Will new dietary guidelines improve health?

Practice points | What has changed? | The Guideline at a glance | More dairy – what’s the evidence? | When no news is bad news | Balance between what and how much | Can we do more? | Useful links | References

Practice points

Ensure your patients are aware of the guidelines – refer them to the consumer summary

Follow recommendations contained in the RACGP Red Book:

• RACGP Red Book recommendations for all people over 18 years
  Assess BMI and waist circumference every 2 years
  Offer education on nutrition and physical activity

• RACGP Red Book recommendations for people at increased risk (Aboriginal and Torres Strait Islander peoples and those from Pacific Islands, people with existing diabetes or CVD, stroke, gout or liver disease)
  Assess BMI and waist circumference every 12 months in adults over 18 years
  Offer individual or group-based education on nutrition and physical activity

• RACGP Red Book recommendations for people with identified risk(those who are overweight or obese)
  Assess weight and waist circumference every 6 months
  Develop a weight management plan to include frequent contact, realistic targets, and monitoring for at least 12 months
  Consider referral for self-management support or coaching in an individual or group-based diet or physical activity program or to an allied health provider (e.g. dietitian, exercise physiologist, psychologist).

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What has changed?

The long-awaited update to the 2003 NHMRC Dietary Guidelines has been released but what has changed? The short answer is not a lot, with the authors themselves acknowledging that there are “no real surprises in the guidelines” but that we can “be surer and surer of the advice”.¹

The updated Australian Dietary Guidelines² provide an evidence-based approach to dietary recommendations and confirm that the evidence for the types of diets that maximise health and well-being (i.e. plenty of fruit, vegetables and wholegrain cereals, but not too many kilojoules) has not changed significantly. Indeed, the latest review of the evidence tells us we have been on the right track with dietary guidelines over the past decade.

More dairy – what’s the evidence?

The 2003 guidelines recommended 2 to 3 serves of low fat milk, yoghurt or cheese, or alternatives, each day for women and 2 to 4 serves for men.³ The latest guidelines now recommend 2½ serves a day for younger adults, pregnant and breastfeeding women, and from 3½–4 serves a day for older adults, particularly women.²

Some have argued the benefits of dairy are overstated.⁴ While the evidence base for the health benefits of increased consumption of reduced fat dairy foods has strengthened since 2003, it mainly consists of small, short-term studies with varied definitions of dairy foods.² However a meta-analysis indicated that milk intake is not associated with total mortality but may be inversely associated with overall risk of cardiovascular disease.⁵ The study also concluded that intake of milk and dairy products does not seem to be harmful but that they cannot be recommended to benefit cardiovascular health outcomes.⁵ Further, dairy products have 50% of their fat as saturated fat, so recommending an increase in dairy to increase unsaturated fat is paradoxical as saturated fat will increase.⁴

While the consensus favours adopting this recommendation of the Guidelines, ensure a balance across the food groups and pay particular attention to serving sizes and total kilojoule intake per day (see Can we do more?).

When no news is bad news

Except for the stronger advocacy for low-fat dairy products in the 2013 Guidelines, the evidence for the types of diets that maximise health and well-being has not changed significantly since 2003. In fact the evidence is now stronger that the dietary recommendations that have been in place over the past decade have been correct.

The bad news is that despite the strength of evidence, these recommendations have not been translated into effective action. Almost 2 in 3 Australian adults are overweight or obese, and the rising tide of diabetes and other diet-related disorders shows no signs of receding.⁶

Based on previous published projections^7,8, the updated 2013 Guidelines report that:
“if current trends continue in Australia, it is estimated that by 2025, 83% of men and 75% of women aged 20 years or more will be overweight or obese.”²

Further:
“the predicted increases would significantly affect disease burden and health care costs, mostly due to an increased incidence of type 2 diabetes. Without intervention, type 2 diabetes will account for around 9% of the total disease burden in Australia in 2023, up from around 5% in 2003.”²

These projected increases are expected to be accompanied by dramatic rises in healthcare costs largely attributed to obesity-related illness. Healthcare expenditure for diabetes alone is projected to increase from $1.4 billion in 2002–2003 to $7 billion by 2032–2033. In 2008, the total annual cost of obesity to Australia, including health system costs, loss of productivity costs and carers’ costs, was estimated at around $58 billion.⁹

NHMRC is reviewing the 2003 Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children¹⁰ and new guidelines are expected to be completed by mid-2013.¹¹

Balance between what and how much

The guidelines at a glance are easily interpreted for choices of food. But the failure to meet health targets for obesity, diabetes and heart disease,and their projected future impact^7,8, raises the question, if we eat the right foods, how much is enough?

A variety of calculators are available on the Eat For Health website and Table 1 summarises the recommendations for the number of serves.

Table 1. Number of serves per day for each of the food groups²

	Cereals (bread, rice, noodles, pasta)	Vegetables, legumes	Fruit	Milk, yoghurt, cheese	Lean meat, fish, poultry, nuts and legumes	Extra foods (cakes, lollies, soft drinks, etc)
Women
19-50 yrs	6	5	2	2.5	2.5	0–2.5
51-70 yrs	4	5	2	4	2	0–2.5
70+ yrs	3	5	2	4	2	0–2
Pregnant (19-50 yrs)	8.5	5	2	2.5	3.5	0–2.5
Breastfeeding (19-50 yrs)	9	7.5	2	2.5	2.5	0–2.5
Men
19-50 yrs	6	6	2	2.5	3	0–3
51-70 yrs	6	5.5	2	2.5	2.5	0–2.5
70+ yrs	4.5	5	2	3.5	2.5	0–2.5

1 standard serve of vegetables = approx. 75 g (100–350 kJ)
1 standard serve of fruit = approx. 150 g (350 kJ)
1 standard serve of grain (cereal) = 500 kJ
1 standard serve of lean meat, fish, poultry, nuts and legumes = 500–600 kJ
1 standard serve of milk, yoghurt, cheese or alternatives = 500–600 kJ

Can we do more?

GPs and other health professionals are in a unique position to identify people with nutrition-related risk factors and raise nutrition awareness and reinforce messages.^12,13 The RACGP Red Book¹⁴ provides guidance on managing healthy eating and weight:

For all people over 18 years:

• assess BMI and waist circumference every 2 years (in children and adolescents use age-specific BMI charts)
• offer education on nutrition¹⁵ and physical activity.¹⁶

For people at increased risk (Aboriginal and Torres Strait Islander peoples and those from Pacific Islands, people with existing diabetes or CVD, stroke, gout or liver disease):

• assess BMI and waist circumference every 12 months inn adults over 18 years
• offer individual or group-based education on nutrition¹⁵ and physical activity¹⁶

For people with identified risk (those who are overweight or obese):

• assess weight and waist circumference every 6 months
• develop weight management plan to include frequent contact, realistic targets, and monitoring for at least 12 months¹⁰
• consider referral for self-management support or coaching in an individual or group-based diet or physical activity program or to an allied health provider (e.g. dietitian, exercise physiologist, psychologist).