||Guideline: Counseling To Promote A Healthy Diet
From The US Preventive Services Task Force
Counseling adults and children over age 2 to limit
dietary intake of fat (especially saturated fat) and cholesterol, maintain
caloric balance in their diet, and emphasize foods containing fiber (i.e.,
fruits, vegetables, grain products) is recommended. There is insufficient
evidence to recommend for or against counseling the general population to
reduce dietary sodium intake or increase dietary intake of iron, beta-carotene,
or other antioxidants to improve health outcomes, but recommendations to reduce
sodium intake may be made on other grounds. Women should be encouraged to
consume recommended quantities of calcium (see Clinical Intervention
). Parents should
be encouraged to breastfeed their infants. Providing pregnant women with specific
nutritional guidelines to enhance fetal and maternal health is recommended.
Although there is insufficient evidence to recommended for or against special
assessment of the dietary needs and habits of older adults, recommendations
to do so can be made on other grounds. There is insufficient evidence that
nutritional counseling by physicians has an advantage over counseling by dietitians
or community interventions in changing the dietary habits of patients. See Chapter 22 regarding the role of iron during pregnancy
and in the diets of newborns and young children, and Chapter
42 regarding the use of folic acid by women of childbearing age.
See Chapter 61 regarding intake of
refined sugars and adherent carbohydrates that may affect dental health. Counseling
regarding alcohol consumption is discussed in Chapter
Burden of Suffering
Diseases associated with dietary excess and imbalance rank among
the leading causes of illness and death in the U.S. Major diseases in which
diet plays a role include coronary heart disease, some types of cancer, stroke,
hypertension, obesity, and non-insulin-dependent diabetes mellitus.
Heart disease is the leading cause of death in the U.S.,
with coronary heart disease accounting for up to 1.5 million
myocardial infarctions and nearly 500,000 deaths each year.
Cancer of the colon, breast, and prostate, the three forms
of cancer most closely associated epidemiologically with nutritional risk
factors, together, cause over 140,000 deaths annually.
Cerebrovascular disease, the third leading cause of death, accounted for about
150,000 deaths in 1993.
Hypertension, another disease
with nutritional risk factors, occurs in about 43 million Americans.
Caloric intake, when it exceeds energy expenditure, can
also lead to overweight and obesity, which affects about 58 million American
adults aged 20 and older.
Obesity is a risk factor
for a number of serious disorders (see Chapter
21), including both hypertension and adult-onset diabetes mellitus.
An estimated 14 million persons in the U.S. have diabetes mellitus, which
accounts for over 55,000 deaths each year and is a leading cause of neuropathy,
peripheral vascular disease, renal failure, and blindness.
Nutritional factors have also been linked to
osteoporosis, constipation, diverticular disease, iron deficiency anemia (see Chapter 22), oral disease, and malnutrition. An
estimated 40% of women in the U.S. will suffer from osteoporosis-related
fractures by the time they reach age 70.
in particular are associated with significant pain and disability, decreased
functional independence, and high mortality; there is a 15-20% reduction
in expected survival in the first year following a hip fracture.
Constipation is a complaint of over 4.5 million Americans,
and intestinal diverticular disease is reported by nearly 1.5 million persons.
The average schoolchild has at least one cavity in permanent
teeth by age 9, three cavities by age 12, and eight by age 17.
The average adult in the U.S. has 10-17 decayed, missing, or filled
permanent teeth and one untreated decayed permanent tooth.
Disorders of both overeating and undereating are common among older adults,
up to 40% of whom have inadequate dietary intake of three or more nutrients.
Many older adults suffer from protein-calorie malnutrition
-- up to 50% of nursing home residents in the U.S. may be malnourished,
and an additional number suffer from marginal malnutrition
that is less clinically evident.
Efficacy of Risk Reduction
Eating habits over a lifetime can
have a significant impact on the incidence and severity of many health disorders.
The complete body of literature regarding the health effects of foods is beyond
the scope of this report and has been the subject of extensive reviews.
In summary, it is clear that a
direct relationship exists between nutritional risk factors and certain key
diseases. It is well established, for example, that caloric imbalance (intake
exceeding expenditure) can lead to overweight and obesity. Persons who are
overweight are at increased risk of glucose intolerance, hypertension, high
blood cholesterol, and other disorders (see Chapter
21); reduction of body weight has been shown to reduce these risks.
The average person is likely to benefit from dietary practices
and physical activity (see Chapter 55)
that keep caloric intake commensurate with daily energy expenditures. In addition
to the overall objective of caloric balance, modified intake of specific dietary
factors may also help prevent certain diseases.
of dietary fat, especially saturated fats (and,
possibly, partially hydrogenated vegetable fats), appears to reduce the risk
of developing coronary heart disease. A large body of epidemiologic evidence
links serum cholesterol levels to the development of coronary atherosclerosis.
cholesterol levels can in turn be modified by dietary measures. Clinical trials
incorporating reduced total or saturated fat intake, either as a sole intervention
or as part of a multifactorial intervention, have reported mixed results in
reducing serum cholesterol levels and in decreasing the incidence of cardiac
events, such as myocardial infarction and sudden death.
Intake of saturated fat correlates
more closely with serum cholesterol levels than does total fat intake. Clinical
trials have also found that serum cholesterol-lowering drugs can reduce the
incidence of coronary heart disease in asymptomatic middle-aged men with hyperlipidemia.
studies found that the incidence of cardiac events in such men is decreased
by an average of 2% for every 1% reduction in serum cholesterol (see Chapter 2). (Evidence regarding benefits in persons
with preexisting coronary heart disease is reviewed in Chapter
Modeling studies based on these data suggest that
coronary heart disease mortality rates in the U.S. could be lowered by 5-20%
if all Americans restricted their fat intake to less than 30% of total calories
but that increases in life expectancy among low-risk persons might be modest.
randomized controlled trials reported that a low-fat diet does not increase
high-density lipoprotein (HDL) cholesterol levels unless coupled with physical
and one meta-analysis
of 27 trials suggested that substantial reductions in dietary fat intake might
lower HDL cholesterol levels.
studies also suggest a possible association between intake of trans-isomers of fatty acids (formed in the partial hydrogenation
of vegetable oils) and unfavorable changes in low-density lipoprotein (LDL)
and HDL cholesterol
in the risk of coronary heart disease;
others suggest an association between fatty acids found
primarily in fish oils and reduced risk of cardiovascular disease.
cholesterol intake may also influence serum cholesterol levels, especially
LDL cholesterol levels, but the association appears to be weaker and more
variable than that of dietary saturated fat intake.
Finally, prospective cohort data suggest that a diet with increased intake
of fruits and vegetables is associated with decreased risk of stroke, but
further study is needed.
between foods high in dietary fat and certain forms of cancer is currently
under investigation. An effect of dietary fat on carcinogenesis has been demonstrated
in animal research. Furthermore, international comparisons of cancer incidence
and most case-control studies have revealed an epidemiologic correlation between
dietary fat consumption and the incidence of cancer of the breast, colon,
prostate, and lung.
Within more homogenous populations,
however, cohort studies to date have been unable to provide consistent evidence
of a causal relationship between increased dietary fat consumption and the
incidence of breast, prostate, colon, or other cancers.
Similarly, inconsistent results have been reported in epidemiologic
studies of the link between low blood cholesterol and cancer.
Clinical trials are now in progress to examine further the
relationship between dietary fat and cancer.
and other studies may help elucidate whether low-fat diets reduce cancer risk
because of decreased fat intake or because of increased intake of fruits,
vegetables, or fiber (see below).
A diet emphasizing the consumption
of foods high in complex carbohydrates and
fiber (e.g., whole grain foods and cereal products, vegetables [including
dried beans and peas], and fruits) is an important means of lowering dietary
fat consumption by replacing caloric intake from fat. Foods high in complex
carbohydrates and fiber and low in fat content also have lower average caloric
density, and they are therefore preferred for maintaining caloric balance
and healthful body weight.
There are other health benefits associated with the replacement
of foods high in simple carbohydrates (e.g., table sugar, honey, corn sweeteners)
with those containing starch and fiber. In addition to improving caloric balance,
reduced intake and less frequent consumption of refined sugars may lower the
risk of developing dental caries (see also Chapter
and the avoidance of highly refined grain products reduces
the contribution of "empty calories" to the diet.
Increased intake of dietary fiber improves
Certain types of dietary
fiber may also be helpful in the treatment of glucose intolerance, weight
reduction, and the control of lipid disorders.
The consumption of foods containing large amounts of soluble
fiber (e.g., dried beans, oat products) appears to lower levels of LDL cholesterol
(independent of their replacement of foods high in saturated fat and cholesterol).
An insoluble high-fiber diet (most
plant foods) may be effective in reducing intracolonic pressure and preventing
The risk of developing colorectal
cancer may also be influenced by dietary fiber intake. At least 15 cross-cultural
studies have shown an inverse relationship between dietary fiber consumption
and the incidence of colon cancer.
Such studies do not, however, provide direct evidence that high dietary fiber
intake, rather than other population dietary characteristics (e.g., low fat
intake), is directly responsible for the lower cancer incidence rate. Case-control
studies have produced inconsistent results regarding the association between
dietary fiber and colon cancer.
Meta-analyses of these studies,
however, suggest an overall benefit from dietary fiber.
Observational studies also suggest an association between
intake of vegetables and fruits and lower risk of cancer.
Cohort studies to date that have examined the relationship between dietary
fiber and cancer have produced inconsistent results and suffer from methodologic
limitations, including the difficulty of determining whether observed benefits
were due to fiber itself or to its substitution of foods high in saturated
Reduced intake of dietary sodium may
be of clinical benefit to persons
who either have sodium-dependent hypertension or are likely to develop it
in the future.
A number of clinical trials and recent
meta-analyses have demonstrated the ability of dietary sodium restriction
to lower blood pressure by at least several millimeters of mercury in some
hypertensive and normotensive individuals.
In addition, cross-cultural studies have shown a correlation
between the sodium intake of different populations and the incidence of hypertension.
multinational study involving 52 sites also demonstrated an association between
sodium excretion and the rate of change of blood pressure with age.
However, controlled prospective studies will ultimately
be necessary to provide definitive evidence that normotensive persons who
practice dietary sodium restriction are at lower risk of developing hypertension
over time than are those with more typical sodium consumption.
Many American women and adolescent girls consume less dietary calcium than is recommended by major groups (men: 1,000
mg/day; adolescents and young adults, 1,200-1,500 mg/day; women 25-50
years of age, 1,000 mg/day; postmenopausal women, 1,000-1,500 mg/day;
pregnant and nursing women, 1,200-1,500 mg/day).
Population and cross-sectional studies suggest that reduced calcium intake
among women, especially young women, may be an important risk factor for bone
mineral loss and postmenopausal osteoporosis,
and studies suggest that calcium supplementation in adolescence
and early adulthood may increase bone mineral density.
Prospective studies of asymptomatic postmenopausal women
have produced inconsistent results about the efficacy of increasing dietary
calcium intake as a means of slowing bone loss. Although some studies have
reported that a daily intake of 750-1,700 mg/day can reduce significantly
the rate of bone loss in asymptomatic postmenopausal women,
other controlled studies have
shown either no effect or an effect only on compact bone with doses as high
as 1,800-2,000 mg/day.
A meta-analysis of intervention
and observational studies concluded that 1,000 mg of calcium daily would prevent
about 1% of bone loss per year.
suggest that calcium supplementation may reduce the risk of fractures in postmenopausal
In such women,
however, estrogen replacement therapy may be a more effective form of chemoprophylaxis
than calcium supplementation (see Chapter 68). (See also the discussion of the relationship between exercise
and bone density in Chapter 55.)
There appears to be little significant risk for women who moderately increase
their consumption of dietary calcium. Gross and prolonged use of calcium supplements
may, under unusual circumstances, result in milk alkali syndrome or an increased
occurrence of kidney stones, although direct evidence of the latter is lacking.
Adequate dietary iron
intake may be important for menstruating women and for young children to maintain
iron stores and prevent iron deficiency anemia. This topic is discussed in
detail in Chapter 22. Although infants
and young children may benefit from iron supplementation (see below), there
is little evidence from prospective studies of older children and menstruating
women that mild anemia in the absence of symptoms is a direct cause of increased
morbidity or mortality. It may be clinically prudent, however, to recommend
diets including iron-rich foods (e.g., lean meats, certain beans, iron-enriched
and whole grain products) for persons at increased risk of iron deficiency.
Current research is exploring the potential health benefits of
other minerals and vitamins. For example, evidence suggests that women of
childbearing age who take folic acid supplements may be less likely to give
birth to children with neural tube defects (see Chapter
The role of beta-carotene, vitamins
(e.g., vitamin A, vitamin C, vitamin E), and other antioxidants in reducing
the risk of cancer, atherosclerosis, and other chronic disease is currently
Infants and Children.
Infants require breast milk or appropriate alternatives (e.g., infant
to provide adequate nutrition. Nutritional status remains important throughout
childhood to facilitate normal growth and development.
Epidemiologic evidence and randomized prospective studies suggest that infant
consumption of breast milk for at least 6 months may reduce the risk of otitis
media, lower respiratory tract illness, meningitis, allergic illness, diarrhea,
hospital admissions, and abnormal cognitive development in the child.
infants often have higher blood cholesterol levels than formula-fed infants,
but current evidence, with the exception of one cohort study,
suggests that these elevations resolve with weaning
and are not linked to adult blood cholesterol levels or increased risk of
heart disease. Iron deficiency anemia during infancy may also be associated
with impaired infant neurologic and cognitive development,
and infants may therefore benefit from iron-fortified formula and foods to
replace depleted iron stores.
The benefits of reduced dietary
fat intake during childhood are uncertain. There is some epidemiologic evidence
of tracking (persistence of childhood elevations of blood cholesterol into
adulthood) and autopsy evidence of atherosclerotic disease among children
and young adults with elevated cholesterol levels,
but evidence of improved health outcomes from lowering
blood cholesterol during childhood is lacking. Observational studies provide
evidence that children can achieve statistically significant reductions in
total and LDL cholesterol levels through dietary fat reduction.
A potential risk of such interventions is that excessive
low-fat diets may not provide children with sufficient nutrients for healthy
growth and development,
but direct evidence of this
adverse effect is limited to extreme cases of dietary restriction. A cross-sectional
study found that 10-year-old children with low fat intake had no significant
differences in anthropometric measurements, but they were more likely to be
deficient in the Recommended Dietary Allowances for calcium, phosphorus, magnesium,
iron, and certain vitamins.
A recent randomized
controlled trial involving children aged 8-10 reported that a diet providing
28% of energy from total fat achieved statistically significant reductions
in LDL cholesterol levels with no significant effects on height, ferritin
levels, or selected psychometric indices.
status is especially important during pregnancy. Studies have shown that low
birth weight and neonatal mortality are more common in pregnant women with
very poor nutritional status
and in those who fail to gain adequate weight during pregnancy,
factors other than nutrient intake may account for these outcomes. Prenatal
programs providing nutritional support for pregnant women have been associated
with improved perinatal outcomes.
increased requirements for energy and specific nutrients, such as protein,
calcium, folic acid, and iron.
Oral iron supplements may be beneficial in preventing iron
deficiency anemia in pregnancy, and they are often prescribed routinely as
part of prenatal health care. Although an association between moderate to
severe iron deficiency anemia and adverse obstetric outcomes has been demonstrated
in some observational studies, there is little direct evidence that routine
iron supplementation during pregnancy (in the absence of documented anemia
or iron deficiency) results in improved clinical outcome for the mother or
The elderly can also have special nutritional requirements.
Depending on the patient's nutritional status, underlying medical disorders,
functional status, dentition, and therapeutic drug regimens, it can be important
to modify recommended daily intake levels of calories, sodium, calcium, water,
dietary fat, fiber, protein, and other nutrients to reduce the risk of complications.
Observational data suggest that older adults benefit to
some extent by reducing elevated blood cholesterol levels.
It is unclear from current evidence whether women who have already developed
clinical evidence of postmenopausal osteoporosis benefit from calcium supplementation.
Clinical recognition of protein-calorie malnutrition,
especially when manifested by clinically subtle findings, is often delayed
among older adults. This has prompted the introduction of nutritional screening
initiatives in this population,
but direct evidence
of clinical benefit from screening is currently lacking.
Effectiveness of Counseling
The effectiveness of nutritional counseling in changing the dietary
habits of patients has been demonstrated in a number of clinical trials.
For example, randomized controlled trials have shown that
dietary counseling of patients with high blood cholesterol can lower serum
lipids in both patients and their families
regular reinforcement can enhance compliance with dietary recommendations.
Tailored printed materials distributed in primary care
settings have also been effective in lowering dietary fat consumption.
Other measures that may enhance compliance with low-fat
diets include setting strict limits on fat intake, frequent (e.g., monthly)
monitoring, involvement of family in nutritional counseling sessions, and
Studies have confirmed the effectiveness
of nutritional counseling among pregnant women
the important role of parental guidance in modifying the diets of children.
In most studies of nutritional counseling,
however, the counselor was not a physician, but rather a nurse, nutritionist,
registered dietitian, health educator, or psychologist. Many of the interventions
tested in these studies were part of highly specialized or community-wide
programs. Such interventions are not easily reproduced in the typical physician-patient
clinical encounter. Although physicians can often provide general guidelines
on proper nutrition, many lack the time and skills to obtain a thorough dietary
history, to address potential barriers to changes in eating habits, and to
offer specific guidance on food selection.
may also have difficulty with long-term compliance,
especially if food selection and preparation for recommended diets are perceived
as unappealing or inconvenient. Fat-containing foods, in particular, are
a popular component of the American diet.
possible, however, that physicians can overcome many of these limitations
by expanding the content of the nutritional information they provide to patients,
by emphasizing to the patient the health benefits of good nutrition, and by
referring those requiring help with dietary changes to qualified registered
dietitians, nutritionists, health educators, nurses, or other providers with
greater nutrition expertise.
Recommendations of Other Groups
Dietary guidelines for the general
population have been issued by the Department of Agriculture and the Department
of Health and Human Services
and reaffirmed by the
in the Year 2000 Objectives for
and in the "Food Guide Pyramid" released
in 1992 by the Department of Agriculture.
and Nutrition Board of the National Research Council has published Recommended
Dietary Allowances (RDAs) for specific nutrients,
and it has released an extensive report on diet and chronic disease risk.
Recommendations for nutritional counseling of patients
have been issued by the American Medical Association,
the American College of Physicians,
and the American Heart Association.
Guidelines for dietary practices
to reduce the risk of cancer have been issued by the National Research Council,
the American Cancer Society,
and the National Cancer Institute.
on nutritional counseling to reduce cardiac risk factors have been issued
by panels convened by the National Heart, Lung, and Blood Institute
and by the National High Blood Pressure Education Program
and National Cholesterol Education Program,
which are endorsed by over 40 organizations and government
agencies. Dietary recommendations for children have been issued by the American
Academy of Pediatrics
and National Cholesterol Education Program.
guidelines for pregnant women have been issued by the American College of
Obstetricians and Gynecologists
and the Institute
Recommendations on the use of folic
acid supplementation by women have been issued by the U.S. Public Health Service.
Dietary guidelines for Americans were updated in 1995.
Adults and children over age 2 should limit dietary
intake of fat (especially saturated fat) ("A" recommendation) and cholesterol
("B" recommendation), maintain caloric balance in their diet ("B" recommendation),
and emphasize fruits, vegetables, and grain products containing fiber ("B"
recommendation). Both diet and exercise should be designed to achieve and
maintain a desirable weight by keeping caloric intake balanced with energy
expenditures. Adolescents and adults, in particular, should reduce total
fat intake to less than 30% of total calories and dietary cholesterol to less
than 300 mg/day. Saturated fat consumption should be reduced to less than
10% of total calories. To achieve these goals, patients should emphasize
consumption of fish, poultry prepared without skin, lean meats, and low-fat
dairy products. They should be encouraged to eat a variety of foods, with
emphasis on the consumption of whole grain products and cereals, legumes,
vegetables, and fruits. Current recommendations from the U.S. Department
of Health and Human Services are for at least five servings of fruits and
vegetables and at least six servings of breads, cereals, or legumes each day.
Detailed food selection guidelines for healthy eating are published elsewhere.
There is insufficient
evidence that, for the general population, reducing dietary sodium intake
or increasing dietary intake of iron, beta-carotene, or other antioxidants
results in improved health outcomes ("C" recommendation); recommendations
to reduce sodium intake may be made on other grounds, including the potential
beneficial effects on blood pressure in salt-sensitive persons. See Chapter 61 for information regarding intake of refined
sugars and dental health. Women should be encouraged to consume recommended
quantities of calcium (adolescents and young adults, 1,200-1,500 mg/day;
adults aged 25-50, 1,000 mg/day; postmenopausal women, 1,000-1,500
mg/day; pregnant and nursing women, 1,200-1,500 mg/day
("B" recommendation). Parents should be encouraged to offer breastfeeding
to their infants ("A" recommendation). Pregnant women should receive specific
nutritional guidelines to enhance fetal and maternal health. See Chapter 22 regarding the role of iron during pregnancy
and in the diets of newborns and young children, and see Chapter
42 regarding the use of folic acid by women of childbearing age.
There is insufficient evidence to recommend for or against the special assessment
of dietary needs and habits of older adults ("C" recommendation), but recommendations
to do so can be made on other grounds, such as the increased prevalence of
nutrition-related disorders in this age group. Counseling regarding alcohol
consumption is discussed in Chapter 52.
There is insufficient evidence
that nutritional counseling by physicians, as opposed to counseling by dietitians
or community interventions, is effective in changing the dietary habits of
patients ("C" recommendation). Clinicians who lack the time or skills to
perform a complete dietary history, to address potential barriers to changes
in eating habits, and to offer specific guidance on meal planning and food
selection and preparation, should either have patients seen by other trained
providers in the office or clinic or should refer patients to a registered
dietitian or qualified nutritionist for further counseling.
The draft update of this chapter was prepared for the U.S. Preventive
Services Task Force by Steven H. Woolf, MD, MPH.
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