiled fat, or to eat more than the recommended amount of food in a in Appendix 3. food group. c The U.S. Food and Drug Administration (FDA) and the U.S. NOTE: The total dietary pattern should not exceed Dietary Guidelines Environmental Protection Agency (EPA) provide joint advice regarding limits for added sugars and saturated fat; be within the Acceptable seafood consumption to limit methylmercury exposure for children. Macronutrient Distribution Ranges for protein, carbohydrate, and Depending on body weight, some children should choose seafood total fats; and stay within calorie limits. Values are rounded. See lowest in methylmercury or eat less seafood than the amounts Appendix 3 for all calorie levels of the pattern. in the Healthy US-Style Dietary Pattern. More information is available on the FDA and EPA websites at FDA.gov/fishadvice and EPA.gov/fishadvice. Page 81 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents AGES 2-18 Current Intakes Figure 3-6 Current Intakes: Ages 9 Through 13 Average Daily Food Group Intakes Compared to Recommended Intake Ranges Recommended Intake Ranges Average Intakes Healthy Eating Index Score 10 (on a scale of 0-100) 9 8 7 52 6 5 4 3 2 1 0 M F M F M F M F M F Total Total Total Total Total Vegetables Fruits Grains Dairy Protein Foods cup eq/day cup eq/day oz eq/day cup eq/day oz eq/day FOOD GROUPS Percent Exceeding Limits of Added Sugars, Exceeding Limit Within Recommended Limit Saturated Fat, and Sodium Added Sugars Saturated Fat Sodium Limit: 10% of total energy Limit: 10% of total energy Limit: 1,800 mg Males Females Males Females Males Fema es 79% 78% 88% 86 l % 97% 96% Average Intakes Average Intakes Average Intakes Males Females Males Females Males Females 322 kcal 264 kcal 259 kcal 229 kcal 3,451 mg 3,030 mg Data Sources: Average Intake and HEI-2015 Scores: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Percent Exceeding Limits: What We Eat in America, NAHgAeNEsS 9 2-01133-2016, 2 days dietary intake data, weighted. Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 82 CUP or OZ EQUIVALENT AGES 2-18 Figure 3-7 Average Intakes of Subgroups Compared to Recommended Intake Ranges: Ages 9 Through 13 Recommended Intake Ranges Average Intakes Vegetables 8 7 6 5 4 3 2 1 0 M F M F M F M F M F M F Total Dark- Red & Beans, Starchy Other Vegetables Green Orange Peas, cup eq/day Lentils cup eq/week 10 Grains 9 8 7 6 5 4 3 2 1 0 M F M F M F Total Whole Grains Refined Grains Grains oz eq/day Protein Foods 35 30 25 20 15 10 5 0 M F M F M* F M F Total Meats, Poultry, Seafood Nuts, Seeds, Protein Foods Eggs Soy Products oz eq/day oz eq/week *NOTE: Estimates may be less precise than others due to small sample size and/or large relative standard error. Data Sources: Average Intakes: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Page 83 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents OZ EQUIVALENT OZ EQUIVALENT CUP EQUIVALENT AGES 2-18 Adolescents Ages 14 Through 18 Adolescent females require about 1,800 to 2,400 calories per day and males require about 2,000 to 3,200 calories per day. Table 3-3 Healthy U�S�-Style Dietary Pattern for Adolescents Ages 14 Through 18, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200 FOOD GROUP OR SUBGROUPb Daily Amount of Food From Each Group (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 2 ½ 2 ½ 3 3 3 ½ 3 ½ 4 4 Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) 1 ½ 1 ½ 2 2 2 ½ 2 ½ 2 ½ 2 ½ Red and Orange Vegetables (cup eq/wk) 5 ½ 5 ½ 6 6 7 7 7 ½ 7 ½ Beans, Peas, Lentils (cup eq/wk) 1 ½ 1 ½ 2 2 2 ½ 2 ½ 3 3 Starchy Vegetables (cup eq/wk) 5 5 6 6 7 7 8 8 Other Vegetables (cup eq/wk) 4 4 5 5 5 ½ 5 ½ 7 7 Fruits (cup eq/day) 1 ½ 2 2 2 2 2 ½ 2 ½ 2 ½ Grains (ounce eq/day) 6 6 7 8 9 10 10 10 Whole Grains (ounce eq/day) 3 3 3 ½ 4 4 ½ 5 5 5 Refined Grains (ounce eq/day) 3 3 3 ½ 4 4 ½ 5 5 5 Dairy (cup eq/day) 3 3 3 3 3 3 3 3 Protein Foods (ounce eq/day) 5 5 ½ 6 6 ½ 6 ½ 7 7 7 Protein Foods Subgroups in Weekly Amounts Meats, Poultry, Eggs (ounce eq/wk) 23 26 28 31 31 33 33 33 Seafood (ounce eq/wk) 8 8 9 10 10 10 10 10 Nuts, Seeds, Soy Products (ounce eq/wk) 4 5 5 5 5 6 6 6 Oils (grams/day) 24 27 29 31 34 36 44 51 Limit on Calories for Other Uses (kcal/day)c 140 240 250 320 350 370 440 580 Limit on Calories for Other Uses (%/day) 8% 12% 11% 13% 13% 13% 15% 18% a Calorie level ranges: Females: 1,800-2,400 calories; Males: 2,000- refined starches, or sodium. If all food choices to meet food group 3,200 calories. Energy levels are calculated based on reference height recommendations are in nutrient-dense forms, a small number of (median) and reference weight (healthy) corresponding with a healthy calories remain within the overall limit of the pattern (i.e., limit on body mass index (BMI). Calorie needs vary based on many factors. The calories for other uses). The number of calories depends on the total DRI Calculator for Healthcare Professionals, available at nal.usda.gov/ calorie level of the pattern and the amounts of food from each food fnic/dri-calculator, can be used to estimate calorie needs based on group required to meet nutritional goals. Calories up to the specified age, sex, height, weight, activity level. limit can be used for added sugars and/or saturated fat, or to eat more than the recommended amount of food in a food group. b Definitions for each food group and subgroup and quantity (i.e., cup or ounce equivalents) are provided in Chapter 1 and are compiled in NOTE: The total dietary pattern should not exceed Dietary Guidelines Appendix 3. limits for added sugars and saturated fat; be within the Acceptable Macronutrient Distribution Ranges for protein, carbohydrate, and total c All foods are assumed to be in nutrient-dense forms; lean or fats; and stay within calorie limits. Values are rounded. See Appendix 3 low-fat; and prepared with minimal added sugars, saturated fat, for all calorie levels of the pattern. Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 84 AGES 2-18 Current Intakes Figure 3-8 Current Intakes: Ages 14 Through 18 Average Daily Food Group Intakes Compared to Recommended Intake Ranges Healthy Eating Index Score Recommended Intake Ranges Average Intakes (on a scale of 0-100) 12 11 10 9 51 8 7 6 5 4 3 2 1 0 M F M F M F M F M F Total Total Total Total Total Vegetables Fruits Grains Dairy Protein Foods cup eq/day cup eq/day oz eq/day cup eq/day oz eq/day FOOD GROUPS Percent Exceeding Limits of Added Sugars, Exceeding Limit Within Recommended Limit Saturated Fat, and Sodium Added Sugars Saturated Fat Sodium Limit: 10% of total energy Limit: 10% of total energy Limit: 2,300 mg Males Females Males Females Males Females 72% 76% 85% 78 % 97% 77% Average Intakes Average Intakes Average Intakes Males Females Males Females Males Females 347 kcal 277 kcal 276 kcal 204 kcal 3,888 mg 2,875 mg Data Sources: Average Intake and HEI-2015 Scores: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Percent Exceeding Limits: What We Eat in America, NAHgAeNsES 1 2401-31-28016, 2 days dietary intake data, weighted. Page 85 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents CUP or OZ EQUIVALENT AGES 2-18 Figure 3-9 Average Intakes of Subgroups Compared to Recommended Intake Ranges: Ages 14 Through 18 Recommended Intake Ranges Average Intakes Vegetables 9 8 7 6 5 4 3 2 1 0 M F M F M F M F M F M F Total Dark- Red & Beans, Starchy Other Vegetables Green Orange Peas, cup eq/day Lentils cup eq/week Grains 12 11 10 9 8 7 6 5 4 3 2 1 0 M F M F M F Total Grains Whole Grains Refined Grains oz eq/day Protein Foods 40 35 30 25 20 15 10 5 0 M F M F M F M F Total Protein Meats, Poultry, Seafood Nuts, Seeds, Foods Eggs Soy Products oz eq/day oz eq/week Data Sources: Average Intakes: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 86 OZ EQUIVALENT OZ EQUIVALENT CUP EQUIVALENT AGES 2-18 Special increases throughout childhood and adolescence, and sugar-sweetened beverages are a top contributor. As Considerations a percent of total daily energy intake, average intake of added sugars is 11 percent among young children and The nutrition considerations for the general U.S. peaks at 15 percent during adolescence. Coinciding with population described in Chapter 1 apply to children this increase is the contribution of sugar-sweetened and adolescents. For example, due to low intakes of beverages to total intake of added sugars. In childhood, food groups as described above, the nutrients of public sugar-sweetened beverages make up about 15 to 25 health concern—calcium, vitamin D, potassium, and percent of total added sugars intake. By adolescence, dietary fiber—apply to these life stages as well. Although their contribution is 32 percent and even higher when the nutritional needs of youth are remarkably similar considering coffee and tea beverages with added to their parents, guardians, and caregivers, these age sugars (an additional 7 percent). Most sugar-sweetened groups do have some special nutrition considerations. beverages (e.g., soda, sports drinks) do not contribute Specifically, increasing intakes of sugar-sweetened to meeting food group goals and often contain a high beverages and decreasing intakes of dairy are dietary number of calories. components with notable and concerning shifts in consumption throughout youth. Dietary intake patterns Decreasing consumption of sugar-sweetened beverages for adolescents, particularly females, also are an area of to reduce added sugars intake will help youth achieve special consideration. a healthy dietary pattern. Beverages that contain no added sugars should be the primary choice for children Accounting for the areas of dietary improvement that and adolescents. These include water and unsweetened are important for all children and adolescents, as well fat-free or low-fat milk—including low-lactose or lactose- as these special considerations, can improve diet quality free options or fortified soy beverage—and 100% juice during a time when food preferences and intake patterns within recommended amounts. Consuming beverages are formed. When consistently followed, these healthy with no added sugars is particularly important for young dietary patterns can provide the foundation for healthy children ages 2 through 8, when only a small number of dietary patterns in adulthood, promote health among calories remains for other uses after meeting food group youth, and help prevent the onset of chronic disease and nutrient needs with nutrient-dense choices (Table later in life. 3-1). The number of calories available for other uses increases slightly as energy needs increase throughout Sugar-Sweetened Beverages adolescence to support growth and development Sugar-sweetened beverages (e.g., soda, fruit drinks, (Tables 3-2 and 3-3). However, most adolescents do not sports and energy drinks) are not necessary in the consume foods and beverages in their nutrient-dense child or adolescent diet nor are they a component of forms, meaning they have few or no calories remaining the USDA Dietary Patterns. Intake of added sugars for added sugars. Page 87 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents AGES 2-18 Juice Many juice products, such as fruit drinks, contain minimal juice content and are considered sugar-sweetened beverages because they are primarily composed of water with added sugars. The percent of juice in a beverage may be found on the package label, such as “contains 25% juice” or “100% fruit juice.” The Nutrition Facts label identifies the amount of sugars in juice products that are not naturally occurring (i.e., added sugars). Although 100% fruit juice without added sugars can be part of a healthy dietary pattern, it is lower in dietary fiber than whole fruit. Dietary fiber is a dietary component of public health concern. With the recognition that fruit should mostly be consumed in whole forms, the amount of fruit juice in the USDA Food Patterns ranges from 4 fluid ounces at the lower calorie levels and no more than 10 fluid ounces at the highest calorie levels. Dairy and Fortified Soy Alternatives Throughout childhood and adolescence, the types of dairy foods consumed and their contribution to a healthy dietary pattern change. Milk consumption, particularly milk as a beverage, is lower and cheese intake, typically as part of mixed dishes such as sandwiches, pizza, or pasta, is higher among adolescents when compared to younger children. These differences in consumption occur alongside the widening gap between current and recommended intakes of dairy foods that occurs throughout youth. Nutrient-dense options within the dairy group are unsweetened fat-free and low-fat (1%) milk, yogurt, cheese, fortified soy beverages and yogurt, and low-lactose and lactose-free dairy products. Dairy and fortified soy alternatives provide protein and a variety of nutrients that are underconsumed during these life stages. These include three nutrients of public health concern discussed in Chapter 1: potassium, calcium, and vitamin D. The nutrient composition of dairy foods highlights the importance of adequate consumption. This is especially relevant for calcium and vitamin D, given that adolescents have an increased need for consumption to support the accrual of bone mass. Adolescent Nutrition The difference between recommended food group amounts and current intakes is greater for adolescents ages 14 through 18 than for any other age group across the lifespan. As a result, adolescents are at greater risk of dietary inadequacy than are other age groups. For adolescent males and females, low intakes of nutrient-dense foods and beverages within the grains, dairy and alternatives, fruits, and vegetables food groups lead to low intakes of phosphorus, magnesium, and choline. Adolescent females also consume less meat, poultry, and eggs than do adolescent males, and in combination with low consumption of seafood and other protein subgroups, including beans, peas, and lentils, this results in the underconsumption of total protein. In addition, adolescent females have low dietary intakes of iron, folate, vitamin B6, and vitamin B12. The potential for nutrient deficiencies existing alongside underconsumption of nutrients of public health concern for all Americans creates a concerning constellation of nutritional risks at a time of rapid growth and development along with the onset of puberty, menarche, and hormonal changes. Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 88 AGES 2-18 Supporting dislike for vegetables in the cooked form but accept the raw version. Or, children may only accept fruit when Healthy Eating it is cut into small, bite-sized pieces. Even with these strategies, parents, guardians, and caregivers of young The physical, mental, and emotional changes that occur children should know it may take up to 8 to 10 exposures as children transition from pre-school to school-age before a child will accept a new food. and into adolescence come with diverse and changing opportunities to support a healthy dietary pattern. Children’s dietary patterns often resemble those of Support and active engagement from the various their household, highlighting the importance of their people and places involved in the lives of children and environment in the establishment of a healthy dietary adolescents is necessary to help establish and maintain pattern. Shared meals through shopping, cooking, healthy dietary patterns that support healthy weight and and consumption provides parents, guardians, and the prevention of chronic disease. caregivers with an opportunity to model healthy eating behaviors and dietary practices. By making In early childhood, parents, guardians, and caregivers nutrient-dense foods and beverages part of the normal have a primary role in supporting healthy eating because household routine, children can observe and learn they control the foods and beverages purchased, healthy behaviors that can extend throughout later prepared, and served. Exposing young children to a life stages. variety of nutrient-dense foods within each food group helps build a healthy dietary pattern at an age when Ideally, children continue to be exposed to a healthy taste preferences are acquired. Introducing children to dietary pattern as they experience changes to their daily a variety of nutrient-dense foods can be challenging. routines, such as spending time in child care or school As children grow, their search for a sense of autonomy settings. As at home, eating occasions in these settings and desire for independence often manifest through can be used as opportunities to support a healthy dietary selective or “picky” eating, food neophobia, or food “jags” pattern. For example, snacks can be used as a way to (eating only one or a few foods for periods of time). promote intake of nutrient-dense fruits and vegetables, Offering the same type of food to children multiple like carrot sticks and hummus or apple slices, instead times, in a variety of forms, or prepared in different ways of foods like chips or cookies. Using snacks as an can increase acceptance and intake of healthy foods opportunity to encourage nutrient-dense food group within food groups. For example, children may show a choices is especially relevant during early childhood when the total volume of food consumed at regular meals is lower and snacking is common. When exposed to nutrient-dense foods and beverages at an early age and supported in making healthy choices across environments, a healthy dietary pattern can be established and maintained as children transition to the adolescence life stage. With this transition comes increasing autonomy, increased influence of peers, and decreased influence of parents, guardians, and caregivers on food choice. As a result, foods and beverages are more commonly consumed outside of the home, often with a preference for convenience foods that often are not nutrient-dense. Parents, guardians, and caregivers can continue to support healthy eating during this life stage by providing convenient access to nutrient-dense foods; involving children and adolescents in meal decisions, shopping, and cooking; and guiding adolescents’ selection of food purchased and consumed outside the home. In schools and community settings, healthy eating can be encouraged by creating an environment that makes healthy choices the norm. Page 89 | Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents AGES 2-18 Accessing a Healthy Dietary Pattern • Outside of the school year, the Summer Food Many resources exist to support healthy growth and Service Program (SFSP) fills the gap by ensuring development during childhood and adolescence. The that children continue to receive nutritious meals following Government programs play an essential role when school is not in session. The SFSP operates in providing access to healthy meals and educational at sites in a community where children can resources to support healthy dietary patterns for all receive nutritious meals in a safe and children and adolescents. supervised environment. • The Supplemental Nutrition Assistance Program Professionals working with youth and their families (SNAP) provides temporary benefits to families with can use these, and additional Government and qualifying incomes for the purchase of foods and non-Government resources that exist at the community, beverages. About one-half of all SNAP participants to support healthy eating during these life stages and to are children.1 establish the foundation for a healthy dietary pattern that will promote health and support disease prevention in • Households with young children may be eligible for later years. the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). WIC can help families with limited resources meet their child’s nutritional needs by providing nutritious foods to Looking Toward supplement diets. WIC serves children up to the age of 5 years who are at nutritional risk. Chapter 4: Adults • In childcare and afterschool settings, the Child This chapter focused on nutrition issues relevant to and Adult Care Food Program (CACFP) can children and adolescents. These issues are particularly support the development of healthy dietary important because this life stage encompasses patterns. CACFP is a nutrition program that provides significant transitions, from young children who are reimbursements for meals and snacks that align still dependent on parents, guardians, and caregivers with the Dietary Guidelines to eligible children for all their food choices, to adolescents who are enrolled at childcare centers, daycare homes, highly independent in their food choices. Diet quality and in afterschool programs. tends to decrease as children mature into adolescence, with resulting concerns about underconsumption • School-age children can benefit from the National of nutrients of public health concern. Establishing School Lunch Program and School Breakfast and maintaining healthy food and beverages choices Program. The school meal programs can provide now can set a firm foundation for healthy dietary nearly two-thirds of daily calories, and therefore play patterns that reduce the risk of diet-related chronic an influential role in the development of a healthy disease, an issue of increasing relevance to adults, dietary pattern. who are considered in the next chapter. 1Source: Characteristics of Supplemental Nutrition Assistance Program Households: Fiscal Year 2018. Available at: www.fns.usda.gov/snap/ characteristics-supplemental-nutrition-assistance-program-households-fiscal-year-2018. Dietary Guidelines for Americans, 2020-2025 | Chapter 3: Children and Adolescents | Page 90 ADULTS AGES 19-59 Page 91 | Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults ADULTS AGES 19-59 CHAPTER4 Adults Dietary Guidelines for Americans,, 2020-2025 | Chapter 4: Adults | Page 92 ADULTS AGES 19-59 Introduction Many individuals enter the adult life stage with an unhealthy dietary pattern already established from The adult life stage (ages 19 through the childhood and adolescent years. 59) is characterized by independence, A concerted effort to change this trajectory and support adults in opportunity, and increased responsibility— adopting a healthy dietary pattern is needed for better health and to from starting or completing education promote the well-being of family and friends across life stages. Learned and training, to managing work and/or food and beverage preferences, and family, to planning for the transition to norms and values placed on diet, physical activity, and health, can older adulthood. Balancing work or school positively or negatively influence health because they can determine responsibilities with personal, family, an individual’s willingness to change and maintain behaviors. These norms or other commitments can create real and values, including preferences or perceived barriers to healthy eating. toward certain types of food, attitudes about healthy eating, and beliefs Constraints on available time and financial about the importance of physical activity, can extend beyond the resources may make it challenging for individual to larger social networks, influencing the behaviors of friends adults to adopt and maintain a healthy and older or younger family members. dietary pattern. Support for healthy food Among adults caring for children, role modeling healthy dietary choices and beverage choices across the multiple is important because the food components of public health concern places where adults live, work, play, observed in earlier life stages are similar for adults. and gather is needed to improve dietary Following a healthy dietary pattern, patterns among adults. engaging in regular physical activity, and managing body weight are critical during this life stage. More than one-half of adults are living with one or more chronic disease—diseases that are often related to poor-quality diets and physical inactivity. Improving dietary patterns in adulthood can play a beneficial role in promoting health and preventing the onset or rate of progression of chronic disease. For adults with overweight or obesity, making healthful changes to dietary patterns and increasing physical activity will improve health and prevent additional weight gain and/ or promote weight loss (see “The Importance of Physical Activity” and “Overweight and Obesity”). Page 93 | Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults ADULTS AGES 19-59 The Importance of Physical Activity Adults who are physically active are healthier, feel better, and are less likely to develop many chronic diseases than are adults who are inactive. For adults, regular physical activity can provide both immediate benefits (e.g., boost mood, reduce stress, improve sleep) and long-term benefits (e.g., improved bone health and reduced risk of many diseases, such as cardiovascular disease, type 2 diabetes, depression, dementia, and many types of cancer). Adults should move more and sit less throughout the day. Some physical activity is better than none. To attain the most health benefits from physical activity, adults need at least 150 to 300 minutes of moderate- intensity aerobic activity, like brisk walking or fast dancing, each week. Adults also need muscle-strengthening activity, like lifting weights or doing push-ups, at least 2 days each week. The U.S. Department of Health and Human Service’s Physical Activity Guidelines for Americans and related Move Your Way® resources have more information about the benefits of physical activity and tips on how to get started. Available at health.gov/paguidelines. Overweight and Obesity In the United States, 74 percent of adults have overweight or obesity, creating an increased risk for the development of other chronic health conditions, including cardiovascular disease, type 2 diabetes, and certain types of cancer. Losing weight and maintaining weight loss is not a simple task. It requires adults to reduce the number of calories they get from foods and beverages and increase the amount expended through physical activity. Weight loss and maintenance are not likely achieved using short-term solutions. They require a commitment to long-term lifestyle change and often need support from healthcare providers, family members, and social networks. Intensive behavioral interventions that use one or more strategies—like group sessions and changes in both diet and physical activity—can be effective for individuals trying to lose a significant amount of weight. In addressing obesity, professionals should be mindful of health problems stemming from obesity-related stigma and discrimination. The Centers for Disease Control and Prevention’s website provides resources to support preventing weight gain (cdc.gov/healthyweight/ prevention/index.html) and losing weight (cdc.gov/healthyweight/ losing_weight/index.html). Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults | Page 94 ADULTS AGES 19-59 Healthy Dietary Patterns Adults are encouraged to follow the recommendations on the types of foods and beverages that make up a healthy dietary pattern described in Chapter 1. Nutrition and Health Across the Lifespan: The Guidelines and Key Recommendations. The USDA Dietary Patterns provide a framework of nutrient-dense foods and beverages that can be adapted to accommodate budget, culture, and personal preferences to help adults follow a healthy dietary pattern and meet the Guidelines and their Key Recommendations. Table 4-1 displays the Healthy U.S.-Style Dietary Pattern at eight calorie levels that are appropriate for most adults ages 19 through 59 years to illustrate the specific amounts and limits for food groups and other dietary components that make up healthy dietary patterns. In general, calorie needs are lower for females compared to males. Calorie needs decline throughout adulthood due to changes in metabolism that accompany aging. Level of physical activity, body composition, and the presence of chronic disease are additional factors that affect calorie needs. Females ages 19 through 30 require about 1,800 to 2,400 calories a day. Males in this age group have higher calorie needs of about 2,400 to 3,000 a day. Calorie needs for adults ages 31 through 59 are generally lower; most females require about 1,600 to 2,200 calories a day and males require about 2,200 to 3,000 calories a day. Additional information on these estimates is provided in Table 4-1 (footnote a) and in Appendix 2. Estimated Calorie Needs. The USDA Dietary Patterns are discussed in greater detail in Chapter 1 and Appendix 3. USDA Dietary Patterns. Nutrient-Dense Foods and Beverages Nutrient-dense foods and beverages provide vitamins, minerals, and other health-promoting components and have little added sugars, saturated fat, and sodium. Vegetables, fruits, whole grains, seafood, eggs, beans, peas, and lentils, unsalted nuts and seeds, fat-free and low-fat dairy products, and lean meats and poultry—when prepared with no or little added sugars, saturated fat, and sodium—are nutrient-dense foods. Page 95 | Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults ADULTS AGES 19-59 Table 4-1 Healthy U�S�-Style Dietary Pattern for Adults Ages 19 Through 59, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 FOOD GROUP OR SUBGROUPb Daily Amount of Food From Each Group (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 2 2 ½ 2 ½ 3 3 3 ½ 3 ½ 4 Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) 1 ½ 1 ½ 1 ½ 2 2 2 ½ 2 ½ 2 ½ Red & Orange Vegetables (cup eq/wk) 4 5 ½ 5 ½ 6 6 7 7 7 ½ Beans, Peas, Lentils (cup eq/wk) 1 1 ½ 1 ½ 2 2 2 ½ 2 ½ 3 Starchy Vegetables (cup eq/wk) 4 5 5 6 6 7 7 8 Other Vegetables (cup eq/wk) 3 ½ 4 4 5 5 5 ½ 5 ½ 7 Fruits (cup eq/day) 1 ½ 1 ½ 2 2 2 2 2 ½ 2 ½ Grains (ounce eq/day) 5 6 6 7 8 9 10 10 Whole Grains (ounce eq/day) 3 3 3 3 ½ 4 4 ½ 5 5 Refined Grains (ounce eq/day) 2 3 3 3 ½ 4 4 ½ 5 5 Dairy (cup eq/day) 3 3 3 3 3 3 3 3 Protein Foods (ounce eq/day) 5 5 5 ½ 6 6 ½ 6 ½ 7 7 Protein Foods Subgroups in Weekly Amounts Meats, Poultry, Eggs (ounce eq/wk) 23 23 26 28 31 31 33 33 Seafood (ounce eq/wk) 8 8 8 9 10 10 10 10 Nuts, Seeds, Soy Products (ounce eq/wk) 4 4 5 5 5 5 6 6 Oils (grams/day) 22 24 27 29 31 34 36 44 Limit on Calories for Other Uses (kcal/day)c 100 140 240 250 320 350 370 440 Limit on Calories for Other Uses (%/day) 6% 8% 12% 11% 13% 13% 13% 15% a Calorie level ranges: Ages 19 through 30, Females: 1,800-2,400 calories; Males: 2,400-3,000 calories. Ages 31 through 59, Females: 1,600-2,200 calories; Males 2,200-3,000 calories. Energy levels are calculated based on median height and body weight for healthy body mass index (BMI) reference individuals. For adults, the reference man is 5 feet 10 inches tall and weighs 154 pounds. The reference woman is 5 feet 4 inches tall and weighs 126 pounds. Calorie needs vary based on many factors. The DRI Calculator for Healthcare Professionals, available at nal.usda.gov/ fnic/dri-calculator, can be used to estimate calorie needs based on age, sex, height, weight, and activity level. b Definitions for each food group and subgroup and quantity (i.e., cup or ounce equivalents) are provided in Chapter 1 and are compiled in Appendix 3. c All foods are assumed to be in nutrient-dense forms; lean or low-fat; and prepared with minimal added sugars, refined starches, saturated fat, or sodium. If all food choices to meet food group recommendations are in nutrient-dense forms, a small number of calories remain within the overall limit of the pattern (i.e., limit on calories for other uses). The number of calories depends on the total calorie level of the pattern and the amounts of food from each food group required to meet nutritional goals. Calories up to the specified limit can be used for added sugars, saturated fat, or alcohol, or to eat more than the recommended amount of food in a food group. NOTE: The total dietary pattern should not exceed Dietary Guidelines limits for added sugars, saturated fat, and alcohol; be within the Acceptable Macronutrient Distribution Ranges for protein, carbohydrate, and total fats; and stay within calorie limits. Values are rounded. See Appendix 3 for all calorie levels of the pattern. Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults | Page 96 ADULTS AGES 19-59 Current Intakes Figure 4-1 Current Intakes: Ages 19 Through 30 Average Daily Food Group Intakes Compared to Healthy Eating Index Score Recommended Intake Ranges (on a scale of 0-100) Recommended Intake Ranges Average Intakes 12 11 10 56 9 8 7 6 5 4 3 2 1 0 M F M F M F M F M F Total Total Total Total Total Vegetables Fruits Grains Dairy Protein Foods cup eq/day cup eq/day oz eq/day cup eq/day oz eq/day FOOD GROUPS Percent Exceeding Limits of Added Sugars, Exceeding Limit Within Recommended Limit Saturated Fat, and Sodium Added Sugars Saturated Fat Sodium Limit: 10% of total energy Limit: 10% of total energy Limit: 2,300 mg Males Females Males Females Males Females 62% 66% 76% 71% 97% 84% Average Intakes Average Intakes Average Intakes Males Females Males Females Males Females 313 kcal 271 kcal 292 kcal 218 kcal 4,274 mg 3,142 mg Data Sources: Average Intakes and HEI-2015 Scores: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Percent Exceeding Limits: What We Eat in America, NAHgAeNsES 1 2901-3-02016, 2 days dietary intake data, weighted. Page 97 | Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults CUP or OZ EQUIVALENT ADULTS AGES 19-59 Figure 4-2 Figures 4-1 to 4-4 highlight the dietary intake of Average Intakes of Subgroups Compared adults, including the Healthy Eating Index-2015 to Recommended Intake Ranges: (HEI) score, which is an overall measure of how Ages 19 Through 30 intakes align with the Dietary Guidelines, as well Recommended Intake Ranges Average Intakes as information on the components of a healthy Vegetables diet—specifically, the food groups. Figures 4-1 and 9 4-3 display the average intakes of the food groups 8 compared to the range of recommended intakes 7 at the calorie levels most relevant to males and 6 females in both adult age groups. Additionally, the percent of adults exceeding the limits for added 5 sugars, saturated fat, and sodium is shown, along 4 with average intakes of these components. Average 3 intakes compared to recommended intake ranges 2 of the subgroups for grains are represented in daily 1 amounts; subgroups for vegetables and protein 0 foods are represented in weekly amounts (see M F M F M F M F M F M F Figures 4-2 and 4-4). Total Dark- Red & Beans, Starchy Other Vegetables Green Orange Peas, cup eq/day Lentils The HEI scores in Figures 4-1 and 4-3 show that cup eq/week adults across this life stage have diets that do not Grains align with the recommendations for food group and 12 nutrient intake as described in Chapter 1. Although 11 10 intake patterns are generally not consistent with the 9 Dietary Guidelines, adults ages 31 through 59 have a 8 slightly higher HEI score (59 out of 100) compared 7 to adults ages 19 through 30 (56 out of 100). 6 5 4 3 2 1 0 M F M F M F Total Whole Grains Refined Grains Grains oz eq/day Protein Foods 50 45 40 35 30 25 20 15 10 5 0 M F M F M* F M F Total Meats, Poultry, Seafood Nuts, Seeds, Protein Foods Eggs Soy Products oz eq/day oz eq/week *NOTE: Estimates may be less precise than others due to small sample size and/or large relative standard error. Data Sources: Average Intakes: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults | Page 98 OZ EQUIVALENT OZ EQUIVALENT CUP EQUIVALENT ADULTS AGES 19-59 Figure 4-3 Current Intakes: Ages 31 Through 59 Average Daily Food Group Intakes Compared to Healthy Eating Index Score Recommended Intake Ranges (on a scale of 0-100) Recommended Intake Ranges Average Intakes 12 11 59 10 9 8 7 6 5 4 3 2 1 0 M F M F M F M F M F Total Total Total Total Total Vegetables Fruits Grains Dairy Protein Foods cup eq/day cup eq/day oz eq/day cup eq/day oz eq/day FOOD GROUPS Percent Exceeding Limits of Added Sugars, Exceeding Limit Within Recommended Limit Saturated Fat, and Sodium Added Sugars Saturated Fat Sodium Limit: 10% of total energy Limit: 10% of total energy Limit: 2,300 mg Males Females Males Females Males Females 59% 63% 73% 70% 97% 82% Average Intakes Average Intakes Average Intakes Males Females Males Females Males Females 348 kcal 233 kcal 284 kcal 211 kcal 4,172 mg 3,062 mg Data Sources: Average Intakes and HEI-2015 Scores: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Percent Exceeding Limits: What We Eat in America, NAHgAeNsES 3 2101-53-92016, 2 days dietary intake data, weighted. Page 99 | Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults CUP or OZ EQUIVALENT ADULTS AGES 19-59 Figure 4-4 Average Intakes of Subgroups Compared to Recommended Intake Ranges: Ages 31 Through 59 Recommended Intake Ranges Average Intakes Vegetables 9 8 7 6 5 4 Average intakes of fruits, vegetables, and dairy 3 fall below the range of recommended intakes for 2 all adults. Although average total grains intakes meets recommendations, Figures 4-2 and 4-4 1 show that intake of whole grains is well below 0 M F M F M F M F M F M F recommendations, and intakes of refined grains Total Dark- Red & Beans, Starchy Other exceeds the upper end of the recommended Vegetables Green Orange Peas, cup eq/day Lentils intake range for adults in both age groups. Intakes cup eq/week of protein foods generally meets or exceeds Grains recommended intake levels. Current patterns 12 generally include meats, poultry, eggs, and nuts, 11 seeds, and soy, while average intake of seafood 10 falls well below recommendations. Beans, peas, 9 8 and lentils—a subgroup of both the vegetable and 7 protein foods groups—also are underconsumed by 6 most adults. 5 4 Figures 4-1 and 4-3 show that adults are exceeding 3 recommendations for added sugars, saturated 2 fat, and sodium. About 60 percent of men and 1 0 65 percent of women exceed the limit for intakes M F M F M F of added sugars. This is an average daily intake Total Whole Grains Refined Grains Grains of about 330 calories from added sugars for oz eq/day men and around 250 calories for women. More Protein Foods than 70 percent of adults are exceeding the 50 recommendations for saturated fat. The average 45 daily intakes of saturated fat is about 290 calories 40 for men and 210 calories for women. The calorie 35 levels relevant to most adults (1,600-3,000 calories) 30 have about 100 to 400 calories remaining after food 25 group recommendations are met through nutrient- 20 dense choices. Combined, these average amounts 15 of calories from added sugars and saturated fat 10 exceed the amount most adults have available— 5 and do not account for calories from alcoholic 0 beverages. For sodium, nearly all men and about M F M F M F M F 80 percent of women consume too much on a given Total Meats, Poultry, Seafood Nuts, Seeds, Protein Foods Eggs Soy Products day. Men generally consume more than 4,000 mg of oz eq/day oz eq/week sodium per day and women more than 3,000 mg. Data Sources: Average Intakes: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults | Page 100 OZ EQUIVALENT OZ EQUIVALENT CUP EQUIVALENT ADULTS AGES 19-59 Special Considerations The dietary considerations for the general U.S. population, including adults, are described in Chapter 1. The following sections of this chapter focus on several special considerations to support a healthy dietary pattern for adults that reflect adults’ current intake patterns and the prevalence of overweight and obesity and diet-related chronic disease that become more apparent in this life stage. These considerations include a focus on dietary changes to increase intakes of dietary fiber, calcium, and vitamin D and to decrease intakes of added sugars, saturated fat, and sodium. Special considerations related to alcoholic beverages also are discussed. Dietary Fiber Dietary patterns that do not meet recommended intakes of fruits, vegetables, and whole grains contribute to low intakes of dietary fiber. More than 90 percent of women and 97 percent of men do not meet recommended intakes for dietary fiber. This aligns with intake patterns where fruits, vegetables, and whole grains are underconsumed by more than 85 percent of adults. Appendix 1. Nutritional Goals for Age-Sex Groups provides dietary fiber goals for men and women based on the Dietary Reference Intakes. These recommendations are based on levels observed to reduce risk of coronary heart disease. Increasing intakes of fruits, vegetables, and replacing refined these nutrients. Particular attention should be given grains with whole grains to improve dietary fiber intakes to consuming adequate amounts of foods with these is especially important during this life stage, as the nutrients during adult years to promote optimal bone impact of poor diet quality becomes apparent with health and prevent the onset of osteoporosis. Adequate the onset and/or progression of diet-related chronic intake of calcium and vitamin D is particularly diseases. Chapter 1 provides strategies on how to important for adults during the time period when peak increase intakes of these important food groups. A list bone mass is still actively accruing (ages 19 through of common food sources of dietary fiber is available at about 30) and, for women, in the post-menopausal DietaryGuidelines.gov� period when rapid bone remodeling occurs. Calcium and Vitamin D A healthy dietary pattern with nutrient-dense, Calcium and vitamin D are important at any age, and calcium-rich foods, such as low-fat milk and yogurt most adults do not consume adequate amounts. and fortified soy alternatives and canned sardines Close to 30 percent of men and 60 percent of women and salmon, can help adults better meet intake older than age 19 years do not consume enough recommendations. Vitamin D aids in the absorption calcium, and more than 90 percent do not consume of calcium. Consuming the recommended amount enough vitamin D. Dietary patterns that do not meet of seafood and choosing foods that are fortified with recommended intake amounts for food groups and vitamin D, including milk, fortified soy beverages, and subgroups, which include sources of calcium and fortified soy yogurt, and some whole-grain cereals, vitamin D—such as dairy foods and fortified soy can help adults meet their needs. In addition to dietary alternatives and seafood—contribute to low intake of sources, the body can make vitamin D from the Page 101 | Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults ADULTS AGES 19-59 About 70 to 75 percent of adults exceed the 10-percent limit on saturated fat as a result of selecting foods and beverages across food groups that are not in nutrient- dense forms. The top sources of saturated fat for adults are sandwiches (e.g., deli sandwiches, burgers, tacos, burritos, grilled cheese, hot dogs) and other grain-based mixed dishes (e.g. spaghetti and meatballs, casseroles, quesadillas) that typically contain ingredients from several food groups that are not in nutrient-dense forms, including grains, protein foods, and dairy. Making changes to the type of ingredients as well as amount and/or frequency of their consumption will help adults lower saturated fat intake without a need to eliminate these foods from the household diet. Strategies include using lean meats and low-fat cheese to prepare these foods or substituting beans in place of meats as the protein source. Saturated fat also can be reduced by substituting certain ingredients with sources of unsaturated fat (e.g., using avocado, nuts, or seeds in a dish instead of cheese). Cooking with oils higher in polyunsaturated and monounsaturated fat (e.g., canola, corn, olive, peanut, safflower, soybean, and sunflower) instead of butter also can reduce intakes of saturated fat. Sodium The number of adults exceeding the Chronic Disease Risk Reduction level for sodium (see Chapter 1 or Appendix 1) during this life stage is concerning given that 45 percent of adults ages 18 and older are living with hypertension. During adulthood, prevalence of sun. However, some individuals may have difficulty hypertension increases from about 22 percent of producing sufficient vitamin D from sunlight exposure adults ages 18 through 39 to about 55 percent of or consuming enough vitamin D from foods and adults ages 40 through 59.1 Changing this trend is beverages, so a supplement may be recommended important because hypertension is a preventable risk by a health professional. Appendix 1 provides calcium factor for cardiovascular disease and stroke. Unlike and vitamin D goals for men and women based on other factors that cannot be changed, such as genetics the Dietary Reference Intakes. A list of common and family history, reduced dietary intake of sodium food sources of calcium and vitamin D is available at is a modifiable risk factor that can help improve blood DietaryGuidelines.gov. pressure control and reduce risk of hypertension. Saturated Fat Overconsumption of sodium occurs for several Chapter 1 explains the importance of limiting intakes reasons, as discussed in Chapter 1. Because sodium is of saturated fat to support healthy dietary patterns. found in foods and beverages across all food groups, Staying within saturated fat limits and replacing with most coming from foods that have salt added saturated fat with unsaturated fat is of particular during commercial processing rather than salt added importance during the adult life stage. The prevalence to foods during or after preparation, reducing sodium of coronary heart disease increases with age, and high consumption will require a joint effort by individuals, LDL cholesterol peaks between the ages of 50 to the food and beverage industry, and food service and 59 in men and 60 to 69 in women. retail establishments. 1 Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension prevalence among adults aged 18 and over: United States, 2017–2018. NCHS Data Brief, no 364. Hyattsville, MD: National Center for Health Statistics. 2020 Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults | Page 102 ADULTS AGES 19-59 Added Sugars sweetened beverages. Intake of sugar-sweetened Most adults exceed recommended limits for added beverages should be limited to small amounts and sugars as a result of eating foods and drinking most often replaced with beverage options that contain beverages higher in added sugars and selecting no added sugars, such as water. foods and beverages across food groups that are not in nutrient-dense forms. Added sugars are of particular concern for adults because exceeding limits OTHER SOURCES OF ADDED SUGARS contributes to excess calorie intake. A variety of foods and beverages contribute to the remaining added sugars consumed by adults. In addition to the contribution of sugar-sweetened BEVERAGES AS A SOURCE OF ADDED SUGARS beverages and sweetened coffees and teas, about Sugar-sweetened beverages (e.g., soda, sports drinks, 30 percent come from desserts and sweet snacks, energy drinks, fruit drinks) and sweetened coffees candies, and sweetened breakfast cereals. The and teas (including ready-to-drink varieties) contribute remaining 30 percent of added sugars is consumed in over 40 percent of daily intake of added sugars. More relatively small amounts across many food categories, than in earlier life stages, adults consume coffees and as discussed in Chapter 1. Many of these food teas with additions, such as sugar and flavored syrup. categories have seen market expansion in recent years. Frequent consumption of these and other beverages For example, over the past decade, beverages, snacks, containing added sugars can contribute to excess and bakery foods have continuously topped the list calorie intake. Some sugar-sweetened beverages, such for the most new product introductions.2 As these and as coffee and tea with milk, contribute to food group other food categories continue to change and expand, intake (e.g., dairy) and can be made without added it is vital for individuals to learn how to identify the sugars. Others, such as fruit drinks, can be replaced amount of added sugars in a beverage or food product with nutrient-dense options such as 100% juice to help by reading the Nutrition Facts label (see Chapter 1). meet fruit group recommendations. Understanding which food choices contribute to intakes of added sugars without contributing to nutrient needs Most adults’ diets include choices across multiple can help individuals remove or replace these foods food groups that are not in nutrient-dense forms and with better choices that meet food group and nutrient therefore cannot accommodate excess calories from recommendations within calorie needs. 2 Additional information is available at ers.usda.gov/topics/food-markets-prices/processing-marketing/new-products.aspx. Page 103 | Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults ADULTS AGES 19-59 Alcoholic Beverages Alcoholic beverages are not a component of the USDA Dietary Patterns and their calories are considered discretionary. Regular consumption of alcoholic beverages can make it challenging for adults to meet food group and nutrient needs while not consuming excess calories. The ingredients in certain mixed drinks, including soda, mixers, and heavy cream, also can contribute to intake of added sugars and saturated fat. The majority of U.S. adults consume alcoholic beverages. About 66 percent of adults ages 21 through 59 report alcoholic beverage consumption in the past month, and of those, approximately half report binge drinking, sometimes multiple times per month. Among adults who choose to drink, average intakes of calories from alcoholic beverages exceed the remaining calorie limit that is available after food group recommendations are met. There are some adults who should not drink alcoholic beverages at all, such as if they are pregnant or might be pregnant; younger than age 21; or recovering from an alcohol use disorder or if they are unable to control the amount they drink. For those who choose to drink, intakes should be limited to 1 drink or less in a day for women and 2 drinks or less in a day for men, on When adults prepare meals themselves, they have more days when alcohol is consumed. More information in control over the types of food ingredients selected and available in Chapter 1 under Alcoholic Beverages. can focus on choosing nutrient-dense options that contribute to food group goals with little or no added Supporting sugars and saturated fat and less sodium. The same is not always true when purchasing prepared foods, Healthy Eating despite changes and innovation in the marketplace, such as menu and product labeling or reformulation. Individuals need support in making healthy choices For some adults, preparing and consuming healthy at home, work, and in the community to build healthy meals at home will mean adopting a new habit and/or dietary patterns. learning new skills, such as meal planning. For others, it may entail small changes to current routines. Planning Food retail outlets (e.g., grocery stores, convenience meals and snacks in advance with food groups and stores, restaurants) provide adults with the option to nutrient-dense foods and beverages in mind can purchase ingredients to prepare foods themselves or support healthy eating at home and improve dietary to purchase foods prepared by others. National food patterns of individuals and families. Preparing meals expenditures suggest the purchase of prepared foods with family and friends also presents an opportunity is a regular habit for most adults, with expenditures for greater connection and enjoyment around food. outpacing those of foods purchased for household For adults who are parents, guardians, or caregivers of meal preparation.3 Estimates also suggest that the children or adolescents, preparing meals also provides younger generation of American adults are spending an opportunity to teach valuable cooking skills and an even larger proportion of their total food dollars on model behaviors that support the adoption of healthy prepared foods than are older generations.4 dietary patterns across younger life stages. 3 Details are available at ers.usda.gov/webdocs/publications/96957/ap-083.pdf?v=5848.3. 4 Details are available at ers.usda.gov/amber-waves/2017/december/millennials-devote-larger-shares-of-their-grocery-spending-to- prepared-foods-pasta-and-sugar-and-sweets-than-other-generations. Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults | Page 104 ADULTS AGES 19-59 It is not realistic or desirable to avoid the purchase and Accessing a Healthy Dietary Pattern consumption of foods prepared by others. Limits on A healthy dietary pattern can only be achieved when available time and the desire for convenience make adequate resources and supports exist in the places restaurant and ready-to-eat meals a part of many where adults live, work, and gather. Food access is household routines. Many of these settings also crucial for adults to achieve a healthy dietary pattern provide for social enjoyment of food with friends and and is influenced by diverse factors, as discussed family. However, foods prepared outside of the home in Chapter 1. Food insecurity, which occurs when can contribute to the overconsumption of calories access to nutritionally adequate and safe food is as a result of large portion sizes and methods of limited or uncertain, is most prevalent in households preparation. Being mindful of the portion sizes and with children and in single-parent households. Income ingredients of prepared foods can help adults achieve is one of the primary characteristics associated with a healthy dietary pattern while still enjoying foods food insecurity. Government programs, such as the prepared by others. Health promotion activities that Supplemental Nutrition Assistance Program (SNAP) or center on increasing consumer knowledge and access the Food Distribution Program on Indian Reservations to healthy options in the places where Americans (FDPIR), serve as a resource for low-income adults purchase prepared foods are needed to provide by supplementing food budgets to support healthy support for adults in these efforts. lifestyles. Adults with children or those caring for older family members also may benefit from resources Health professionals play an important role in discussed in Chapters 2, 3, and 6. supporting adults’ healthy eating behaviors. Helping adults become more aware of the foods and Additional Government and non-Government beverages that make up their typical dietary patterns resources, such as food banks or community meal and identifying areas for improvement can empower sites and programming offered through SNAP individuals to make changes to the types of foods they Education (SNAP-Ed) and the Expanded Food and purchase or prepare. Teaching skills like cooking and Nutrition Education Program (EFNEP), play a role in meal planning and helping adults understand how to providing food and educational resources to support read labels or make healthy menu substitutions also adults in making healthy food choices within a limited will support the adoption of a healthy dietary pattern budget. Innovative approaches to support health, such during this life stage. as incentive programs at farmers markets or healthy corner-store initiatives, continue to expand. Continued In settings where adults spend their time, changing attention and creativity in approaches to expand organizational practices, approaches, and/or policies food access are needed to support a healthy dietary to support improved dietary patterns also is needed. pattern for adults and the larger social networks that Strategies include offering healthy meals and snacks they influence. in workplace cafeterias and vending machines, or implementing educational programs tailored to working adults. Or, communities can support farmers markets, community gardens, and related educational programming efforts. Learn More The Federal Foodservice Guidelines is a resource that food service providers can use to help make healthy choices more available in food service establishments. The Guidelines are available at cdc.gov/nutrition/healthy-food- environments/food-serv-guide.html. Page 105 | Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults ADULTS AGES 19-59 Looking Toward Chapter 5: Women Who Are Pregnant or Lactating and Chapter 6: Older Adults This chapter has discussed the importance of promoting overall health. These considerations are a healthy dietary pattern and related special especially important for the life stages discussed in considerations during the adult life stage. The chapter the next two chapters. Chapter 5 takes a closer look recognizes that dietary patterns are generally well at a special time in the life of many adults—pregnancy established by the time individuals reach adulthood and lactation. This chapter echoes the same guidance and encourages adults to take advantage of the many for adults on following a healthy dietary pattern and opportunities available to make changes that support discusses several special considerations that arise a healthy dietary pattern. Making these changes during this life stage. Chapter 6 then makes the can have important benefits for achieving a healthy transition from the Adults chapter to a focused look at weight status, reducing chronic disease risk, and healthy eating for older adults. Dietary Guidelines for Americans, 2020-2025 | Chapter 4: Adults | Page 106 WOMEN WHO ARE PREGNANT OR LACTATING Page 107 | Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating WOMEN WHO ARE PREGNANT OR LACTATING CHAPTER5 Women Who Are Pregnant or Lactating DDieiettaarryy G Guuidideelilnineess f foorr A Ameerricicaannss, ,2 2002200--22002255 | | C Chhaapptteerr 5 5:: Woomeenn Whhoo A Arree P Prreeggnnaanntt o orr L Laaccttaattiinngg | Page 108 WOMEN WHO ARE PREGNANT OR LACTATING Introduction This chapter addresses some important nutritional considerations for women before pregnancy and Pregnancy and lactation are special stages contains nutrition guidance for women during pregnancy and of life for women, and nutrition plays a lactation. A healthy dietary pattern, along with changing calorie and vital role before, during, and after these life nutrient needs during pregnancy and stages to support the health of the mother lactation, are described throughout the chapter. Special consideration is and her child. Following a healthy dietary given to the importance of achieving and maintaining a healthy weight pattern is especially important for those who before pregnancy, gaining weight within gestational weight gain are pregnant or lactating for several reasons. guidelines, and returning to a healthy Increased calorie and nutrient intakes weight during the postpartum period. A healthy weight status are necessary to support the growth and during these life stages has short- and long-term health benefits for the development of the baby and to maintain mother and her child. The chapter also discusses other considerations the mother’s health. Consuming a healthy important to pregnancy and dietary pattern before and during pregnancy lactation, including those related to intake of seafood, alcohol, and also may improve pregnancy outcomes. In caffeinated beverages. Finally, during pregnancy, nausea, vomiting, addition, following a healthy dietary pattern food aversions, and food cravings can make it difficult for some before and during pregnancy and lactation women to achieve optimal dietary intake. The chapter discusses how has the potential to affect health outcomes these can be considered when for both the mother and child in subsequent helping women who are pregnant or lactating make healthy food and life stages. beverage choices. Page 109 | Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating WOMEN WHO ARE PREGNANT OR LACTATING Healthy Dietary of pregnancy and throughout lactation. In short, women should meet their increased calorie and nutrient needs Patterns with nutrient-dense foods instead of with foods high in added sugars, saturated fat, and sodium. Women who are pregnant or lactating are encouraged to follow the recommendations on the types of The customizable components of the USDA Dietary foods and beverages that make up a healthy dietary Patterns provide flexibility that allows women—or pattern described in Chapter 1. Nutrition and Health professionals adapting these patterns—to choose from a Across the Lifespan: The Dietary Guidelines and Key variety of foods and beverages within each food group to Recommendations. The core elements of a healthy diet suit individual preference, lifestyle, traditions, culture, and for women during these life stages are similar to the budget. This flexibility in being able to select among a recommendations for women who are not pregnant. variety of nutrient-dense options is particularly important Table 5-1 shows the Healthy U.S.-Style Dietary Pattern for women who experience pregnancy-induced nausea, to illustrate the specific amounts and limits for food vomiting, or food aversions. groups and other dietary components that make up healthy dietary patterns at the six calorie levels most When making food and beverage choices, women relevant to women who are pregnant or lactating. should know that unless it’s medically indicated to Following a healthy dietary pattern during these life avoid for her own health, women do not need to restrict stages can help women meet the Guidelines and its their choices during pregnancy or lactation to prevent Key Recommendations. The USDA Dietary Patterns are food allergy from developing in their child. However, discussed in greater detail in Chapter 1 and Appendix 3. women who are pregnant should pay attention to some USDA Dietary Patterns. important food safety considerations (see “Food Safety During Pregnancy”). Table 5-2 summarizes estimated daily calorie needs during pregnancy and lactation compared to prepregnancy needs for women with a healthy prepregnancy weight. Additional information on estimates of prepregnancy calorie needs is provided in Table 5-1 (footnote a) and in Appendix 2. Estimated Nutrient-Dense Foods Calorie Needs. As shown in Table 5-2, calorie needs and Beverages generally increase as pregnancy progresses and remain Nutrient-dense foods and elevated during lactation. However, it is important to beverages provide vitamins, note that women with a prepregnancy weight that is minerals, and other health-promoting considered overweight or obese have lower weight components and have little added sugars, gain recommendations than do women with a healthy saturated fat, and sodium. Vegetables, fruits, prepregnancy weight (see “Weight Management”). whole grains, seafood, eggs, beans, peas, and Women should follow their healthcare provider’s lentils, unsalted nuts guidance regarding appropriate caloric intake during and seeds, fat-free and pregnancy and lactation, as many factors, including low-fat dairy products, prepregnancy weight status, gestational weight gain, and lean meats and and multiple pregnancies, may affect calorie needs. poultry—when prepared In general, it is important for women who are pregnant with no or little added to be under the care of a healthcare provider who sugars, saturated can monitor their health status and the progress of fat, and sodium—are their pregnancy. nutrient-dense foods. The increased calorie and nutrient needs for these life stages should be met by consuming nutrient-dense food choices as part of a healthy dietary pattern. One way to achieve this is to follow the Healthy U.S.-Style Dietary Pattern throughout pregnancy and lactation, but adjust intake of food groups to reflect higher calorie patterns recommended during the second and third trimesters Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating | Page 110 WOMEN WHO ARE PREGNANT OR LACTATING Table 5-1 Healthy U�S�-Style Dietary Pattern for Women Who Are Pregnant or Lactating, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 1,800 2,000 2,200 2,400 2,600 2,800 FOOD GROUP OR SUBGROUPb Daily Amount of Food From Each Group (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 2 ½ 2 ½ 3 3 3 ½ 3 ½ Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) 1 ½ 1 ½ 2 2 2 ½ 2 ½ Red & Orange Vegetables (cup eq/wk) 5 ½ 5 ½ 6 6 7 7 Beans, Peas, Lentils (cup eq/wk) 1 ½ 1 ½ 2 2 2 ½ 2 ½ Starchy Vegetables (cup eq/wk) 5 5 6 6 7 7 Other Vegetables (cup eq/wk) 4 4 5 5 5 ½ 5 ½ Fruits (cup eq/day) 1 ½ 2 2 2 2 2 ½ Grains (ounce eq/day) 6 6 7 8 9 10 Whole Grains (ounce eq/day) 3 3 3 ½ 4 4 ½ 5 Refined Grains (ounce eq/day) 3 3 3 ½ 4 4 ½ 5 Dairy (cup eq/day) 3 3 3 3 3 3 Protein Foods (ounce eq/day) 5 5 ½ 6 6 ½ 6 ½ 7 Protein Foods Subgroups in Weekly Amounts Meats, Poultry, Eggs (ounce eq/wk) 23 26 28 31 31 33 Seafood (ounce eq/wk)c 8 8 9 10 10 10 Nuts, Seeds, Soy Products (ounce eq/wk) 4 5 5 5 5 6 Oils (grams/day) 24 27 29 31 34 36 Limit on Calories for Other Uses (kcal/day)d 140 240 250 320 350 370 Limit on Calories for Other Uses (%/day) 8% 12% 11% 13% 13% 13% a Calorie level ranges: Prepregnancy energy levels are calculated body weight, some women should choose seafood lowest in based on median height and body weight for healthy body mass methylmercury or eat less seafood than the amounts in the Healthy index (BMI) for a reference woman, who is 5 feet 4 inches tall and U.S.-Style Dietary Pattern. More information is available on the FDA weighs 126 pounds. The calorie levels shown in this table include and EPA websites at FDA.gov/fishadvice and EPA.gov/fishadvice. estimates for women during the first trimester of pregnancy, when d calorie needs generally do not increase compared to prepregnancy All foods are assumed to be in nutrient-dense forms; lean or needs, plus the additional calories needed for the later trimesters low-fat; and prepared with minimal added sugars, refined starches, of pregnancy and during lactation. Calorie needs vary based on saturated fat, or sodium. If all food choices to meet food group many factors. Women with overweight or obesity have lower recommendations are in nutrient-dense forms, a small number of recommended gestational weight gain during pregnancy, which calories remain within the overall limit of the pattern (i.e., limit on may affect calorie needs. The DRI Calculator for Healthcare calories for other uses). The number of calories depends on the total Professionals, available at nal.usda.gov/fnic/dri-calculator, can be calorie level of the pattern and the amounts of food from each food used to estimate calorie needs based on age, sex, height, weight, group required to meet nutritional goals. Calories up to the specified activity level, and pregnancy or lactation status. limit can be used for added sugars and/or saturated fat, or to eat more than the recommended amount of food in a food group. b Definitions for each food group and subgroup and quantity (i.e., cup or ounce equivalents) are provided in Chapter 1 and are compiled in NOTE: The total dietary pattern should not exceed Dietary Guidelines Appendix 3. limits for added sugars and saturated fat; be within the Acceptable Macronutrient Distribution Ranges for protein, carbohydrate, and total c The U.S. Food and Drug Administration (FDA) and the U.S. fats; and stay within calorie limits. Values are rounded. See Appendix Environmental Protection Agency (EPA) provide joint advice regarding 3 for all calorie levels of the pattern. seafood consumption to limit methylmercury exposure for women who might become or are pregnant or lactating. Depending on Page 111 | Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating WOMEN WHO ARE PREGNANT OR LACTATING Table 5-2 Estimated Change in Calorie Needs During Pregnancy and Lactation for Women With a Healthya Prepregnancy Weight Estimated Change in Daily Calorie Needs Stage of Pregnancy or Lactation Compared to Prepregnancy Needs Pregnancy: 1st trimester + 0 calories Pregnancy: 2nd trimester + 340 calories Pregnancy: 3rd trimester + 452 calories Lactation: 1st 6 months + 330 caloriesb Lactation: 2nd 6 months + 400 caloriesc a These estimates apply to women with a healthy prepregnancy c The EER for the second 6 months of lactation is calculated by weight. Women with a prepregnancy weight that is considered adding 400 calories/day to prepregnancy needs to account for the overweight or obese should consult their healthcare provider for energy needed for milk production during this time period. Weight guidance regarding appropriate caloric intake during pregnancy stability is assumed after 6 months postpartum. and lactation. NOTE: Estimates are based on Estimated Energy Requirements (EER) b The EER for the first 6 months of lactation is calculated by set by the Institute of Medicine. Source: Institute of Medicine. Dietary adding 500 calories/day to prepregnancy needs to account for the Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, energy needed for milk production during this time period, then Cholesterol, Protein, and Amino Acids. Washington, DC: The National subtracting 170 calories/day to account for weight loss in the first Academies Press; 2005. 6 months postpartum. Weight Management Table 5-3 Weight management is complex, so women should Weight Gain Recommendations for Pregnancya seek advice from a healthcare provider on the best way to achieve their goals. Women should Rates of Weekly Pre- Weight Gainb in be encouraged to achieve and maintain a healthy pregnancy Body Range of Weight Mass Total the 2nd and 3rd weight before becoming pregnant, as well as follow Index Weight Trimesters the gestational weight gain guidelines developed by Category Gain (lb) (mean [range], the National Academies of Sciences, Engineering, lbs) and Medicine during pregnancy. These guidelines Underweight Less than 18.5 28-40 1 [1-1.3] are outlined in Table 5-3 and serve as a tool to help balance the benefits and risks associated with Healthy pregnancy weight change. Weight 18.5-24.9 25-35 1 [0.8-1] It is important to note that about half of women retain Overweight 25-29.9 15-25 0.6 [0.5-0.7] 10 pounds or more and nearly 1 in 4 women retain 20 Obese 30 and greater 11-20 0.5 [0.4-0.6] pounds or more at 12 months postpartum. Postpartum weight retention results in about 1 in 7 women a moving from a healthy weight classification before Reference: Institute of Medicine and National Research Council. 2009. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, pregnancy to an overweight classification postpartum. DC: The National Academies Press. doi.org/10.17226/12584. Current estimates show that about half of women b Calculations assume a 1.1 to 4.4 lb weight gain in the first trimester. of childbearing age have a weight classification of overweight or obese. Women with overweight or obesity frequently exceed gestational weight gain recommendations during pregnancy, which increases the likelihood of excess postpartum weight retention. Weight gain is a natural part of pregnancy, which is why it is important to have a plan. Meeting weight management goals may improve pregnancy outcomes, such as increasing the likelihood of delivering a healthy weight infant and improving the long-term health of both mother and child. Women are encouraged to partner with their healthcare provider and other medical professionals to achieve their goals and optimize health outcomes. Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating | Page 112 WOMEN WHO ARE PREGNANT OR LACTATING Current Intakes Figures 5-1 and 5-2 highlight the dietary intakes of women who are pregnant or lactating, including the Healthy Eating Index-2015 score, which is an overall measure of how intakes align with the Dietary Guidelines, as well as information on the components of a healthy diet—specifically, the food groups. Figure 5-1 displays the average intakes of the food groups compared to the range of recommended intakes at the calorie levels most relevant to these life stages. Figure 5-1 Current Intakes: Women Who Are Pregnant or Lactating Average Daily Food Group Intakes Compared to Healthy Eating Index Score Recommended Intake Ranges (on a scale of 0-100) Recommended Intake Ranges Average Intake s 12 63 11 62 10 54 9 8 7 6 5 4 3 2 1 0 P L P L P L P L P L Total Total Total Total Total Adult Women Women Vegetables Fruits Grains Dairy Protein Foods Women Who Are Who Are cup eq/day cup eq/day oz eq/day cup eq/day oz eq/day Pregnant Lactating FOOD GROUPS Percent Exceeding Limits of Added Sugars, Exceeding Limit Within Recommended Limit Saturated Fat, and Sodium Added Sugars Saturated Fat Sodium Limit: 10% of total energy Limit: 10% of total energy Limit: 2,300 mg Pregnant Lactating Pregnant Lactating Pregnant Lactating 70% 51% 75% 77% 88%* 97%* Average Intakes Average Intakes Average Intakes Pregnant Lactating Pregnant Lactating Pregnant Lactating 288 kcal 248 kcal 240 kcal 264 kcal 3,305 mg 3,880 mg *NOTE: Estimates may be less precise than others due to small sample size and/or large relative standard error. Data Sources: Average Intakes and HEI-2015 Scores: Analysis of What We Eat in America, NHANES 2013-2016, women ages 20-44, day 1 dPiertaergy inntaankec dya taa, nwdei gLhatecd.t Raetcioomnmended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Percent Exceeding Limits: What We Eat in America, NHANES 2013-2016, 2 days dietary intake data, weighted. Page 113 | Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating CUP or OZ EQUIVALENT WOMEN WHO ARE PREGNANT OR LACTATING Figure 5-2 Average Intakes of Subgroups Compared to Recommended Intake Ranges: Women Who Are Pregnant or Lactating Recommended Intake Ranges Average Intakes Vegetables 8 7 6 5 4 3 2 1 0 P L P L* P L P L* P L P L Total Dark- Red & Beans, Starchy Other Vegetables Green Orange Peas, cup eq/day Lentils cup eq/week Grains 12 11 10 Additionally, the percent of women exceeding the 9 8 limits for added sugars, saturated fat, and sodium 7 are shown, along with average intakes of these 6 components. Finally, average intakes compared 5 to recommended intake ranges of the subgroups 4 for grains in daily amounts and for vegetables and 3 protein foods in weekly amounts are also provided 2 1 in Figure 5-2. 0 P L P L P L Total Whole Grains Refined Grains The Healthy Eating Index score is 63 for women Grains who are pregnant and 62 for women who are oz eq/day lactating. Although diet quality is higher among Protein Foods women during these life stages compared to peers 45 who are not pregnant or lactating (54), intakes 40 are still not optimal. Women who are pregnant or 35 lactating can benefit from making dietary changes 30 to better align with healthy dietary patterns. 25 20 As described in Chapter 1, consistent with the 15 general U.S. population, women who are pregnant 10 or lactating are not meeting recommendations for food group and nutrient intake. Figures 5-1 and 5-2 5 show average intakes are generally below or in the 0 P L P L P* L* P L lower range of recommendations for food groups Total Meats, Poultry, Seafood Nuts, Seeds, and subgroups, while exceeding limits for added Protein Foods Eggs Soy Products oz eq/day oz eq/week sugars, saturated fat, and sodium. *NOTE: Estimates may be less precise than others due to small sample size and/or large relative standard error. Data Sources: Average Intakes: Analysis of What We Eat in America, NHANES 2013-2016, women ages 20-44, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating | Page 114 OZ EQUIVALENT OZ EQUIVALENT CUP EQUIVALENT WOMEN WHO ARE PREGNANT OR LACTATING Special Considerations The nutrition considerations for the general U.S. population described in Chapter 1 apply to women who are pregnant or lactating. For example, the nutrients of public health concern—calcium, vitamin D, potassium, and dietary fiber—apply to these life stages as well. In addition, iron is a nutrient of public health concern for women who are pregnant. These life stages also have some special nutrient and dietary considerations regarding folate, iodine, choline, seafood, alcoholic beverages, and caffeinated beverages that are discussed in the following sections of this chapter. Meeting Nutrient Needs As discussed in Chapter 1, nutritional needs should be met primarily through foods and beverages. However, this may be difficult for some women, especially those who are pregnant. Most healthcare providers recommend women who are pregnant or planning to become pregnant take a daily prenatal vitamin and months of pregnancy. Dietary supplements may contain mineral supplement in addition to consuming a healthy either folic acid or 5-methyltetrahydrofolate (5-MTHF), dietary pattern. This may be especially important to but only folic acid has been shown to prevent neural tube meet folate/folic acid, iron, iodine, and vitamin D needs defects. Most prenatal supplements sold in the United during pregnancy (see Appendix 1. Nutritional Goals for States contain folic acid. Age-Sex Groups). The recommendation for folic acid supplementation is Nutrient needs for women who are lactating differ from in addition to the amounts of food folate contained in those who are pregnant. Continued use of prenatal a healthy eating pattern. Folate is found inherently in supplements by women who are lactating may exceed dark-green vegetables and beans, peas, and lentils. All their needs for folic acid and iron. Women who are enriched grains (i.e., bread, pasta, rice, and cereal) and lactating should not exceed the Tolerable Upper Intake some corn masa flours are fortified with folic acid. Level (UL) of 1,000 micrograms of folic acid and 45 milligrams of iron. Women should seek guidance from Iron a healthcare provider on appropriate use of prenatal or Iron needs increase during pregnancy compared to other dietary supplements during lactation. prepregnancy. For women who are lactating, before menstruation returns, iron needs fall and then return Folate/Folic Acid to prepregnancy levels once menstruation resumes The RDA for folate is higher during pregnancy and (see Appendix 1). lactation than all other life stages (see Appendix 1). Adequate folic acid intake is particularly important prior Iron is a key nutrient during pregnancy that supports to conception and during the first trimester to help fetal development. Iron deficiency affects about 1 in prevent neural tube defects. 10 women who are pregnant and 1 in 4 women during their third trimester. Heme iron, which is found in animal The United States Preventative Services Task Force source foods (e.g., lean meats, poultry, and some (USPSTF) recommends that all women who are planning seafood) is more readily absorbed by the body than the or capable of pregnancy take a daily supplement non-heme iron found in plant source foods (e.g., beans, containing 400 to 800 mcg of folic acid. The critical peas, lentils, and dark-green vegetables). Additional iron period for supplementation starts at least 1 month sources include foods enriched or fortified with before conception and continues through the first 2 to 3 iron, such as many whole-wheat breads and ready-to-eat Page 115 | Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating WOMEN WHO ARE PREGNANT OR LACTATING More than half of women continue to use prenatal supplements during lactation. Most prenatal supplements are designed to meet the higher iron needs of pregnancy. Depending on various factors—such as when menstruation returns—prenatal supplements may exceed the iron needs of women who are lactating. Women should seek guidance from a healthcare provider regarding the appropriate level of iron supplementation during lactation based on their unique needs. Iodine Iodine needs increase substantially during pregnancy and lactation (see Appendix 1). Adequate iodine intake during pregnancy is important for neurocognitive development of the fetus. Although women of reproductive age generally have adequate iodine intake, some women, particularly those who do not regularly consume dairy products, eggs, seafood, or use iodized table salt, may not consume enough iodine to meet increased needs during pregnancy and lactation. cereals. Absorption of iron from non-heme sources is Women who are pregnant or lactating should not be enhanced by consuming them along with vitamin C-rich encouraged to start using table salt if they do not do so foods. Food source lists for both heme and non-heme already. However, they should ensure that any table salt iron are available at DietaryGuidelines.gov. Women used in cooking or added to food at the table is iodized. who are pregnant or who are planning to become Additionally, women who are pregnant or lactating may pregnant are advised to take a supplement containing need a supplement containing iodine in order to achieve iron when recommended by an obstetrician or other adequate intake. Many prenatal supplements do not healthcare provider. contain iodine. Thus, it is important to read the label. Vegetarian or Vegan Dietary Patterns During Pregnancy and Lactation Women following a vegetarian or vegan dietary pattern during these life stages may need to take special care to ensure nutrient adequacy. Iron may be of particular concern because plant source foods only contain non-heme iron, which is less bioavailable than heme iron. Food source lists for both heme and non-heme iron are available at DietaryGuidelines.gov. Vitamin B12 also is of concern because it is present only in animal source foods. Women following a vegetarian or vegan dietary pattern should consult with a healthcare provider to determine whether supplementation of iron, vitamin B12, and/or other nutrients such as choline, zinc, iodine , or EPA/DHA is necessary and if so, the appropriate levels to meet their unique needs. Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating | Page 116 WOMEN WHO ARE PREGNANT OR LACTATING Choline Drug Administration (FDA) and the U.S. Environmental Choline needs also increase during pregnancy and Protection Agency (EPA) provide joint advice regarding lactation (see Appendix 1). Adequate intake of choline seafood consumption to limit methylmercury exposure during these life stages helps to both replenish maternal for women who might become or who are pregnant stores and support the growth and development of the or lactating. Methylmercury can be harmful to the child’s brain and spinal cord. brain and nervous system if a person is exposed to too much of it over time; this is particularly important Most women do not meet recommended intakes of during pregnancy because eating too much of it can choline during pregnancy and lactation. Women are have negative effects on the developing fetus. Based encouraged to consume a variety of choline-containing on FDA and EPA’s advice, depending on body weight, foods during these life stages. Choline can be found some women should choose seafood lowest in throughout many food groups and subgroups. Meeting methylmercury or eat less seafood than the amounts recommended intakes for the dairy and protein in the Healthy U.S.-Style Dietary Pattern. Additionally, food groups—with eggs, meats, and some seafood certain species of seafood (e.g., shark, swordfish, king being notable sources—as well as the beans, peas, mackerel) should be avoided during pregnancy. More and lentils subgroup can help meet choline needs. information is available on the FDA or EPA websites at Meeting nutrient needs through foods and beverages FDA.gov/fishadvice and EPA.gov/fishadvice. is preferred, but women who are concerned about meeting recommendations should speak with their Alcoholic Beverages healthcare provider to determine whether choline Women who are or who may be pregnant should not supplementation is appropriate. Many prenatal drink alcohol. However, consumption of alcohol during supplements do not contain choline or only contain pregnancy continues to be of concern in the United small amounts inadequate to meet recommendations. States. Among women who are pregnant, about 1 in 10 reported consuming alcohol during the past month, Seafood with an average intake of 2 or more drink equivalents on Seafood intake during pregnancy is recommended, as days alcohol is consumed. it is associated with favorable measures of cognitive development in young children. Women who are It is not safe for women to drink any type or amount of pregnant or lactating should consume at least 8 and alcohol during pregnancy. Women who drink alcohol up to 12 ounces of a variety of seafood per week, from and become pregnant should stop drinking immediately choices lower in methylmercury. The U.S. Food and and women who are trying to become pregnant should Page 117 | Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating WOMEN WHO ARE PREGNANT OR LACTATING Food Safety During Pregnancy Women who are pregnant and their unborn children are more susceptible than are the general population to the effects of foodborne illnesses, such as listeriosis. They need to take special care to keep foods safe and to not eat foods that increase the risk of foodborne illness. During pregnancy, women should only eat foods containing seafood, meats, poultry, or not drink at all. Alcohol can harm the baby at any time during pregnancy, eggs that have been cooked to even during the first or second month when a woman may not know she recommended safe minimum is pregnant. internal temperatures. They also should take special precautions Not drinking alcohol also is the safest option for women who are lactating. not to consume unpasteurized Generally, moderate consumption of alcoholic beverages by a woman who (raw) juice or milk, raw sprouts, is lactating (up to 1 standard drink in a day) is not known to be harmful or some soft cheeses made from to the infant, especially if the woman waits at least 2 hours after a single unpasteurized milk. Deli and drink before nursing or expressing breast milk. Additional information luncheon meats and hot dogs on breastfeeding and alcohol can be found at: cdc.gov/breastfeeding/ should be reheated to steaming breastfeeding-special-circumstances/vaccinations-medications-drugs/ hot or 165°F to kill Listeria, the alcohol.html. Women considering consuming alcohol during lactation bacteria that causes listeriosis. should talk to their healthcare provider. Additional food safety resources Caffeine for pregnant women are available Many women consume caffeine during pregnancy or lactation. As discussed at fda.gov/media/83740/ in Chapter 1, most intake of caffeine in the United States comes from coffee, download and foodsafety.gov/ tea, and soda. Caffeinated beverages vary widely in their caffeine content. people-at-risk/pregnant-women, Caffeine passes from the mother to infant in small amounts through breast and specific answers to food milk, but usually does not adversely affect the infant when the mother safety questions are available at consumes low to moderate amounts (about 300 milligrams or less per fsis.usda.gov/wps/portal/fsis/ day, which is about 2 to 3 cups of coffee). More information is available topics/food-safety-education/ at: cdc.gov/breastfeeding/breastfeeding-special-circumstances/diet- get-answers. and-micronutrients/maternal-diet.html. Women who could be or who are pregnant should consult their healthcare providers for advice concerning caffeine consumption. Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating | Page 118 WOMEN WHO ARE PREGNANT OR LACTATING Physical Activity During Pregnancy and Postpartum PREGNANCY Physical activity during pregnancy can benefit both the mother and the baby. Physical activity increases or maintains cardiorespiratory fitness and reduces the risk of excessive weight gain and gestational diabetes. For many benefits, healthy women without contraindications should do a least 150 minutes of moderate- intensity aerobic activity a week, as they are able. Women who habitually did vigorous-intensity activity or a lot of aerobic or muscle-strengthening physical activity before pregnancy can continue to do so during pregnancy. Women can consult their healthcare provider about whether or how to adjust their physical activity during pregnancy. POSTPARTUM Physical activity following the birth of a child continues to benefit a woman’s overall health. Physical activity during the postpartum period increases cardiorespiratory fitness, improves mood, and reduces the symptoms of postpartum depression. Additionally, physical activity can help achieve and maintain a healthy weight and, when combined with caloric restriction, helps promote weight loss. Women should start slow and build back up to more activity over time. Women should aim for at least 150 minutes of moderate-intensity aerobic activity a week. The U.S. Department of Health and Human Service’s Physical Activity Guidelines for Americans and the Move Your Way® communications campaign have information about the benefits of physical activity and tips to get started. Available at health.gov/paguidelines. Page 119 | Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating WOMEN WHO ARE PREGNANT OR LACTATING Supporting can also serve as resources for low-income women and their families by both supplementing food budgets Healthy Eating to support health and by providing nutrition education through the SNAP-Ed program. Additionally, USDA’s Many women have increased interest in and motivation Healthy Eating on A Budget1 can help women and to make healthy lifestyle changes during pregnancy families plan and prepare healthy, inexpensive meals. and lactation. Furthermore, the dietary choices made Other Government and non-Government resources, during these life stages can affect women’s health such as food banks or community meal programs, and the health of their children. Supporting women in also provide food and educational resources that can adopting healthy dietary patterns during this important support women in making healthy food choices for time of life and sustaining them thereafter also enables themselves and their families. them to serve as role models when their children begin transitioning to complementary foods. Support during lactation can help women meet their breastfeeding goals, despite significant Women who are pregnant or lactating face many demands on their time and energy during this life real or perceived barriers when trying to meet the stage. Worksite programs and policies that allow recommendations of the Dietary Guidelines. Constraints women adequate time to pump breast milk when on time and financial resources, limited access to high- away from their child, as well as access to good quality childcare and family leave policies, as well as quality childcare, can allow women who return to inadequate breastfeeding support at home or at work work to achieve breastfeeding goals. Access to are barriers women may face. These barriers should breastfeeding peer counselors, such as those used be considered by all those who support women in their in WIC, or free breastfeeding support groups through efforts to follow a healthy dietary pattern. local hospitals also can support women during this life stage. Additionally, health professionals can Ensuring women have access to healthy, safe food promote the USDA’s WIC Breastfeeding Support2 is vital due to the critical role nutrition plays in health and the U.S. Department of Health and Human promotion during these life stages. This is particularly Services Office of Women’s Health (OWH) Your Guide critical for families dealing with food insecurity, which to Breastfeeding3 and their National Breastfeeding is most prevalent in households with children and Helpline4 (800-994-9662), which are freely accessible in single-parent households. Participation in Federal to all women. programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Health professionals, policymakers, worksite which serves low-income pregnant, breastfeeding, and administrators, community leaders, families, non-breastfeeding postpartum women, and infants and and friends should consider these barriers and children up to age 5, can help alleviate these challenges opportunities when seeking to support women and and improve dietary intake for many women and families. Developing programs and resources that children facing economic hardship. The Supplemental reduce barriers and create opportunities can help Nutrition Assistance Program (SNAP) and the Food women meet their dietary needs and improve their Distribution Program on Indian Reservations (FDPIR) overall health and the health of their children. For more information on meeting the Dietary Guidelines for children during their first 2 years of life, see Chapter 2. Infants and Toddlers 1 Available at: MyPlate.gov/budget 2 Available at: wicbreastfeeding.fns.usda.gov/ 3 Available at: womenshealth.gov/files/your-guide-to-breastfeeding.pdf 4 Available at: womenshealth.gov/about-us/what-we-do/programs-and-activities/helpline Dietary Guidelines for Americans, 2020-2025 | Chapter 5: Women Who Are Pregnant or Lactating | Page 120 ADULTS AGES 60 AND OLDER Page 121 | Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults ADULTS AGES 60 AND OLDER CHAPTER6 Older Adults Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults | Page 122 ADULTS AGES 60 AND OLDER Introduction Older adults include individuals ages Nutrient-Dense Foods and Beverages 60 and older—a life stage that Nutrient-dense foods and beverages provide vitamins, includes a broad range of ages and is minerals, and other health- promoting components and influenced by a number of health and have little added sugars, saturated fat, and sodium. social changes that affect this population’s Vegetables, fruits, whole nutritional status. Compared to younger grains, seafood, eggs, beans, peas, and lentils, unsalted nuts adults, older adults are at greater risk of and seeds, fat-free and low-fat dairy products, and lean meats chronic diseases, such as cardiovascular and poultry—when prepared with no or little added sugars, disease and cancer, as well as health saturated fat, and sodium—are nutrient-dense foods. conditions related to changes in bone and muscle mass, such as osteoporosis and sarcopenia, respectively. An increasing number of older adults start this life stage with excess body weight. Preventing additional weight gain and achieving a healthy weight by following a healthy dietary pattern and adopting an active lifestyle can support healthy aging. Selecting healthy food and beverage choices is important for people throughout this life stage, regardless of their race or ethnicity or their current health status. It is never too late to make improvements. Older adults should follow a healthy dietary pattern because of the changing dietary needs and the heightened risk of malnutrition that occurs with age. Older adults generally have lower calorie needs but similar or even increased nutrient needs compared to younger adults. The overall nutrient density of dietary patterns is particularly important to this age group. Lower calorie needs result from less physical activity, changes in metabolism, and/or age-related loss in bone and muscle mass. Other factors may affect nutrient needs and absorption of nutrients in older adults, including chronic disease and conditions, use of multiple medications, and changes in body composition. The healthy dietary patterns described below take the unique needs of older adults into account and are further supported by special considerations and strategies for professionals to support healthy aging. Page 123 | Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults ADULTS AGES 60 AND OLDER Healthy Dietary physically active. Females ages 60 and older require about 1,600 to 2,200 calories per day and males ages 60 Patterns and older require about 2,000 to 2,600 calories per day. Additional information on these estimates is provided Older adults are encouraged to follow the in Table 6-1 (footnote a) and in Appendix 1. Estimated recommendations on the types of foods and beverages Calorie Needs. that make up a healthy dietary pattern described in Chapter 1. Nutrition and Health Across the Lifespan: The USDA Food Patterns are discussed in greater detail in The Guidelines and Key Recommendations. Table Chapter 1. Nutrition and Health Across the Lifespan: The 6-1 displays the Healthy U.S.-Style Dietary Pattern to Guidelines and Key Recommendations and Appendix illustrate the specific food group amounts and limits 3. USDA Dietary Patterns. The USDA Dietary Patterns for other dietary components that make up healthy provide a framework to help older adults follow a healthy dietary patterns at the six calorie levels most relevant dietary pattern and meet the Guidelines and their Key to older adults. Recommendations. The Patterns provide a variety of food and beverage choices that allow individuals to customize Calorie needs are generally lower for females compared their choices within each food group based on lifestyle, to males, and for those who are older, smaller, and less traditions, culture, and/or other individual needs. Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults | Page 124 ADULTS AGES 60 AND OLDER Table 6-1 Healthy U�S�-Style Dietary Pattern for Adults Ages 60 and Older, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 1,600 1,800 2,000 2,200 2,400 2,600 FOOD GROUP OR SUBGROUPb Daily Amount of Food From Each Group (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 2 2 ½ 2 ½ 3 3 3 ½ Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) 1 ½ 1 ½ 1 ½ 2 2 2 ½ Red & Orange Vegetables (cup eq/wk) 4 5 ½ 5 ½ 6 6 7 Beans, Peas, Lentils (cup eq/wk) 1 1 ½ 1 ½ 2 2 2 ½ Starchy Vegetables (cup eq/wk) 4 5 5 6 6 7 Other Vegetables (cup eq/wk) 3 ½ 4 4 5 5 5 ½ Fruits (cup eq/day) 1 ½ 1 ½ 2 2 2 2 Grains (ounce eq/day) 5 6 6 7 8 9 Whole Grains (ounce eq/day) 3 3 3 3 ½ 4 4 ½ Refined Grains (ounce eq/day) 2 3 3 3 ½ 4 4 ½ Dairy (cup eq/day) 3 3 3 3 3 3 Protein Foods (ounce eq/day) 5 5 5 ½ 6 6 ½ 6 ½ Protein Foods Subgroups in Weekly Amounts Meats, Poultry, Eggs (ounce eq/wk) 23 23 26 28 31 31 Seafood (ounce eq/wk) 8 8 9 9 10 10 Nuts, Seeds, Soy Products (ounce eq/wk) 4 4 5 5 5 5 Oils (grams/day) 22 24 27 29 31 34 Limit on Calories for Other Uses (kcal/day)c 100 140 240 250 320 350 Limit on Calories for Other Uses (%/day) 7% 8% 12% 12% 13% 5 a Calorie level ranges: Females: 1,600-2,200 calories; Males: 2,000-2,600 calories. Energy levels are calculated based on median height and body weight for healthy body mass index (BMI) reference individuals. For adults, the reference man is 5 feet 10 inches tall and weighs 154 pounds. The reference woman is 5 feet 4 inches tall and weighs 126 pounds. Calorie needs vary based on many factors. The DRI Calculator for Healthcare Professionals, available at nal.usda.gov/fnic/dri-calculator, can be used to estimate calorie needs based on age, sex, height, weight, and physical activity level. b Definitions for each food group and subgroup and quantity (e.g., cup or ounce equivalents) are provided in Chapter 1 and are compiled in Appendix 3. c All foods are assumed to be in nutrient-dense forms; lean or low-fat and prepared with minimal added sugars; refined starches, saturated fat, or sodium. If all food choices to meet food group recommendations are in nutrient-dense forms, a small number of calories remain within the overall limit of the pattern (i.e., limit on calories for other uses). The number of calories depends on the total calorie level of the pattern and the amounts of food from each food group required to meet nutritional goals. Calories up to the specified limit can be used for added sugars, saturated fat, and/or alcohol, or to eat more than the recommended amount of food in a food group. *NOTE: The total dietary pattern should not exceed Dietary Guidelines limits for added sugars, saturated fat, and alcohol; be within the Acceptable Macronutrient Distribution Ranges for protein, carbohydrate, and total fats; and stay within calorie limits. Values are rounded. See Appendix 3 for all calorie levels of the pattern. Page 125 | Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults ADULTS AGES 60 AND OLDER Current Intakes Figures 6-1 and 6-2 highlight the dietary intakes of older adults, including the Healthy Eating Index-2015 score, which is an overall measure of how intakes align with the Dietary Guidelines, as well as information on the components of a healthy diet—specifically, the food groups. Figure 6-1 displays the average intakes of the food groups compared to the range of recommended intakes at the calorie levels most relevant to males and females in this age group. Additionally, the percent of older adults exceeding the recommended limits for added sugars, saturated fat, and sodium are shown, along with average intakes of these components. Figure 6-1 Current Intakes: Ages 60 and Older Average Daily Food Group Intakes Compared to Healthy Eating Index Score Recommended Intake Ranges (on a scale of 0-100) Recommended Intake Ranges Average Intakes 10 9 63 8 7 6 5 4 3 2 1 0 M F M F M F M F M F Total Total Total Total Total Vegetables Fruits Grains Dairy Protein Foods cup eq/day cup eq/day oz eq/day cup eq/day oz eq/day FOOD GROUPS Percent Exceeding Limits of Added Sugars, Exceeding Limit Within Recommended Limit Saturated Fat, and Sodium Added Sugars Saturated Fat Sodium Limit: 10% of total energy Limit: 10% of total energy Limit: 2,300 mg Males Females Males Females Males Females 54% 58% 80% 77 % 94% 72% Average Intakes Average Intakes Average Intakes Males Females Males Females Males Females 247 kcal 213 kcal 269 kcal 203 kcal 3,799 mg 2,802 mg Data Sources: Average Intakes and HEI-2015 Scores: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Percent Exceeding Limits: What We Eat in America, NAHgANeEsS 62001+3-2016, 2 days dietary intake data, weighted. Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults | Page 126 CUP or OZ EQUIVALENT ADULTS AGES 60 AND OLDER Figure 6-2 Average intakes compared to recommended intake Average Intakes of Subgroups ranges of the subgroups for grains are represented Compared to Recommended Intake Ranges: in daily amounts; subgroups for vegetables and Ages 60 and Older protein foods are represented in weekly amounts in Figure 6-2. Recommended Intake Ranges Average Intakes Vegetables Diet quality is highest among older adults 8 compared to other ages. Consistent with the 7 general U.S. population, however, this age group is 6 not meeting the recommendations for food group and nutrient intakes and has a Healthy Eating 5 Index score of 63 out of 100. Older adults can 4 improve dietary intake by increasing consumption 3 of fruit, vegetables, whole grains, and dairy, while 2 ensuring protein intake meets recommendations. Reducing intakes of added sugars, saturated fat, 1 and sodium also will help older adults achieve 0 recommendations and manage and avoid chronic M F M F M F M F M F M F Total Dark- Red & Beans, Starchy Other conditions (Figure 6-1). Older adults should Vegetables Green Orange Peas, choose nutrient-dense options within each food cup eq/day Lentils group and consume appropriate portion sizes cup eq/week because calorie needs decline with age. Grains 10 9 8 7 6 5 4 3 2 1 0 M F M F M F Total Whole Grains Refined Grains Grains oz eq/day Protein Foods 40 35 30 25 20 15 10 5 0 M F M F M F M F Total Meats, Poultry, Seafood Nuts, Seeds, Protein Foods Eggs Soy Products oz eq/day oz eq/week Data Sources: Average Intakes: Analysis of What We Eat in America, NHANES 2015-2016, day 1 dietary intake data, weighted. Recommended Intake Ranges: Healthy U.S.-Style Dietary Patterns (see Appendix 3). Page 127 | Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults OZ EQUIVALENT OZ EQUIVALENT CUP EQUIVALENT ADULTS AGES 60 AND OLDER Special this subgroup a common source of protein foods for older adults (Table 6-1). However, seafood, dairy and Considerations fortified soy alternatives, and beans, peas, and lentils are underconsumed, yet provide important nutrients that The nutrition considerations for the general U.S. support healthy dietary patterns. For example, the dairy population described in Chapter 1. apply to older food group provides calcium, vitamin D, and vitamin adults. For example, the nutrients of public concern— B12 and the beans, peas, and lentils subgroup provides calcium, vitamin D, potassium, and dietary fiber—apply dietary fiber. Many choices within the seafood subgroup to this age group as well. However, this age group also also provide vitamins D and B12 and calcium (if eaten has some special nutrition considerations that are with bones), and beneficial fatty acids. Food sources discussed in the following sections of this chapter. For of calcium, vitamin D, and dietary fiber are available at example, several additional nutrients are more likely to DietaryGuidelines.gov. be underconsumed during this life stage. These include dietary protein and vitamin B12. Beverage intake, Many older adults can improve their dietary pattern particularly as it relates to hydration status, also is an and better meet nutrient needs by choosing from area of special consideration. a wider variety of protein sources. In some cases, this may mean using seafood more often in place Protein of meats, poultry, or eggs or using beans, peas, and Consuming enough protein is important to prevent the lentils in mixed dishes, such as soups, rice, or pasta loss of lean muscle mass that occurs naturally with dishes. For others, it may mean maintaining current age. Monitoring protein intake is especially important intakes of protein and finding enjoyable ways to add as older adults transition through this life stage. Intake protein foods from underconsumed food groups and patterns show average intakes of protein foods is subgroups in order to ensure that overall protein needs lower for individuals ages 71 and older compared to are met. adults ages 60 through 70. About 50 percent of women and 30 percent of men 71 and older fall short of protein Vitamin B12 foods recommendations. Vitamin B12 is of concern for some older adults because the ability to absorb this nutrient can decrease with The majority of protein in the Healthy U.S.-Style Dietary age and use of certain medications can decrease Pattern is accounted for in the protein foods subgroups: absorption. Older adults are encouraged to meet the seafood; meats, poultry and eggs; nuts, seeds, and recommendations for protein foods, a common source soy products; and the vegetable subgroup of beans, of vitamin B12, and include foods fortified with vitamin peas, and lentils, which also is considered a protein B12, such as breakfast cereals. Some individuals foods subgroup. The dairy and fortified soy alternatives also may require vitamin B12 dietary supplements. food group is another source of dietary protein. Individuals are encouraged to speak with their Most older adults are meeting or exceeding weekly healthcare provider to determine what, if any, recommendations for meats, poultry, and eggs, making supplementation is appropriate. Dietary Supplements Many adults in the United States take one or more dietary supplements either as a pill or drink. Popular supplements include some nutrients that are underconsumed among older adults, including calcium and vitamins D and B12. All sources of a nutrient or food component—whether from food or a dietary supplement—should be considered when assessing an individual’s dietary pattern, including any added sugars that may come from supplement drinks. Older adults should track and discuss all dietary supplement use with their healthcare provider. Beverage supplements should not replace regular food intake unless instructed by a health professional. The National Institutes of Health, Office of Dietary Supplements provides the My Dietary Supplement and Medicine Record1, to help individuals track supplement and medicine use. 1 Available at: ods.od.nih.gov/pubs/DietarySupplementandMedicineRecord.pdf Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults | Page 128 ADULTS AGES 60 AND OLDER Beverages Many older adults do not drink enough fluids to stay Supporting hydrated. One reason for this is that the sensation of Healthy Eating thirst tends to decline with age. Concerns about bladder control or issues with mobility also may hinder intake of Similar to other life stages, older adults can be fluids among older adults. Mean intakes of beverages supported by professionals, family, and friends to show adults ages 60 and older consume significantly achieve a healthy dietary pattern that accounts for fewer fluid ounces across all beverage types compared factors such as cost, preferences, traditions, and to adults ages 59 and under—about 2 fewer cups per access. Additional factors to consider when supporting day, most of which is due to drinking less water. healthy eating for older adults include: It is important that older adults drink plenty of water • Enjoyment of food: Sharing meals with friends and to prevent dehydration and aid in the digestion of family can help increase food enjoyment and promote food and absorption of nutrients. In addition to water, adequacy of dietary intake for older adults. choosing unsweetened beverages such as 100% fruit or vegetable juice and low-fat or fat-free milk • Ability to chew or swallow foods: Experimenting with or fortified soy beverage can support fluid intake to the preparation of foods from all food groups can prevent dehydration while helping to achieve food group help identify textures that are acceptable, appealing, recommendations. The water that is contained in foods, and enjoyable for adults who have difficulties chewing such as fruits, vegetables, and soups, contributes to or swallowing. Good dental health is critical to overall hydration status and is a contributor to total fluid intake. health, as well as the ability to chew foods properly. • Food safety: Practicing safe food handling ALCOHOLIC BEVERAGES procedures is of particular importance for older The Dietary Guidelines do not recommend initiating adults due to a decline in immune system function alcohol consumption for any reason. To help older that accompanies age and that increases the risk of adults move toward a healthy dietary pattern and foodborne illness. For more information: Foodsafety. minimize risks associated with drinking, older adults gov for older adults: foodsafety.gov/people-at- can choose not to drink or drink in moderation—limiting risk/older-adults or FDA: fda.gov/media/83744/ intakes to 2 drinks or less in a day for men and 1 drink download. or less in a day for women, when alcohol is consumed. Older adults who choose to drink may experience the Older adults have access to a variety of Government effects of alcohol more quickly than they did when they resources to support a healthy dietary pattern as part were younger. This puts older adults at higher risk of of overall healthy aging. Professionals working with falls, car crashes, and other injuries that may result from older Americans can use these resources to better drinking. In addition, older adults tend to have a greater support access to healthy, safe, and affordable number of comorbid health conditions than younger food choices. adults, and alcohol use or misuse may adversely affect the condition or interfere with management of the • Congregate Nutrition Services: The Older Americans disease. Certain older adults should avoid drinking Act authorizes meals and related services in alcohol completely, including those who: congregate settings for any person age 60 and older and their spouse of any age. Program sites offer • Plan to drive or operate machinery, or participate in older individuals healthy meals and opportunities to activities that require skill, coordination, and alertness. socialize. Congregate meals are typically provided • Take certain over-the-counter or in senior centers, schools, churches, or other prescription medications. community settings. • Have certain medical conditions. • Supplemental Nutrition Assistance Program • Are recovering from alcohol use disorder or are (SNAP): Older adults with limited income may qualify unable to control the amount they drink. for SNAP, a Federal program that provides temporary benefits to help individuals purchase foods and • More information on alcoholic beverages and their beverages to support a healthy dietary pattern when relationship to health is provided in Chapter 1. resources are constrained. Page 129 | Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults ADULTS AGES 60 AND OLDER Physical Activity and Older Adults The benefits of regular physical activity occur throughout life and are essential for healthy aging. It is never too late to start being physically active. For older adults, regular physical activity supports a number of additional health benefits including improved cognition, balance, and bone strength. These benefits make it easier to perform activities of daily living, preserves function and mobility, and lowers the risk of falls and injuries from falls. Adults should move more and sit less throughout the day. Some physical activity is better than none. To attain the most health benefits from physical activity, older adults need at least 150 to 300 minutes of moderate-intensity aerobic activity per week. The talk test is a good way to assess moderate intensity for older adults. A person doing moderate-intensity aerobic activity can talk, but not sing. Older adults also need muscle-strengthening activity at least 2 days each week. Older adults should incorporate multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities. The U.S. Department of Health and Human Service’s Physical Activity Guidelines for Americans and the related Move Your Way® resources have information about the benefits of physical activity and tips to get started. Available at health.gov/paguidelines. • Commodity Supplemental Food Program (CSFP): teach older adults cooking and shopping skills. The CSFP supplements the diets of low-income older Individuals working within these settings must ensure adults by providing nutritious USDA packaged food the availability of nutrient-dense foods and assist older to support a healthy dietary pattern. The CSFP is adults in choosing a healthy dietary pattern that fits in federally funded, and private and nonprofit institutions their cultural and food preferences. facilitate the distribution of monthly CSFP packages to eligible older adults. Healthy Eating • Home-Delivered Nutrition Services: The Older Americans Act authorizes meals and related services Through the Lifespan in a person’s home for individuals ages 60 and older and their spouse of any age. Older adults who This chapter has focused on the unique nutritional experience difficulty leaving the home due to frailty, considerations of the older adult life stage. It also has health concerns, or certain medical conditions may reinforced the idea that the core elements of a healthy benefit from home-delivered meals offered under the dietary pattern are remarkably consistent across the Older Americans Act. lifespan and across health outcomes. More than that, a healthy dietary pattern is flexible—people can customize • Child and Adult Care Food Program (CACFP): the Dietary Guidelines recommendations to suit their The CACFP is a Federal program that provides personal preferences, cultural traditions, and budget reimbursements for nutritious meals and snacks considerations. to older adults enrolled in daycare facilities. Older adults receiving care at nonresidential care centers Beginning at the earliest life stage—infancy and may receive meals and snacks that meet nutrition toddlerhood—a healthy dietary pattern can help people standards of the CACFP. achieve and maintain good health and reduce the risk of chronic diseases. However, it is never too late to Additional resources to support older adults exist at make improvements. People at any stage of life can the community level. For example, the Senior Farmers benefit by changing to nutrient-dense forms of foods Market Nutrition Program (SFMNP) provides many and beverages across all food groups, in recommended low-income seniors with access to fruits and vegetables amounts, and within calorie limits. The bottom line: grown in their local communities. SNAP Education For lifelong good health, make every bite count with (SNAP-Ed) programming may also be offered and the Dietary Guidelines for Americans! Dietary Guidelines for Americans, 2020-2025 | Chapter 6: Older Adults | Page 130 Appendix 1: Nutritional Goalsa for Age-Sex Groups Table A1-1 Daily Nutritional Goals, Ages 6 Through 11 Months and 12 Through 23 Months 6 Through 11 Months 12 Through 23 Months Nutrient Goal Source of Goalb Goal Source of Goalb Macronutrients Protein (g) 11 RDA 13 RDA Carbohydrate (g) 95 AI 130 RDA Fiber, total dietary (g) n/ad n/ad 19 AI Total lipid (% kcal) n/ad n/ad 30-40 AMDR 18:2 Linoleic acid (g) 4.6 AI 7 AI 18:3 Linolenic acid (g) 0.5 AI 0.7 AI Minerals Calcium (mg) 260 AI 700 RDA Iron (mg) 11 RDA 7 RDA Magnesium (mg) 75 AI 80 RDA Phosphorus (mg) 275 AI 460 RDA Potassium (mg) 860 AI 2,000 AI Sodium (mg) 370 AI 1,200 CDRR Zinc (mg) 3 RDA 3 RDA Vitamins Vitamin A (mcg RAEc) 500 AI 300 RDA Vitamin E (mg ATc) 5 AI 6 RDA Vitamin D (IUc) 400 AI 600 RDA Vitamin C (mg) 50 AI 15 RDA Thiamin (mg) 0.3 AI 0.5 RDA Riboflavin (mg) 0.4 AI 0.5 RDA Niacin (mg) 4 AI 6 RDA Page 131 | Dietary Guidelines for Americans, 2020-2025 | Appendix 1 Table A1-1 (continued) Daily Nutritional Goals, Ages 6 Through 11 Months and 12 Through 23 Months 6 Through 11 Months 12 Through 23 Months Nutrient Goal Source of Goalb Goal Source of Goalb Vitamin B-6 (mg) 0.3 AI 0.5 RDA Vitamin B-12 (mcg) 0.5 AI 0.9 RDA Choline (mg) 150 AI 200 AI Vitamin K (mcg) 2.5 AI 30 AI Folate (mcg DFEc) 80 AI 150 RDA a Goals reflect Dietary Reference Intakes developed for 7 to 12 months or 6 to 12 months applied to ages 6 to 12 months and DRIs for 1 to 3 years applied to 12 to 24 months. b AI = Adequate Intake, CDRR = Chronic Disease Risk Reduction Level, RDA = Recommended Dietary Allowance. c AT = alpha-tocopherol, DFE = Dietary Folate Equivalent, IU = International Units, RAE = Retinol Activity Equivalents. d n/a = not applicable to this age group. Sources: Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: The National Academies Press; 2006. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press; 2011. National Academies of Sciences, Engineering, and Medicine. Dietary Reference Intakes for Sodium and Potassium. Washington, DC: The National Academies Press; 2019. Dietary Guidelines for Americans, 2020-2025 | Appendix 1 | Page 132 Table A1-2 Daily Nutritional Goals, Ages 2 and Older Age-Sex Groups MACRONUTRIENTS, MINERALS & VITAMINS M/F F F F F F F M M M M M M 2-3 4-8 9-13 14-18 19-30 31-50 51+ 4-8 9-13 14-18 19-30 31-50 51+ Calorie Level Source Assessed of Goala 1,000 1,200 1,600 1,800 2,000 1,800 1,600 1,400 1,800 2,200 2,400 2,200 2,000 Macronutrients Protein (% kcal) AMDR 5-20 10-30 10-30 10-30 10-35 10-35 10-35 10-30 10-30 10-30 10-35 10-35 10-35 Protein (g) RDA 13 19 34 46 46 46 46 19 34 52 56 56 56 Carbohydrate (% kcal) AMDR 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 Carbohydrate (g) RDA 130 130 130 130 130 130 130 130 130 130 130 130 130 14g/ Fiber (g) 1,000 14 17 22 25 28 25 22 20 25 31 34 31 28 kcal Added Sugars (% kcal) DGA <10 <10 <10 <10 <10 <10 <10 <10 <10 <10 <10 <10 <10 Total lipid (% kcal) AMDR 30-40 25-35 25-35 25-35 20-35 20-35 20-35 25-35 25-35 25-35 20-35 20-35 20-35 Saturated Fatty Acids DGA <10 <10 <10 <10 <10 <10 <10 <10 <10 <10 <10 <10 <10 (% kcal) 18:2 Linoleic acid (g) AI 7 10 10 11 12 12 11 10 12 16 17 17 14 18:3 Linoleic acid (g) AI 0.7 0.9 1.0 1.1 1.1 1.1 1.1 0.9 1.2 1.6 1.6 1.6 1.6 Minerals Calcium (mg) RDA 700 1,000 1,300 1,300 1,000 1,000 1,200 1,000 1,300 1,300 1,000 1,000 1,000b Iron (mg) RDA 7 10 8 15 18 18 8 10 8 11 8 8 8 Magnesium (mg) RDA 80 130 240 360 310 320 320 130 240 410 400 420 420 Phosphorus (mg) RDA 460 500 1,250 1,250 700 700 700 500 1,250 1,250 700 700 700 Potassium (mg) AI 2,000 2,300 2,300 2,300 2,600 2,600 2,600 2,300 2,500 3,000 3,400 3,400 3,400 Sodium (mg) CDRR 1,200 1,500 1,800 2,300 2,300 2,300 2,300 1,500 1,800 2,300 2,300 2,300 2,300 Zinc (mg) RDA 3 5 8 9 8 8 8 5 8 11 11 11 11 Page 133 | Dietary Guidelines for Americans, 2020-2025 | Appendix 1 Table A1-2 (continued) Daily Nutritional Goals, Ages 2 and Older Age-Sex Groups MACRONUTRIENTS, MINERALS & VITAMINS M/F F F F F F F M M M M M M 2-3 4-8 9-13 14-18 19-30 31-50 51+ 4-8 9-13 14-18 19-30 31-50 51+ Calorie Level Source Assessed of Goala 1,000 1,200 1,600 1,800 2,000 1,800 1,600 1,400 1,800 2,200 2,400 2,200 2,000 Vitamins Vitamin A (mcg RAEd) RDA 300 400 600 700 700 700 700 400 600 900 900 900 900 Vitamin E (mg ATd) RDA 6 7 11 15 15 15 15 7 11 15 15 15 15 Vitamin D (IUd) RDA 600 600 600 600 600 600 600c 600 600 600 600 600 600c Vitamin C (mg) RDA 15 25 45 65 75 75 75 25 45 75 90 90 90 Thiamin (mg) RDA 0.5 0.6 0.9 1.0 1.1 1.1 1.1 0.6 0.9 1.2 1.2 1.2 1.2 Riboflavin (mg) RDA 0.5 0.6 0.9 1.0 1.1 1.1 1.1 0.6 0.9 1.3 1.3 1.3 1.3 Niacin (mg) RDA 6 8 12 14 14 14 14 8 12 16 16 16 16 Vitamin B-6 (mg) RDA 0.5 0.6 1.0 1.2 1.3 1.3 1.5 0.6 1.0 1.3 1.3 1.3 1.7 Vitamin B-12 (mcg) RDA 0.9 1.2 1.8 2.4 2.4 2.4 2.4 1.2 1.8 2.4 2.4 2.4 2.4 Choline (mg) AI 200 250 375 400 425 425 425 250 375 550 550 550 550 Vitamin K (mcg) AI 30 55 60 75 90 90 90 55 60 75 120 120 120 Folate (mcg DFEd) RDA 150 200 300 400 400 400 400 200 300 400 400 400 400 a AI = Adequate Intake, CDRR = Chronic Disease Risk Reduction Level, DGA = Dietary Guidelines for Americans, 2020-2025 , RDA = Recommended Dietary Allowance. b Calcium RDA for males ages 71+ years is 1,200 mg. c Vitamin D RDA for males and females ages 71+ years is 800 IU. d AT = alpha-tocopherol, DFE = Dietary Folate Equivalent, IU = International Units, RAE = Retinol Activity Equivalents. Sources: Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: The National Academies Press; 2006. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press; 2011. National Academies of Sciences, Engineering, and Medicine. Dietary Reference Intakes for Sodium and Potassium. Washington, DC: The National Academies Press; 2019. Dietary Guidelines for Americans, 2020-2025 | Appendix 1 | Page 134 Table A1-3 Daily Nutritional Goals for Women Who Are Pregnant, by Age Group and Trimester Age Group (Years) MACRONUTRIENTS, 14-18 19-30 31-50 MINERALS & VITAMINS Trimester 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd Calorie Level Assessed Source of Goala 1,800 2,200 2,400 2,000 2,400 2,600 1,800 2,200 2,400 Macronutrients Protein (% kcal) AMDR 10-30 10-30 10-30 10-35 10-35 10-35 10-35 10-35 10-35 Protein (g) RDA 71 71 71 71 71 71 71 71 71 Carbohydrate (%kcal) AMDR 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 45-65 Carbohydrate (g) RDA 175 175 175 175 175 175 175 175 175 Fiber (g) 14g/ 1,000 kcal 25 31 34 28 34 36 25 31 34 Added Sugars (% kcal) DGA <10 <10 <10 <10 <10 <10 <10 <10 <10 Total lipid (% kcal) AMDR 25-35 25-35 25-35 20-35 20-35 20-35 20-35 20-35 20-35 Saturated Fatty Acids (% kcal) DGA <10 <10 <10 <10 <10 <10 <10 <10 <10 18:2 Linoleic acid (g) AI 13 13 13 13 13 13 13 13 13 18:3 Linolenic acid (g) AI 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 Minerals Calcium (mg) RDA 1,300 1,300 1,300 1,000 1,000 1,000 1,000 1,000 1,000 Iron (mg) RDA 27 27 27 27 27 27 27 27 27 Magnesium (mg) RDA 400 400 400 350 350 350 360 360 360 Phosphorus (mg) RDA 1,250 1,250 1,250 700 700 700 700 700 700 Potassium (mg) AI 2,600 2,600 2,600 2,900 2,900 2,900 2,900 2,900 2,900 Sodium (mg) CDRR 2,300 2,300 2,300 2,300 2,300 2,300 2,300 2,300 2,300 Zinc (mg) RDA 12 12 12 11 11 11 11 11 11 Iodine (mcg) RDA 220 220 220 220 220 220 220 220 220 Vitamins Vitamin A (mcg RAEb) RDA 750 750 750 770 770 770 770 770 770 Vitamin E (mg ATb) RDA 15 15 15 15 15 15 15 15 15 Vitamin D (IUb) RDA 600 600 600 600 600 600 600 600 600 Page 135 | Dietary Guidelines for Americans, 2020-2025 | Appendix 1 Table A1-3 (continued) Daily Nutritional Goals for Women Who Are Pregnant, by Age Group and Trimester Age Group (Years) MACRONUTRIENTS, 14-18 19-30 31-50 MINERALS & VITAMINS Trimester 1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd Calorie Level Assessed Source of Goala 1,800 2,200 2,400 2,000 2,400 2,600 1,800 2,200 2,400 Vitamins Vitamin C (mg) RDA 80 80 80 85 85 85 85 85 85 Thiamin (mg) RDA 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 Riboflavin (mg) RDA 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 Niacin (mg) RDA 18 18 18 18 18 18 18 18 18 Vitamin B-6 (mg) RDA 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 1.9 Vitamin B-12 (mcg) RDA 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 2.6 Choline (mg) AI 450 450 450 450 450 450 450 450 450 Vitamin K (mcg) AI 75 75 75 90 90 90 90 90 90 Folate (mcg DFEb) RDA 600 600 600 600 600 600 600 600 600 a AI = Adequate Intake, CDRR = Chronic Disease Risk Reduction Level, DGA = Dietary Guidelines for Americans, 2020-2025 , RDA = Recommended Dietary Allowance. b AT = alpha-tocopherol, DFE = Dietary Folate Equivalent, IU= International Units, RAE = Retinol Activity Equivalents. Sources: Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: The National Academies Press; 2006. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press; 2011. National Academies of Sciences, Engineering, and Medicine. Dietary Reference Intakes for Sodium and Potassium. Washington, DC: The National Academies Press; 2019. Dietary Guidelines for Americans, 2020-2025 | Appendix 1 | Page 136 Table A1-4 Daily Nutritional Goals for Women Who Are Lactating, by Age Group and Months Postpartum Age Group (Years) 14-18 19-30 31-50 MACRONUTRIENTS, MINERALS & VITAMINS Months Postpartum 0-6 7-12 0-6 7-12 0-6 7-12 Calorie Level Assessed Source of Goala 2,200 2,200 2,400 2,400 2,200 2,200 Macronutrients Protein (% kcal) AMDR 10-30 10-30 10-35 10-35 10-35 10-35 Protein (g) RDA 71 71 71 71 71 71 Carbohydrate (% kcal) AMDR 45-65 45-65 45-65 45-65 45-65 45-65 Carbohydrate (g) RDA 210 210 210 210 210 210 Fiber (g) 14g/1,000kcal 31 31 34 34 31 31 Added sugars (% kcals) DGA <10 <10 <10 <10 <10 <10 Total lipid (% kcal) AMDR 25-35 25-35 20-35 20-35 20-35 20-35 Saturated Fatty Acids (% kcal) DGA <10 <10 <10 <10 <10 <10 18:2 Linoleic acid (g) AI 13 13 13 13 13 13 18:3 Linolenic acid (g) AI 1.3 1.3 1.3 1.3 1.3 1.3 Minerals Calcium (mg) RDA 1,300 1,300 1,000 1,000 1,000 1,000 Iron (mg) RDA 10 10 9 9 9 9 Magnesium (mg) RDA 360 360 310 310 320 320 Phosphorus (mg) RDA 1,250 1,250 700 700 700 700 Potassium (mg) AI 2,500 2,500 2,800 2,800 2,800 2,800 Sodium (mg) CDRR 2,300 2,300 2,300 2,300 2,300 2,300 Zinc (mg) RDA 13 13 12 12 12 12 Iodine (mcg) RDA 290 290 290 290 290 290 Page 137 | Dietary Guidelines for Americans, 2020-2025 | Appendix 1 Table A1-4 (continued) Daily Nutritional Goals for Women Who Are Lactating, by Age Group and Months Postpartum Age Group (Years) 14-18 19-30 31-50 MACRONUTRIENTS, MINERALS & VITAMINS Months Postpartum 0-6 7-12 0-6 7-12 0-6 7-12 Calorie Level Assessed Source of Goala 2,200 2,200 2,400 2,400 2,200 2,200 Vitamins Vitamin A (mcg RAEb) RDA 1,200 1,200 1,300 1,300 1,300 1,300 Vitamin E (mg ATb) RDA 19 19 19 19 19 19 Vitamin D (IUb) RDA 600 600 600 600 600 600 Vitamin C (mg) RDA 115 115 120 120 120 120 Thiamin (mg) RDA 1.4 1.4 1.4 1.4 1.4 1.4 Riboflavin (mg) RDA 1.6 1.6 1.6 1.6 1.6 1.6 Niacin (mg) RDA 17 17 17 17 17 17 Vitamin B-6 (mg) RDA 2 2 2 2 2 2 Vitamin B-12 (mcg) RDA 2.8 2.8 2.8 2.8 2.8 2.8 Choline (mg) AI 550 550 550 550 550 550 Vitamin K (mcg) AI 75 75 90 90 90 90 Folate (mcg DFEb) RDA 500 500 500 500 500 500 a AI = Adequate Intake, CDRR = Chronic Disease Risk Reduction Level, DGA = Dietary Guidelines for Americans, 2020-2025 , RDA = Recommended Dietary Allowance. b AT = alpha-tocopherol, DFE = Dietary Folate Equivalent, IU= International Units, RAE = Retinal Activity Equivalents. Sources: Institute of Medicine. Dietary Reference Intakes: The Essential Guide to Nutrient Requirements. Washington, DC: The National Academies Press; 2006. Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: The National Academies Press; 2011. National Academies of Sciences, Engineering, and Medicine. Dietary Reference Intakes for Sodium and Potassium. Washington, DC: The National Academies Press; 2019. Dietary Guidelines for Americans, 2020-2025 | Appendix 1 | Page 138 Appendix 2: Estimated Calorie Needs The total number of calories a person needs each day varies depending on the person’s age, sex, height, weight, and level of physical activity. In addition, a need to lose, maintain, or gain weight, and other factors affect how many calories should be consumed. Estimated amounts of calories needed to maintain energy balance for various age and sex groups at three different levels of physical activity are provided in Table A2-1 for toddlers ages 12 through 23 months and Table A2-2 for ages 2 and older. These estimates are based on the Estimated Energy Requirements (EER) equations, using reference heights (average) and reference weights (healthy) for each age-sex group. For toddlers, children, and adolescents, reference height and weight vary by age. For adults, the reference man is 5 feet 10 inches tall and weighs 154 pounds. The reference woman is 5 feet 4 inches tall and weighs 126 pounds. Estimates range from 700 to 1,000 calories for toddlers ages 12 through 23 months. Estimated needs for young children ages 2 through 8 range from 1,000 to 2,000 calories. A wider range of 1,400 to 3,200 calories is estimated for older children and adolescents, with males generally having higher calorie needs than females. Adult estimated calorie needs range from 1,600 to 2,400 calories per day for females and 2,000 to 3,000 calories per day for males. As shown, males generally require more calories than females. Due to reductions in basal metabolic rate that occur with aging, calorie needs generally decrease for adults as they age. Estimated calorie needs during the first trimester of pregnancy generally do not increase compared to prepregnancy needs. Additional calories needed for the later trimesters of pregnancy and during lactation are outlined in Table A2-3 and include approximately 300 to 400 additional calories. It is recommended that women follow their healthcare provider’s guidance regarding appropriate caloric intake during pregnancy as many factors, including prepregnancy weight status, gestational weight gain, and multiple pregnancies, may affect calorie needs. Women with overweight or obesity have lower recommended gestational weight gain during pregnancy, which may affect calorie needs. These calorie needs are only estimates, and approximations of individual calorie needs can be determined with online tools. The DRI Calculator for Healthcare Professionals, available at nal.usda.gov/fnic/dri-calculator, can be used to estimate calorie needs based on age, sex, height, weight, activity level, and pregnancy or lactation status. Table A2-1 Estimated Calorie Needs per Day, by Age and Sex, Ages 12 Through 23 Months AGE IN MONTHS Males Females 12 800 800 15 900 800 18 1,000 900 21 through 23 1,000 1,000 Source: Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington (DC): The National Academies Press; 2002. Page 139 | Dietary Guidelines for Americans, 2020-2025 | Appendix 2 Table A2-2 Estimated Calorie Needs per Day, by Age, Sex, and Physical Activity Level, Ages 2 and Older Males Females AGE Sedentarya Moderately Activeb Activec Sedentarya Moderately Activeb Activec 2 1,000 1,000 1,000 1,000 1,000 1,000 3 1,000 1,400 1,400 1,000 1,200 1,400 4 1,200 1,400 1,600 1,200 1,400 1,400 5 1,200 1,400 1,600 1,200 1,400 1,600 6 1,400 1,600 1,800 1,200 1,400 1,600 7 1,400 1,600 1,800 1,200 1,600 1,800 8 1,400 1,600 2,000 1,400 1,600 1,800 9 1,600 1,800 2,000 1,400 1,600 1,800 10 1,600 1,800 2,200 1,400 1,800 2,000 11 1,800 2,000 2,200 1,600 1,800 2,000 12 1,800 2,200 2,400 1,600 2,000 2,200 13 2,000 2,200 2,600 1,600 2,000 2,200 14 2,000 2,400 2,800 1,800 2,000 2,400 15 2,200 2,600 3,000 1,800 2,000 2,400 16 2,400 2,800 3,200 1,800 2,000 2,400 17 2,400 2,800 3,200 1,800 2,000 2,400 18 2,400 2,800 3,200 1,800 2,000 2,400 19-20 2,600 2,800 3,000 2,000 2,200 2,400 21-25 2,400 2,800 3,000 2,000 2,200 2,400 26-30 2,400 2,600 3,000 1,800 2,000 2,400 31-35 2,400 2,600 3,000 1,800 2,000 2,200 36-40 2,400 2,600 2,800 1,800 2,000 2,200 41-45 2,200 2,600 2,800 1,800 2,000 2,200 46-50 2,200 2,400 2,800 1,800 2,000 2,200 51-55 2,200 2,400 2,800 1,600 1,800 2,200 56-60 2,200 2,400 2,600 1,600 1,800 2,200 Dietary Guidelines for Americans, 2020-2025 | Appendix 2 | Page 140 Table A2-2 (continued) Estimated Calorie Needs per Day, by Age, Sex, and Physical Activity Level, Ages 2 and Older Males Females AGE Sedentarya Moderately Activeb Activec Sedentarya Moderately Activeb Activec 61-65 2,000 2,400 2,600 1,600 1,800 2,000 66-70 2,000 2,200 2,600 1,600 1,800 2,000 71-75 2,000 2,200 2,600 1,600 1,800 2,000 76 and up 2,000 2,200 2,400 1,600 1,800 2,000 a Sedentary means a lifestyle that includes only the physical activity of independent living. b Moderately Active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the activities of independent living. c Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles per day at 3 to 4 miles per hour, in addition to the activities of independent living. Source: Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington (DC): The National Academies Press; 2002. Table A2-3 Estimated Change in Calorie Needs During Pregnancy and Lactation for Women With a Healthya Prepregnancy Weight STAGE OF PREGNANCY OR LACTATION Estimated Change in Daily Calorie Needs Compared to Prepregnancy Needs Pregnancy: 1st trimester + 0 calories Pregnancy: 2nd trimester + 340 calories Pregnancy: 3rd trimester + 452 calories Lactation: 1st 6 months + 330 caloriesb Lactation: 2nd 6 months + 400 caloriesc a These estimates apply to women with a healthy prepregnancy weight. Women with a prepregnancy weight that is considered overweight or obese should consult their healthcare provider for guidance regarding appropriate caloric intake during pregnancy and lactation. b The EER for the first 6 months of lactation is calculated by adding 500 calories/day to prepregnancy needs to account for the energy needed for milk production during this time period, then subtracting 170 calories/day to account for weight loss in the first 6 months postpartum. c The EER for the second 6 months of lactation is calculated by adding 400 calories/day to prepregnancy needs to account for the energy needed for milk production during this time period. Weight stability is assumed after 6 months postpartum. Note: Estimates are based on Estimated Energy Requirements (EER) set by the Institute of Medicine. Source: Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: The National Academies Press; 2005. Page 141 | Dietary Guidelines for Americans, 2020-2025 | Appendix 2 Appendix 3: USDA Dietary Patterns The Healthy U.S.-Style Dietary Pattern (Tables A3-1 and A3-2) is based on the types and proportions of foods Americans typically consume but in nutrient-dense forms and appropriate amounts. The Healthy Vegetarian Dietary Pattern (Tables A3-3 and A3-4) and the Healthy Mediterranean-Style Dietary Pattern (Table A3-5) are variations that also exemplify a healthy dietary pattern. For the first time, the Healthy U.S.-Style and Healthy Vegetarian Dietary Patterns are provided for toddlers ages 12 through 23 months who are no longer receiving human milk or infant formula. These patterns are designed to meet nutrient needs while not exceeding calorie requirements and while staying within limits for overconsumed dietary components, such as added sugars, saturated fat, and sodium. The methodology used to develop and update these Patterns builds on the rich history USDA has in developing food guides. This methodology includes using current food consumption data to determine the mix and proportions of foods to include in each group. Food composition data is used to select a nutrient-dense representative for each food and calculate nutrient profiles for each food group. As would be expected, most foods in their nutrient-dense forms do contain some sodium and saturated fat. In a few cases, such as in the case of whole-wheat bread, the most appropriate representative in current Federal databases contains a small amount of added sugars. Detailed information about the representative foods, nutrient profiles, and patterns is available in the online appendix of the Scientific Report of the 2020 Dietary Guidelines Advisory Committee.1 Amounts of each food group and subgroup within the patterns are based on nutrient and Dietary Guidelines standards (see Appendix 1. Nutritional Goals for Age-Sex Groups). Standards for nutrient adequacy aim to meet the Recommended Dietary Allowances (RDA), which are designed to cover the needs of 97 percent of the population, and Adequate Intakes (AI), which are used when an average nutrient requirement cannot be determined. The Patterns meet these standards for almost all nutrients. For a few nutrients (vitamin D and vitamin E for all ages, and choline for ages 2 and older), amounts in the Patterns are marginal or below the RDA or AI standard for many or all age/sex groups. In most cases, an intake of these nutrients below the RDA or AI is not considered to be of public health concern. For more information on dietary components of public health concern, see Chapter 1. The Patterns have 12 calorie levels to meet the needs of individuals across the lifespan ages 2 and older. For toddlers ages 12 through 23 months, who are no longer receiving either human milk or infant formula, the Patterns are provided at 4 calorie levels. Chapters 2, 3, 4, 5, and 6 describe healthy dietary patterns and relevant calorie levels for each life stage. To follow these Patterns, identify the appropriate calorie level, choose a variety of foods in each group and subgroup over time in recommended amounts, and limit choices that are not in nutrient-dense forms so that the overall calorie limit is not exceeded. 1Available at: dietaryguidelines.gov/2020-advisory-committee-report/food-pattern-modeling Dietary Guidelines for Americans, 2020-2025 | Appendix 3 | Page 142 Table A3-1 Healthy U�S�-Style Dietary Pattern for Toddlers Ages 12 Through 23 Months Who Are No Longer Receiving Human Milk or Infant Formula, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 700 800 900 1,000 FOOD GROUP OR SUBGROUPb,c Daily Amount of Food From Each Groupd (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) ⅔ ¾ 1 1 Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) 1 ⅓ ½ ½ Red and Orange Vegetables (cup eq/wk) 1 1 ¾ 2 ½ 2 ½ Beans, Peas, Lentils (cup eq/wk) ¾ ⅓ ½ ½ Starchy Vegetables (cup eq/wk) 1 1 ½ 2 2 Other Vegetables (cup eq/wk) ¾ 1 ¼ 1 ½ 1 ½ Fruits (cup eq/day) ½ ¾ 1 1 Grains (ounce eq/day) 1 ¾ 2 ¼ 2 ½ 3 Whole Grains (ounce eq/day) 1 ½ 2 2 2 Refined Grains (ounce eq/day) ¼ ¼ ½ 1 Dairy (cup eq/day) 1 ⅔ 1 ¾ 2 2 Protein Foods (ounce eq/day) 2 2 2 2 Protein Foods Subgroups in Weekly Amounts Meats, Poultry (ounce eq/wk) 8 ¾ 7 7 7 ¾ Eggs (ounce eq/wk) 2 2 ¾ 2 ¼ 2 ¼ Seafood (ounce eq/wk)e 2-3 2-3 2-3 2-3 Nuts, Seeds, Soy Products (ounce eq/wk) 1 1 1 ¼ 1 ¼ Oils (grams/day) 9 9 8 13 a Calorie level ranges: Energy levels are calculated based on median available for additional added sugars, saturated fat, or to eat more than length and body weight reference individuals. Calorie needs vary based the recommended amount of food in a food group. on many factors. The DRI Calculator for Healthcare Professionals available at nal.usda.gov/fnic/dri-calculator/ can be used to estimate d In some cases, food subgroup amounts are greatest at the lower calorie needs based on age, sex, and weight. calorie levels to help achieve nutrient adequacy when relatively small number of calories are required. b Definitions for each food group and subgroup and quantity (i.e., cup or ounce equivalents) are provided in Chapter 1 and are compiled in Table e If consuming up to 2 ounces of seafood per week, children should A3-2 (footnote c). only be fed cooked varieties from the “Best Choices” list in the U.S. Food and Drug Administration (FDA) and the U.S. Environmental Protection c All foods are assumed to be in nutrient-dense forms and prepared with Agency (EPA) joint “Advice About Eating Fish,” available at FDA.gov/ minimal added sugars, refined starches (which are a source of calories fishadvice and EPA.gov/fishadvice. If consuming up to 3 ounces of but few or no other nutrients), or sodium. Food are also lean or in low-fat seafood per week, children should only be fed cooked varieties from the forms with the exception of dairy, which includes whole-fat fluid milk, “Best Choices” list that contain even lower methylmercury: flatfish (e.g., reduced-fat plain yogurts, and reduced-fat cheese. There are no calories flounder), salmon, tilapia, shrimp, catfish, crab, trout, haddock, oysters, Page 143 | Dietary Guidelines for Americans, 2020-2025 | Appendix 3 Table A3-1 Footnotes (continued) sardines, squid, pollock, anchovies, crawfish, mullet, scallops, whiting, clams, shad, and Atlantic mackerel. If consuming up to 3 ounces of seafood per week, many commonly consumed varieties of seafood should be avoided because they cannot be consumed at 3 ounces per week by children without the potential of exceeding safe methylmercury limits; examples that should not be consumed include: canned light tuna or white (albacore) tuna, cod, perch, black sea bass. For a complete list please see: FDA.gov/fishadvice and EPA.gov/fishadvice. Table A3-2 Healthy U�S�-Style Dietary Pattern for Ages 2 and Older, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200 FOOD GROUP OR SUBGROUPb Daily Amountc of Food From Each Group (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 1 1 ½ 1 ½ 2 2 ½ 2 ½ 3 3 3 ½ 3 ½ 4 4 Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) ½ 1 1 1 ½ 1 ½ 1 ½ 2 2 2 ½ 2 ½ 2 ½ 2 ½ Red and Orange Vegetables (cup eq/wk) 2 ½ 3 3 4 5 ½ 5 ½ 6 6 7 7 7½ 7½ Beans, Peas, Lentils (cup eq/wk) ½ ½ ½ 1 1½ 1½ 2 2 2 ½ 2 ½ 3 3 Starchy Vegetables (cup eq/wk) 2 3 ½ 3 ½ 4 5 5 6 6 7 7 8 8 Other Vegetables (cup eq/wk) 1 ½ 2 ½ 2 ½ 3 ½ 4 4 5 5 5 ½ 5 ½ 7 7 Fruits (cup eq/day) 1 1 1 ½ 1 ½ 1 ½ 2 2 2 2 2 ½ 2 ½ 2 ½ Grains (ounce eq/day) 3 4 5 5 6 6 7 8 9 10 10 10 Whole Grains (ounce eq/day)d 1 ½ 2 2 ½ 3 3 3 3 ½ 4 4 ½ 5 5 5 Refined Grains (ounce eq/day) 1 ½ 2 2 ½ 2 3 3 3 ½ 4 4 ½ 5 5 5 Dairy (cup eq/day) 2 2 ½ 2 ½ 3 3 3 3 3 3 3 3 3 Protein Foods (ounce eq/day) 2 3 4 5 5 5 ½ 6 6 ½ 6 ½ 7 7 7 Protein Foods Subgroups in Weekly Amounts Meats, Poultry, Eggs (ounce eq/wk) 10 14 19 23 23 26 28 31 31 33 33 33 Seafood (ounce eq/wk)e 2-3f 4 6 8 8 8 9 10 10 10 10 10 Nuts, Seeds, Soy Products (ounce eq/wk) 2 2 3 4 4 5 5 5 5 6 6 6 Oils (grams/day) 15 17 17 22 24 27 29 31 34 36 44 51 Limit on Calories for Other Uses (kcal/day)g 130 80 90 100 140 240 250 320 350 370 440 580 Limit on Calories for Other Uses (%/day) 13% 7% 6% 6% 8% 12% 11% 13% 13% 13% 15% 18% a Patterns at 1,000, 1,200, and 1,400 kcal levels are designed to meet the nutritional needs of children ages 2 through 8 years. Patterns from 1,600 to 3,200 kcal are designed to meet the nutritional needs of children 9 years and older and adults. If a child 4 through 8 years of age needs more energy and, therefore, is following a pattern at 1,600 calories or more, his/her recommended amount from the dairy group should be 2½ cup eq per day. Amount of dairy for children ages 9 through 18 is 3 cup eq per day regardless of calorie level. The 1,000 and 1,200 kcal level patterns are not intended for children 9 and older or adults. The 1,400 kcal level is not intended for children ages 10 and older or adults. Dietary Guidelines for Americans, 2020-2025 | Appendix 3 | Page 144 Table A3-2 Footnotes (continued) b Foods in each group and subgroup are: Vegetables Dark-Green Vegetables: All fresh, frozen, and canned dark-green leafy vegetables and broccoli, cooked or raw: for example, amaranth leaves, basil, beet greens, bitter melon leaves, bok choy, broccoli, chamnamul, chrysanthemum leaves, chard, cilantro, collards, cress, dandelion greens, kale, lambsquarters, mustard greens, poke greens, romaine lettuce, spinach, nettles, taro leaves, turnip greens, and watercress. Red and Orange Vegetables: All fresh, frozen, and canned red and orange vegetables or juice, cooked or raw: for example, calabaza, carrots, red chili peppers, red or orange bell peppers, pimento/pimiento, sweet potatoes, tomatoes, 100% tomato juice, and winter squash such as acorn, butternut, kabocha, and pumpkin. Beans, Peas, Lentils: All cooked from dry or canned beans, peas, chickpeas, and lentils: for example, black beans, black-eyed peas, bayo beans, brown beans, chickpeas (garbanzo beans), cowpeas, edamame, fava beans, kidney beans, lentils, lima beans, mung beans, navy beans, pigeon peas, pink beans, pinto beans, split peas, soybeans, and white beans. Does not include green beans or green peas. Starchy Vegetables: All fresh, frozen, and canned starchy vegetables: for example, breadfruit, burdock root, cassava, corn, jicama, lotus root, lima beans, immature or raw (not dried) peas (e.g., cowpeas, black-eyed peas, green peas, pigeon peas), plantains, white potatoes, salsify, tapioca, taro root (dasheen or yautia), water chestnuts, yam, and yucca. Other Vegetables: All other fresh, frozen, and canned vegetables, cooked or raw: for example, artichoke, asparagus, avocado, bamboo shoots, bean sprouts, beets, bitter melon (bitter gourd, balsam pear), broccoflower, Brussels sprouts, cabbage (green, red, napa, savoy), cactus pads (nopales), cauliflower, celeriac, celery, chayote (mirliton), chives, cucumber, eggplant, fennel bulb, garlic, ginger root, green beans, iceberg lettuce, kohlrabi, leeks, luffa (Chinese okra), mushrooms, okra, onions, peppers (chili and bell types that are not red or orange in color), radicchio, sprouted beans (e.g. sprouted mung beans), radish, rutabaga, seaweed, snow peas, summer squash, tomatillos, turnips, and winter melons. Fruits All fresh, frozen, canned, and dried fruits and 100% fruit juices: for example, apples, apricots, Asian pears, bananas, berries (e.g., blackberries, blueberries, cranberries, currants, dewberries, huckleberries, kiwifruit, loganberries, mulberries, raspberries, and strawberries); citrus fruit (e.g., calamondin, grapefruit, kumquats, lemons, limes, mandarin oranges, pomelos, tangerines, and tangelos); cherries, dates, figs, grapes, guava, jackfruit, lychee, mangoes, melons (e.g., cantaloupe, casaba, honeydew, and watermelon); nectarines, papaya, passion fruit, peaches, pears, persimmons, pineapple, plums, pomegranates, prunes, raisins, rhubarb, sapote, soursop, starfruit, and tamarind. Grains Whole Grains: All whole-grain products and whole grains used as ingredients: for example, amaranth, barley (not pearled), brown rice, buckwheat, bulgur, millet, oats, popcorn, quinoa, dark rye, triticale, whole-grain cornmeal, whole-wheat bread, whole-wheat chapati, whole-grain cereals and crackers, and wild rice. Refined Grains: All refined-grain products and refined grains used as ingredients: for example, white breads, refined-grain cereals and crackers, corn grits, cream of rice, cream of wheat, barley (pearled), masa, pasta, and white rice. Refined-grain choices should be enriched. Dairy All fluid, dry, or evaporated milk, including lactose-free and lactose-reduced products and fortified soy beverages (soy milk), buttermilk, yogurt, kefir, frozen yogurt, dairy desserts, and cheeses (e.g., brie, camembert, cheddar, cottage cheese, colby, edam, feta, fontina, goat, gouda, gruyere, limburger, Mexican cheeses [queso anejo, queso asadero, queso chihuahua], monterey, mozzarella, muenster, parmesan, provolone, ricotta, and Swiss). Most choices should be fat-free or low-fat. Cream, sour cream, and cream cheese are not included due to their low calcium content. Protein Foods Meats, Poultry, Eggs: Meats include beef, goat, lamb, pork, and game meat (e.g., bear, bison, deer, elk, moose, opossum, rabbit, raccoon, squirrel). Poultry includes chicken, Cornish hens, dove, duck, game birds (e.g., ostrich, pheasant, and quail), goose, and turkey. Organ meats include brain, chitterlings, giblets, gizzard, heart, kidney, liver, stomach, sweetbreads, tongue, and tripe. Eggs include chicken eggs and other birds’ eggs. Meats and poultry should be lean or low-fat. Seafood: Seafood examples that are lower in methylmercury include: anchovy, black sea bass, catfish, clams, cod, crab, crawfish, flounder, haddock, hake, herring, lobster, mackerel, mullet, oyster, perch, pollock, salmon, sardine, scallop, shrimp, sole, squid, tilapia, freshwater trout, light tuna, and whiting. Nuts, Seeds, Soy Products: Nuts and seeds include all nuts (tree nuts and peanuts), nut butters, seeds (e.g., chia, flax, pumpkin, sesame, and sunflower), and seed butters (e.g., sesame or tahini and sunflower). Soy includes tofu, tempeh, and products made from soy flour, soy protein isolate, and soy concentrate. Nuts should be unsalted. Beans, Peas, Lentils: Can be considered part of the protein foods group as well as the vegetable group, but should be counted in one group only. Page 145 | Dietary Guidelines for Americans, 2020-2025 | Appendix 3 c Food group amounts shown in cup equivalents (cup eq) or ounce equivalents (ounce eq). Oils are shown in grams. Quantity equivalents for each food group are: Vegetables, Fruits (1 cup eq): 1 cup raw or cooked vegetable or fruit; 1 cup vegetable or fruit juice; 2 cups leafy salad greens; ½ cup dried fruit or vegetable. Grains (1 ounce eq): ½ cup cooked rice, pasta, or cereal; 1 ounce dry pasta or rice; 1 medium (1 ounce) slice bread, tortilla, or flatbread; 1 ounce of ready-to-eat cereal (about 1 cup of flaked cereal). Dairy (1 cup eq): 1 cup milk, yogurt, or fortified soymilk; 1½ ounces natural cheese such as cheddar cheese or 2 ounces of processed cheese. Protein Foods (1 ounce eq): 1 ounce lean meats, poultry, or seafood; 1 egg; ¼ cup cooked beans or tofu; 1 tbsp nut or seed butter; ½ ounce nuts or seeds. d Amounts of whole grains in the Patterns for children are less than the minimum of 3 ounce-eq in all Patterns recommended for adults. e The U.S. Food and Drug Administration (FDA) and the U.S. Environmental Protection Agency (EPA) provide joint advice regarding seafood consumption to limit methylmercury exposure for women who might become or are pregnant or breastfeeding, and children. Depending on body weight, some women and many children should choose seafood lowest in methylmercury or eat less seafood than the amounts in the Healthy US-Style Eating Pattern. For more information, see the FDA and EPA websites FDA.gov/fishadvice; EPA.gov/fishadvice. f If consuming up to 2 ounces of seafood per week, children should only be fed cooked varieties from the “Best Choices” list in the FDA/EPA joint “Advice About Eating Fish,” available at FDA.gov/fishadvice and EPA.gov/fishadvice. If consuming up to 3 ounces of seafood per week, children should only be fed cooked varieties from the “Best Choices” list that contain even lower methylmercury: flatfish (e.g., flounder), salmon, tilapia, shrimp, catfish, crab, trout, haddock, oysters, sardines, squid, pollock, anchovies, crawfish, mullet, scallops, whiting, clams, shad, and Atlantic mackerel. If consuming up to 3 ounces of seafood per week, many commonly consumed varieties of seafood should be avoided because they cannot be consumed at 3 ounces per week by children without the potential of exceeding safe methylmercury limits; examples that should not be consumed include: canned light tuna or white (albacore) tuna, cod, perch, black sea bass. For a complete list please see: FDA.gov/fishadvice and EPA.gov/fishadvice. g Foods are assumed to be in nutrient-dense forms, lean or low-fat and prepared with minimal added saturated fat, added sugars, refined starches, or salt. If all food choices to meet food group recommendations are in nutrient-dense forms, a small number of calories remain within the overall limit of the pattern (i.e., limit on calories for other uses). The amount of calories depends on the total calorie level of the pattern and the amounts of food from each food group required to meet nutritional goals. Calories up to the specified limit can be used for added sugars, added refined starches, saturated fat, alcohol, or to eat more than the recommended amount of food in a food group. NOTE: The total dietary pattern should not exceed Dietary Guidelines limits for added sugars, saturated fat, and alcohol; be within the Acceptable Macronutrient Distribution Ranges for protein, carbohydrate, and total fats; and stay within calorie limits. Values are rounded. Dietary Guidelines for Americans, 2020-2025 | Appendix 3 | Page 146 Table A3-3 Healthy Vegetarian Dietary Pattern for Toddlers Ages 12 Through 23 Months Who Are No Longer Receiving Human Milk or Infant Formula, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERN a 700 800 900 1,000 FOOD GROUP OR SUBGROUPb,c Daily Amount of Food From Each Groupd (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 1 1 1 1 Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) ½ ½ ½ ½ Red and Orange Vegetables (cup eq/wk) 2 ½ 2 ½ 2 ½ 2 ½ Beans, Peas, Lentils (cup eq/wk) ¾ ¾ ¾ ¾ Starchy Vegetables (cup eq/wk) 2 2 2 2 Other Vegetables (cup eq/wk) 1 ½ 1 ½ 1 ½ 1 ½ Fruits (cup eq/day) ½ ¾ 1 1 Grains (ounce eq/day) 1 ¾ 2 ¼ 2 ¾ 3 Whole Grains (ounce eq/day) 1 ¼ 1 ¾ 2 2 Refined Grains (ounce eq/day) ½ ½ ¾ 1 Dairy (cup eq/day) 1 ½ 1 ¾ 1 ¾ 2 Protein Foods (ounce eq/day) 1 1 1 1 Protein Foods Subgroups in Weekly Amounts Eggs (ounce eq/wk) 3 ½ 3 ½ 3 ½ 3 ½ Nuts, Seeds, Soy Products (ounce eq/wk) 4 4 4 4 Oils (grams/day) 9 8 ½ 10 15 a Calorie level ranges: Energy levels are calculated based on median length and body weight reference individuals. Calorie needs vary based on many factors. The DRI Calculator for Healthcare Professionals available at nal.usda.gov/fnic/dri-calculator/ can be used to estimate calorie needs based on age, sex, and weight. b Definitions for each food group and subgroup and quantity (i.e., cup or ounce) equivalents are provided in Chapter 1 and are compiled in Table A3-2 (footnote c). c All foods are assumed to be in nutrient-dense forms and prepared with minimal added sugars, refined starches (which are a source of calories but few or no other nutrients), or sodium. Food are also lean or in low-fat forms with the exception of dairy which includes whole-fat fluid milk, reduced-fat plain yogurts, and reduced-fat cheese. There are no calories available for additional added sugars, saturated fat, or to eat more than the recommended amount of food in a food group. d In some cases, food subgroup amounts are greatest at the lower calorie levels to help achieve nutrient adequacy when relatively small number of calories are required. Page 147 | Dietary Guidelines for Americans, 2020-2025 | Appendix 3 Table A3-4 Healthy Vegetarian Dietary Pattern for Ages 2 and Older, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200 FOOD GROUP OR SUBGROUPb Daily Amountc of Food From Each Group (Vegetable and protein foods subgroup amountsb are per week.) Vegetables (cup eq/day) 1 1 ½ 1 ½ 2 2 ½ 2 ½ 3 3 3 ½ 3 ½ 4 4 Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) ½ 1 1 1 ½ 1 ½ 1 ½ 2 2 2 ½ 2 ½ 2 ½ 2 ½ Red and Orange Vegetables (cup eq/wk) 2 ½ 3 3 4 5 ½ 5½ 6 6 7 7 7½ 7½ Beans, Peas, Lentils (cup eq/wk)d ½ ½ ½ 1 1 ½ 1 ½ 2 2 2 ½ 2 ½ 3 3 Starchy Vegetables (cup eq/wk) 2 3 ½ 3 ½ 4 5 5 6 6 7 7 8 8 Other Vegetables (cup eq/wk) 1 ½ 2 ½ 2 ½ 3 ½ 4 4 5 5 5 ½ 5 ½ 7 7 Fruits (cup eq/day) 1 1 1 ½ 1 ½ 1 ½ 2 2 2 2 2 ½ 2 ½ 2 ½ Grains (ounce eq/day) 3 4 5 5 ½ 6 ½ 6 ½ 7 ½ 8 ½ 9 ½ 10 ½ 10 ½ 10 ½ Whole Grains (ounce eq/day) 1 ½ 2 2 ½ 3 3 ½ 3 ½ 4 4 ½ 5 5 ½ 5 ½ 5 ½ Refined Grains (ounce eq/day) 1 ½ 2 2 ½ 2 ½ 3 3 3 ½ 4 4 ½ 5 5 5 Dairy (cup eq/day) 2 2 ½ 2 ½ 3 3 3 3 3 3 3 3 3 Protein Foods (ounce eq/day) 1 1 ½ 2 2 ½ 3 3 ½ 3 ½ 4 4 ½ 5 5 ½ 6 Protein Foods Subgroups in Weekly Amounts Eggs (ounce eq/wk) 2 3 3 3 3 3 3 3 3 4 4 4 Beans, Peas, Lentils (cup eq/wk)d 1 2 4 4 6 6 6 8 9 10 11 12 Soy Products (ounce eq/wk) 2 3 4 6 6 8 8 9 10 11 12 13 Nuts, Seeds (ounce eq/wk) 2 2 3 5 6 7 7 8 9 10 12 13 Oils (grams/day) 15 17 17 22 24 27 29 31 34 36 44 51 Limit on Calories for Other Uses (kcal/day)e 170 140 160 150 150 250 290 350 350 350 390 500 Limit on Calories for Other Uses (%/day) 17% 12% 11% 9% 8% 13% 13% 15% 13% 13% 13% 16% a, b, c See Table A3-2 footnotes. d About half of beans, peas, lentils are shown as vegetables, in cup eq, and half as protein foods, in ounce eq. Beans, peas, lentils in the patterns, in cup eq, is the amount in the vegetable group plus the amount in protein foods group (in ounce eq) divided by four. e See Table A3-2 footnotes. NOTE: The total dietary pattern should not exceed Dietary Guidelines limits for added sugars, saturated fat, and alcohol; be within the Acceptable Macronutrient Distribution Ranges for protein, carbohydrate, and total fats; and stay within calorie limits. Values are rounded. Dietary Guidelines for Americans, 2020-2025 | Appendix 3 | Page 148 Table A3-5 Healthy Mediterranean-Style Dietary Pattern for Ages 2 and Older, With Daily or Weekly Amounts From Food Groups, Subgroups, and Components CALORIE LEVEL OF PATTERNa 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200 FOOD GROUP OR SUBGROUPb Daily Amountc of Food From Each Group (Vegetable and protein foods subgroup amounts are per week.) Vegetables (cup eq/day) 1 1 ½ 1 ½ 2 2 ½ 2 ½ 3 3 3 ½ 3 ½ 4 4 Vegetable Subgroups in Weekly Amounts Dark-Green Vegetables (cup eq/wk) ½ 1 1 1 ½ 1 ½ 1 ½ 2 2 2 ½ 2 ½ 2 ½ 2 ½ Red and Orange Vegetables (cup eq/wk) 2 ½ 3 3 4 5 ½ 5 ½ 6 6 7 7 7 ½ 7 ½ Beans, Peas, Lentils (cup eq/wk) ½ ½ ½ 1 1 ½ 1 ½ 2 2 2 ½ 2 ½ 3 3 Starchy Vegetables (cup eq/wk) 2 3 ½ 3 ½ 4 5 5 6 6 7 7 8 8 Other Vegetables (cup eq/wk) 1 ½ 2 ½ 2 ½ 3 ½ 4 4 5 5 5 ½ 5 ½ 7 7 Fruits (cup eq/day) 1 1 1 ½ 2 2 2 ½ 2 ½ 2 ½ 2 ½ 3 3 3 Grains (ounce eq/day) 3 4 5 5 6 6 7 8 9 10 10 10 Whole Grains (ounce eq/day)d 1 ½ 2 2 ½ 3 3 3 3 ½ 4 4 ½ 5 5 5 Refined Grains (ounce eq/day) 1 ½ 2 2 ½ 2 3 3 3 ½ 4 4 ½ 5 5 5 Dairy (cup eq/day)d 2 2 ½ 2 ½ 2 2 2 2 2 ½ 2 ½ 2 ½ 2 ½ 2 ½ Protein Foods (ounce eq/day) 2 3 4 5 ½ 6 6 ½ 7 7 ½ 7 ½ 8 8 8 Protein Foods Subgroups in Weekly Amounts Meats, Poultry, Eggs (ounce eq/wk) 10 14 19 23 23 26 28 31 31 33 33 33 Seafood (ounce eq/wk)e 3 4 6 11 15 15 16 16 17 17 17 17 Nuts, Seeds, Soy Products (ounce eq/wk) 2 2 3 4 4 5 5 5 5 6 6 6 Oils (grams/day) 15 17 17 22 24 27 29 31 34 36 44 51 Limit on Calories for Other Uses (kcal/day)f 130 80 90 120 140 240 250 280 300 330 400 540 Limit on Calories for Other Uses (%/day) 13% 7% 6% 8% 8% 12% 11% 12% 12% 12% 13% 17% a,b,c See Table A3-2 footnotes. and prepared with minimal added sugars, refined starches (which are a source of calories but few or no other nutrients), saturated fat, or d Amounts of dairy recommended for children and adolescents are as sodium. If all food choices to meet food group recommendations are follows, regardless of the calorie level of the pattern: for age 2 years, in nutrient-dense forms, a small number of calories remain within the 2 cup-eq per day; for ages 3 through 8 years, 2 ½ cup-eq per day; for overall limit of the pattern (i.e., limit on calories for other uses). The ages 9 through 18 years, 3 cup-eq per day. amount of calories depends on the total calorie level of the pattern and the amounts of food from each food group required to meet e The U.S. Food and Drug Administration (FDA) and the U.S. nutritional goals. Calories up to the specified limit can be used for Environmental Protection Agency (EPA) provide joint advice regarding added sugars, saturated fat, and/or alcohol (for nonpregnant adults of seafood consumption to limit methylmercury exposure for women who legal drinking age only) or to eat more than the recommended amount might become or are pregnant or lactating, and children. Depending on of food in a food group. body weight, some women and children should choose seafood lowest in methylmercury or eat less seafood than the amounts in the Healthy NOTE: The total dietary pattern should not Dietary Guidelines U.S.-Style Dietary Pattern. For more information, see the FDA and EPA limits for added sugars, saturated fat, and alcohol; be within websites at FDA.gov/fishadvice and EPA.gov/fishadvice. the Acceptable Macronutrient Distribution Ranges for protein, carbohydrate, and total fats; and stay within calorie limits. Values f Foods are assumed to be in nutrient-dense forms; lean or low-fat; are rounded. Page 149 | Dietary Guidelines for Americans, 2020-2025 | Appendix 3 DietaryGuidelines.gov USDA Publication #: USDA-FNS-2020-2025-DGA HHS Publication #: HHS-ODPHP-2020-2025-01-DGA-A recommended levels of dairy intake per federal guidelines.

Evolving Science Supports Whole and 2% Milk

Nutrition science has evolved in the past decade to show neutral or positive benefits of full-fat dairy foods such as whole milk, including less weight gain, neutral or lower risk of heart disease, and lower childhood obesity. Learn more about the importance of milk—especially whole and 2% milk—in the diets of healthy children at www.wholemilkforkids.com.

“It is time for Congress to allow dairy farmers and milk processors to serve their best products to students. Reinstating whole and 2% milk in schools will increase milk consumption, ensuring more children get the necessary nutrients they need to thrive every day. The same is true for allowing whole and 2% milk, cheese and yogurt varieties to be eligible for SNAP dairy nutrition incentives as part of the Farm Bill. IDFA urges the House and Senate to swiftly pass the Whole Milk for Healthy Kids Act and grant U.S. students the ability to access the nutritious milk options they prefer to drink,” said Dykes.

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Contact: press@idfa.org

The International Dairy Foods Association (IDFA), Washington, D.C., represents the nation’s dairy manufacturing and marketing industry, which supports more than 3.2 million jobs that generate $49 billion in direct wages and $794 billion in overall economic impact. IDFA’s diverse membership ranges from multinational organizations to single-plant companies, from dairy companies and cooperatives to food retailers and suppliers, all on the cutting edge of innovation and sustainable business practices. Together, they represent most of the milk, cheese, ice cream, yogurt and cultured products, and dairy ingredients produced and marketed in the United States and sold throughout the world. Delicious, safe and nutritious, dairy foods offer unparalleled health and consumer benefits to people of all ages.