Dietary Guidelines for Americans

The Dietary Guidelines for Americans (DGA) provide nutritional advice for Americans who are healthy or who are at risk for chronic disease but do not currently have chronic disease.[1][2] The Guidelines are published every five years by the US Department of Agriculture, together with the US Department of Health and Human Services. Notably, the most recent ninth edition for 2020–2025 includes dietary guidelines for children from birth to 23 months.[3]

The nominal purpose of the Dietary Guidelines for Americans is to help health professionals and policymakers to advise Americans about healthy choices for their diet. More than half of the members of the expert panel that developed the new guidelines had conflicts of interest due to ties to the food industry.[4] In formulating the Dietary Guidelines for 2020–2025, the US Federal government rejected the advice of the expert scientific panel that the guidelines set new low targets for consumption of sugar and alcoholic beverages.[5] Some experts have criticized the current Dietary Guidelines for a lack of adherence to a rigorous, verified scientific methodology and inadequate efforts to increase transparency and manage bias as was recommended by two Congressionally-mandated reports issued by the National Academies of Sciences, Engineering, and Medicine (NASEM) in 2017. It has been noted that the 2020 Report does not comply with the law, as it does not reflect the “preponderance of scientific and medical knowledge which is current at the time the report is prepared.”[6]

The current edition (2020-2025) gives four overarching guidelines: Follow a healthy dietary pattern throughout life; use nutrient-dense food and beverages to reflect personal preferences, cultural traditions, and budgetary considerations; meet dietary food group needs with nutrient-dense foods and beverages within calorie limits; and limit foods and beverages with higher added sugars, saturated fat, and sodium, and limit alcoholic beverages. In support of these four guidelines, the key recommendations are: avoid added sugars for infants and toddlers and limit added sugars to less than 10% of calories for those 2 years old and older; limit saturated fat to less than 10% of calories starting at age 2; limit sodium to less than 2,300mg per day (or even less if younger than 14) and limit alcoholic beverages (if consumed) to 2 drinks or less daily for men and 1 drink or less a daily for women.[7]

Since the introduction of the Dietary Guidelines for Americans in 1980, many Americans have followed the recommendations in these guidelines, markedly increasing their consumption of carbohydrates. Since 1980, there has been a marked increase in obesity and diabetes mellitus type 2 in the American population.[8]

History

The efforts of the US Federal Government to establish a scientific basis for human nutrition began with Wilbur Olin Atwater,[9] who published the first dietary recommendations for Americans in 1894, notably stating that, "We live not upon what we eat, but upon what we digest."[10]

In 1977, despite limited and contradictory input from nutrition experts, the United States Senate Select Committee on Nutrition and Human Needs, chaired by Senator George McGovern, published the Dietary Goals for the United States,[11] recommending that Americans avoid becoming obese by consuming only as much energy as was expended and to reverse obesity by decreasing energy intake and increasing energy expenditure. The Dietary Goals also recommended increasing complex carbohydrates and naturally occurring sugars from 28% to 48% of energy intake, reducing refined and processed sugars to about 10% of energy intake, reducing fat from 40% to 30% of energy intake, reducing eating saturated fat to 10% of energy intake, reducing cholesterol consumption to 300 milligrams daily, and reducing salt intake to 5 grams daily.[12] The 1977 Dietary Goals for the United States were not based on a consensus among scientists and for this reason were criticized by agriculture and food manufacturing interests, and also by some scientists.[13] A second version of the report was published in 1980, with less stringent changes from the standard American diet.

The Dietary Guidelines for Americans has been published every five years beginning in 1980, producing nine guidelines to date.[14] One consistent recommendation of these nine guidelines has been that Americans reduce their dietary consumption of fat and animal products, including meat, dairy, and eggs and to increase their dietary consumption of carbohydrates and plant foods, including fruits, vegetables, and grains.[15]

Purpose

The Guidelines were established so as to provide dietary advice that would improve the health of Americans and reduce their risk for chronic conditions, such as cancer, atherosclerosis, hypertension, heart disease, stroke, and renal disease. The Dietary Guidelines have the purpose of guiding the development of Federal policies and programs related to food, nutrition, and health. The guidelines influence and guide policymakers for Federally-financed food and dietary education programs. They also influence clinicians in the United States and in other countries.

The intended audience for the Dietary Guidelines for Americans are policymakers, nutrition scientists, and dieticians and other health professionals. The Guidelines themselves are not intended to directly inform the general public, but instead to serve as an authoritative, evidence-based information source that policymakers and health professionals can use to advise Americans about making healthy choices in their daily lives so as to enjoy a healthy diet that also prevents chronic disease. The Dietary Guidelines for Americans provide an evidence-base that is used by the Federal government to develop nutrition education materials for Americans.

Federal law and regulation require that Federal government publications provide dietary guidance consistent with the Dietary Guidelines for Americans. For the United States Department of Agriculture (USDA) the guidelines provide the scientific rationale for the National School Lunch Program and School Breakfast Program, feeding 30 million children every school day, and the Special Supplemental Nutrition Program for Women, Infants and Children, which has 8 million beneficiaries. For the United States Department of Health and Human Services Administration on Aging, the guidelines provide the rationale for the Older Americans Act Nutrition Services programs which include more than 5,000 community-based nutrition service providers (e.g., Meals on Wheels), serving more than 900,000 meals a day across the United States. The Department of Defense uses the guidelines as the rationale for meal rations for military personnel and the Department of Veterans Affairs uses the guidelines to inform nutrition education for veterans who are patients of the VA Hospital System. In addition to these governmental audiences, the Dietary Guidelines for Americans are widely used by state and local governments, schools, commercial enterprises, community groups, the media, and the food industry to inform policy and program development intended to serve the general public.[16]

Current guidelines

The Dietary Guidelines for Americans (2020–2025) were published.[17] The Trump Administration had proposed a budget of more than $12 million for the 2020-2025 guidelines for the evaluation of scientific evidence, development of the Dietary Guidelines for Americans, and dissemination of the new edition to its target audience of policymakers, nutrition experts, and clinicians; this budget request has been supported by multiple organizations.[18]

In June, 2020, a letter was sent to the U.S. Department of Agriculture and the U.S. Department of Health and Human Services from The Nutrition Coalition, describing serious problems observed by one or more whistleblowers. According to this letter, these whistleblowers, who were members of the Dietary Guidelines Advisory Committee (DGAC), reported that there had been inadequate time to complete scientific reviews, that some reviews were deleted and some were added by the DGAC without giving the required public notice, that there were inconsistencies in how scientific evidence was evaluated across the various DGAC subcommittees. Also noted was that the DGAC had rejected the reforms that had been recommended by the National Academies of Sciences, Engineering, and Medicine (NASEM), that important scientific evidence had been excluded from consideration by the DGAC, including studies of weight loss and also studies of low-carbohydrate diets, and that communication restrictions had been in place among members of the DGAC.[19]

2015–2020 guidelines

Although the 2015–2020 Dietary Guidelines for Americans (DGA) were purported to be based on a systematic review of the current body of nutrition science, critics have argued that the 2015–2020 Advisory Committee tasked with formulating the plan for retrieval and analysis of the scientific evidence for the current edition of the DGA used a less than rigorous process for assessing the health effects of consumption of saturated fat and salt and for assessing the health effects of a low-fat, high-carbohydrate diet. This less than rigorous review of the nutrition science literature resulted in omission of multiple large, high-quality, clinical trials and also omission of some high-quality prospective observational studies. Some Advisory Committee members also had conflicts of interest[20] that were not fully disclosed. For these reasons, the quality of the Advisory Committee's Scientific Report and the validity of the 2015–2020 DGA itself has been challenged by critics as being unduly influenced by commercial interests and as being flawed due to confirmation bias of some members of the Advisory Committee.[21][22][23][24][25]

The Dietary Guidelines for Americans (2015–2020) were developed in three stages, beginning with a review of scientific evidence, followed by development of the guidelines, and finally with implementation of the guidelines.[26] Compared to previous guidelines, the 2015–2020 guidelines emphasized replacing saturated fats with unsaturated fats, particularly polyunsaturated fats, with the goal of preventing heart attack and stroke (see lipid hypothesis).[27]

The guidelines provide a general recommendation that people follow a healthy eating pattern with appropriate calories, and that the evaluation of one's eating pattern accounts for all foods and beverages, including snacks. The recommended healthy eating pattern includes:

Include these in diet:

  • A broad selection of vegetables, including dark green, red and orange, legumes (beans and peas), starches (potatoes, squash, etc), and others
  • An emphasis on whole fruits
  • An emphasis on whole grains
  • Dairy products that are either fat-free or low fat, including milk, yogurt, cheese, and fortified soy beverages
  • Protein foods to include seafood, lean meats, poultry, eggs, legumes (beans and peas), and nuts, seeds, and soy products[28]

Limit these in diet:

  • Trans fats
  • Saturated fats to less than 10% of calories
  • Added sugars to less than 10% of calories
  • Sodium to less than 2.3 g/day (5.8 g of salt/day), including both added table salt and salt in foods
  • If consumed, use alcohol in moderation and only for adults — up to 1 drink daily for women and 2 drinks daily for men.[28]

The Dietary Guidelines also include a key recommendation to meet the Physical Activity Guidelines for Americans.[28]

The MyPlate initiative, based on the recommendations of the 2015–2020 Dietary Guidelines for Americans and produced by the USDA Center for Nutrition Policy and Promotion, is a nutrition education program directed at the general public, providing a guide to "finding healthy eating solutions to fit your lifestyle."[29]

Criticisms of the 2015–2020 Guidelines

Each edition of the Dietary Guidelines for Americans has had attendant controversy, with objections particularly from scientists whose point-of-view was not reflected in the guidelines and from commercial interests negatively affected by the recommendations therein.[30] The response to the 2015–2020 guidelines was particularly contentious,[31] resulting in action by Congress mandating the National Academies of Sciences, Engineering, and Medicine to evaluate the process used to update the DGA.[32] This review by the National Academies resulted in two reports. The first report, entitled "Optimizing the Process for Establishing the Dietary Guidelines for Americans: The Selection Process", identified opportunities for improving the process for selecting members of the Dietary Guidelines Advisory Committee.[33] In September 2018, the USDA issued an official response to the first report of the National Academies committee.[34] The second report from National Academies of Sciences, entitled "Redesigning the Process for Establishing the Dietary Guidelines for Americans", offers an exhaustive review and provides recommendations for improving the process of revising the Dietary Guidelines so as to best identify, analyze, and present the scientific evidence.[35]

Methodology

One critic contends that the current guidelines do not promote the public interest and have been corrupted by regulatory capture, advancing the commercial concerns of agribusiness and large food processors, and the political concerns of scientists intent on preserving their point-of-view.[36] Another critic notes that the DGAs make recommendations that overvalue the findings of observational studies and surrogate measures of outcomes and that undervalue the findings of high-quality randomized controlled trials.[22]

There is compelling evidence that food frequency questionnaires and other methods that rely on human memory do not accurately measure dietary intake.[37] An analysis of the validity of the methods used by the USDA to estimate per capita calorie consumption found that these methods lack validity and the authors of this study recommend that these methods not be used to inform public policy.[38] A systematic review found that only a few studies have measured the accuracy or reliability of dietary assessment methods in schoolchildren. The few studies that have been done found that schoolchildren did not accurately report foods consumed but that they did accurately report total calories consumed.[39] The 2015 Guidelines were based on the Scientific Report of the 2015 Dietary Guidelines Advisory Committee,[40] which did not rely on actual measurements of dietary intake but instead relied on memory-based dietary assessments, including interviews and surveys despite clear evidence that such methods markedly underestimate actual calorie consumption and nutrient intake. Thus, the conclusions expressed in the Scientific Report have been criticized, and the Dietary Guidelines for Americans are considered invalid by some experts, as the DGAs rely on invalid methods and draw conclusions that do not agree with the available scientific literature.[41]

Restriction of dietary fat and cholesterol

The Dietary Guidelines for Americans have been criticized for recommending a diet that is low in total fat, and for not adequately emphasizing the harmful effect of industrially-produced trans fats.[42] A systematic review of 62,421 participants in 10 dietary trials found that reducing dietary fat intake had no effect on coronary heart disease and had no effect on overall mortality. The authors of this meta-analysis conclude that the available evidence from randomized controlled trials does not support the recommendation of the 2015–2020 Dietary Guidelines for Americans that people reduce their fat intake.[43] A 2020 meta-analysis in the Cochrane Database found that reducing dietary saturated fats for at least two years reduced risk of cardiovascular events.[44] A subsequent re-analysis of the same clinical trials identified errors in the prior meta-analysis and instead found that reducing saturated fat intake had no effect on the risk of cardiovascular disease, (pooled relative risk of 0.93, 95% confidence interval: 0.74–1.16).[45] The 2015–2020 Dietary Guidelines for Americans recommended limiting dietary cholesterol intake to as little as possible while maintaining healthy eating patterns.

Dietary salt restriction

The Dietary Guidelines for Americans have been criticized for recommending a diet that contains less than 2.3  grams of sodium (5.8 grams of salt/day). Notably, 95% of the world's populations have a mean intake of salt that is between 6g and 12g daily and evidence on the health effects of salt does not support such a severe restriction on salt intake. An analysis of dietary guidelines found that this recommendation for restriction of salt intake is not supported by evidence from randomized controlled trials nor is it supported by evidence from prospective observational studies. In fact, intake of less than 5.8 g of salt per day typically results in activation of the renin-angiotensin-aldosterone system, which leads to an increase in plasma lipids and increased mortality. The authors of this analysis suggest a redesign of the dietary guidelines for salt intake is needed.[46]

A Committee of the National Academies Institute of Medicine evaluated the evidence about dietary salt intake and health. Overall, the committee found evidence that higher salt intake was associate with increased risk of cardiovascular disease. However, the Committee also found that the evidence did not support the claim that lowering sodium intake in the general population to less than 2,300 mg/day was associated with a lower risk of death nor with a higher risk of death.[47]

Alcoholic beverage consumption

The Dietary Guidelines for Americans recommend limiting alcoholic beverages consumption to no more than 1 drink daily for women and no more than 2 drinks daily for men. The 2015–2020 Scientific Report of the Dietary Guidelines Advisory Committee asserts that most studies show that moderate consumption of alcohol has been shown to be part of a beneficial dietary pattern. However, a systematic review and meta-analysis of scientific studies of alcohol consumption and all-cause mortality found that consumption of up to 2 alcoholic beverages per day had no net mortality benefit compared with lifetime abstention from alcohol.[48] A systematic analysis of data from the Global Burden of Disease study found that consumption of ethanol increases the risk of cancer and increases the risk of all-cause mortality, and that the level of ethanol consumption that minimizes disease is zero consumption.[49]

The Guidelines recommend that people not mix alcohol and beverages containing caffeine, as this combined intake may result in greater alcohol consumption, with a greater risk of alcohol-related injury.

Classification of honey and maple syrup as "added sugars"

Producers of honey and maple syrup have objected to the proposed Federal regulatory requirement that honey and maple syrup include the term "added sugar" on product labeling, despite the fact that no additional sugar is added to these products. This regulatory requirement follows from the recommendation in the 2015–2020 Guidelines that added sugars be limited to less than 10% of calories and that honey and maple syrup are themselves considered by federal regulators to be added sugars.[50]

Future guidelines

The USDA has invited interested parties, including members of the general public, to participate and follow the development of the 2025–2030 edition of the Dietary Guidelines for Americans.[51] As mandated by the Agriculture Act of 2014, this next edition of the guidelines will cover the full life-span of Americans from birth, including recommendations for pregnant women, infants, and children younger than two years old.

See also

References

  1. ↑ "Purpose of the Dietary Guidelines | Dietary Guidelines for Americans".
  2. ↑ https://www.dietaryguidelines.gov
  3. ↑ Robinson, Daniel T. (23 March 2021). "Big steps for advising the smallest bites: Dietary Guidelines for Americans address feeding infants and toddlers". Journal of Perinatology. 41 (5): 926–927. doi:10.1038/s41372-021-01027-4. PMID 33758397. S2CID 232315152.
  4. ↑ Jacobs, Andrew (17 June 2020). "Scientific Panel on New Dietary Guidelines Draws Criticism from Health Advocates". The New York Times.
  5. ↑ Rabin, Roni Caryn (29 December 2020). "U.S. Diet Guidelines Sidestep Scientific Advice to Cut Sugar and Alcohol". The New York Times.
  6. ↑ "Nutrition Coalition Submits Final Public Comments to USDA re: 2020 Expert Report".
  7. ↑ https://health.gov/our-work/nutrition-physical-activity/dietary-guidelines/current-dietary-guidelines
  8. ↑ "Widespread Criticism".
  9. ↑ "nutrition : USDA ARS". Ars.usda.gov.
  10. ↑ Arwater, W (1894). "Farmer's Bulletin" (PDF). Ars.usda.gov.
  11. ↑ "Dietary goals for the United States". 1977. pp. xli, 83 : ill., 24 cm.–Other US.
  12. ↑ "History of the Dietary Guidelines | Dietary Guidelines for Americans".
  13. ↑ Oppenheimer, Gerald M.; Benrubi, I. Daniel (January 2014). "McGovern's Senate Select Committee on Nutrition and Human Needs Versus the: Meat Industry on the Diet-Heart Question (1976–1977)". American Journal of Public Health. 104 (1): 59–69. doi:10.2105/AJPH.2013.301464. PMC 3910043. PMID 24228658.
  14. ↑ "Dietary Guidelines for Americans – History". Health.gov.
  15. ↑ Center for Nutrition Policy and Promotion. Dietary guidelines for Americans, 1980 TO 2000. www.health.gov/dietaryguidelines/1980_2000_chart.pdf.
  16. ↑ "The Dietary Guidelines for Americans: What It Is, What It Is Not - 2015-2020 Dietary Guidelines - health.gov". health.gov.
  17. ↑ https://www.dietaryguidelines.gov/sites/default/files/2021-03/Dietary_Guidelines_for_Americans-2020-2025.pdf
  18. ↑ "Academy Supports Funding for the 2020–2025 Dietary Guidelines for Americans". eatrightpro.org. Academy of Nutrition and Dietetics. 11 May 2018. Archived from the original on 4 July 2018. Retrieved 10 July 2019.
  19. ↑ https://www.nutritioncoalition.us/news/assistant-secretary-of-health-letter-to-tnc
  20. ↑ Alvim Leite, Maria; Aksnes, Brooke; Garduno-Diaz, Sara Diana (2017). "The normalization of conflicts of interest in the USA and their potential impact on public health nutrition". World Nutrition. 8 (1): 123–127. doi:10.26596/wn.201781123-127.
  21. ↑ Teicholz, Nina (2015). "The scientific report guiding the US dietary guidelines: is it scientific?". BMJ. 351: h4962. doi:10.1136/bmj.h4962. PMID 26400973.
  22. 1 2 Nissen, Steven E (2016). "US dietary guidelines: an evidence-free zone". Annals of Internal Medicine. 164 (8): 558–559. doi:10.7326/m16-0035. PMID 26783992. S2CID 207538573.
  23. ↑ Harcombe, Zoë (2017). "Dietary fat guidelines have no evidence base: where next for public health nutritional advice?". Br J Sports Med. 51 (10): 769–774. doi:10.1136/bjsports-2016-096734. PMID 27797736.
  24. ↑ Hite, Adele H (2017). "The 2015 Dietary Guidelines for Americans: Irrelevant or Alarming? or Both?". Journal of Evolution and Health. 2 (1): 14. doi:10.15310/2334-3591.1046.
  25. ↑ Feinman, Richard D.; Pogozelski, Wendy K.; Astrup, Arne; Bernstein, Richard K.; Fine, Eugene J.; Westman, Eric C.; Accurso, Anthony; et al. (2015). "Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base". Nutrition. 31 (1): 1–13. doi:10.1016/j.nut.2014.06.011. PMID 25287761.
  26. ↑ "2015–2020 Dietary Guidelines". Health.gov.
  27. ↑ Wang, Dong D.; Hu, Frank B. (2017). "Dietary fat and risk of cardiovascular disease: recent controversies and advances". Annual Review of Nutrition. 37: 423–446. doi:10.1146/annurev-nutr-071816-064614. PMID 28645222.
  28. 1 2 3 "Executive Summary – 2015–2020 Dietary Guidelines". Health.gov. 2015. Retrieved 1 July 2018. Public Domain This article incorporates text from this source, which is in the public domain.
  29. ↑ "MyPlate, MyWins". Choosemyplate.gov. 12 December 2016. Retrieved 1 July 2018.
  30. ↑ Nestle M. Perspective: Challenges and Controversial Issues in the Dietary Guidelines for Americans, 1980–2015. Advances in Nutrition. 2018 Mar 1;9(2):148–50.
  31. ↑ Hite, Adele H.; Schoenfeld, Pamela (2015). "Open letter to the secretaries of the US Departments of Agriculture and Health and Human Services on the creation of the 2015 Dietary Guidelines for Americans". Nutrition. 31 (5): 776–779. doi:10.1016/j.nut.2014.12.019. PMID 25837226.
  32. ↑ Whoriskey, Peter (18 December 2015). "Congress: We need to review the Dietary Guidelines for Americans". Washingtonpost.com. Retrieved 1 July 2018.
  33. ↑ Division, Health Medicine; Board, Food Nutrition (16 December 2017). Optimizing the Process for Establishing the Dietary Guidelines for Americans: The Selection Process : Health and Medicine Division. nationalacademies.org. ISBN 9780309453608. Retrieved 1 July 2018.
  34. ↑ "Center for Nutrition Policy and Promotion (CNPP) | USDA-FNS". www.fns.usda.gov.
  35. ↑ National Academies Of Sciences, Engineering; Division, Health Medicine; Board, Food Nutrition; Committee to Review the Process to Update the Dietary Guidelines for Americans (16 November 2017). Redesigning the Process for Establishing the Dietary Guidelines for Americans. Nap.edu. doi:10.17226/24883. ISBN 978-0-309-46482-6. PMID 29232083. Retrieved 1 July 2018.
  36. ↑ Paarlberg, Robert. "Governing the dietary transition: Linking agriculture, nutrition, and health." Edited by Shenggen Fan and Rajul Pandya-Lorch (2012): 191.
  37. ↑ Archer, Edward; Pavela, Gregory; Lavie, Carl J. (2015). "A discussion of the refutation of memory-based dietary assessment methods (M-BMs): the rhetorical defense of pseudoscientific and inadmissible evidence". Mayo Clinic Proceedings. 90 (12): 1736–1739. doi:10.1016/j.mayocp.2015.10.003. PMID 26653304.
  38. ↑ Archer, Edward; Thomas, Diana M.; McDonald, Samantha M.; Pavela, Gregory; Lavie, Carl J.; Hill, James O.; Blair, Steven N. (2016). "The Validity of US Nutritional Surveillance: USDA's Loss-Adjusted Food Availability Data Series 1971–2010". Current Problems in Cardiology. 41 (11–12): 268–292. doi:10.1016/j.cpcardiol.2016.10.007. PMC 5147486. PMID 27914522.
  39. ↑ Tugault-Lafleur, Claire N.; Black, Jennifer L.; Barr, Susan I. (2017). "A Systematic Review of Methods to Assess Children's Diets in the School Context–". Advances in Nutrition. 8 (1): 63–79. doi:10.3945/an.116.013144. PMC 5227974. PMID 28096128.
  40. ↑ "Scientific Report of the 2015 Dietary Guidance Advisory Committee" (PDF). Health.gov. Retrieved 1 July 2018.
  41. ↑ Archer, Edward; Pavela, Gregory; Lavie, Carl J. (2015). "The inadmissibility of what we eat in America and NHANES dietary data in nutrition and obesity research and the scientific formulation of national dietary guidelines". Mayo Clinic Proceedings. 90 (7): 911–926. doi:10.1016/j.mayocp.2015.04.009. PMC 4527547. PMID 26071068.
  42. ↑ Forouhi, Nita G.; Krauss, Ronald M.; Taubes, Gary; Willett, Walter (2018). "Dietary fat and cardiometabolic health: evidence, controversies, and consensus for guidance". BMJ. 361: k2139. doi:10.1136/bmj.k2139. PMC 6053258. PMID 29898882.
  43. ↑ Harcombe, Zoë; Baker, Julien S.; DiNicolantonio, James J.; Grace, Fergal; Davies, Bruce (2016). "Evidence from randomised controlled trials does not support current dietary fat guidelines: a systematic review and meta-analysis". Open Heart. 3 (2): e000409. doi:10.1136/openhrt-2016-000409. PMC 4985840. PMID 27547428.
  44. ↑ Hooper, Lee; Martin, Nicole; Jimoh, Oluseyi F.; Kirk, Christian; Foster, Eve; Abdelhamid, Asmaa S. (21 August 2020). "Reduction in saturated fat intake for cardiovascular disease". The Cochrane Database of Systematic Reviews. 2020 (8): CD011737. doi:10.1002/14651858.CD011737.pub3. ISSN 1469-493X. PMC 8092457. PMID 32827219.
  45. ↑ Thornley S, Schofield G, Zinn C, Henderson G (November 2019). "How reliable is the statistical evidence for limiting saturated fat intake? A fresh look at the influential Hooper meta-analysis". Intern Med J. 49 (11): 1418–1424. doi:10.1111/imj.14325. PMID 30989765. S2CID 117717364.
  46. ↑ Graudal, Niels, and Gesche Jürgens. "Conflicting Evidence on Health Effects Associated with Salt Reduction Calls for a Redesign of the Salt Dietary Guidelines." Progress in Cardiovascular Diseases (2018).
  47. ↑ Medicine, Institute of (May 14, 2013). Sodium Intake in Populations: Assessment of Evidence. The National Academies Press. ISBN 9780309282956 – via www.nap.edu.
  48. ↑ Stockwell, Tim; Zhao, Jinhui; Panwar, Sapna; Roemer, Audra; Naimi, Timothy; Chikritzhs, Tanya (2016). "Do "moderate" drinkers have reduced mortality risk? A systematic review and meta-analysis of alcohol consumption and all-cause mortality". Journal of Studies on Alcohol and Drugs. 77 (2): 185–198. doi:10.15288/jsad.2016.77.185. PMC 4803651. PMID 26997174.
  49. ↑ Griswold, Max G; et al. (August 2018). "Alcohol use and burden for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016". Lancet. 392 (10152): 1015–1035. doi:10.1016/S0140-6736(18)31310-2. PMC 6148333. PMID 30146330.
  50. ↑ McKay, Betsy (26 June 2018). "In Vermont, Pure Outrage Over Pure Syrup". Wsj.com. Retrieved 1 July 2018.
  51. ↑ Welcome to the portal for you to participate and follow the development of the 2020–2025 Dietary Guidelines for Americans.
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