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Am Fam Physician. 2021;104(5):533-536

Related editorial: Translating the 2020-2025 U.S. Dietary Guidelines into Clinical Practice

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• For people two years and older, vegetables and whole fruits represent one-half of a healthy diet.

• Potentially allergenic foods should be introduced to infants at about six months of age with solid foods to reduce food allergies.

• During pregnancy, there is no need to limit potentially allergenic foods without a known food allergy, although large fish, unpasteurized juices and dairy products, and alcohol should be avoided.

• In older adults, high-protein diets can limit natural decreases in lean muscle mass and vitamin B12 deficiency caused by decreased absorption.

From the AFP Editors

More than one-half of U.S. adults have at least one diet-related chronic disease such as type 2 diabetes mellitus, cardiovascular disease, and some cancers. About three-fourths are overweight or obese. Foods are consumed in patterns, and it is these dietary patterns that affect disease risk. Because surveys show minimal improvement in healthy eating over the past 10 years, simple guidance is needed in improving food and beverage choices. The U.S. Departments of Agriculture and Health and Human Services published updated guidelines for healthy eating across a person's lifespan.

Core Dietary Elements

For people two years and older, healthy dietary patterns involve choosing nutrient-dense foods and beverages. Nutrient-dense foods provide vitamins, minerals, and other essential nutrients, and are lower in added sugar, saturated fat, and sodium (Table 1). At least one-half of food eaten should be fruits and vegetables, especially whole fruits and vegetables of a variety of colors. The core elements of the other half of food that should be eaten include grains, dairy, protein, and oils with lower saturated fat. At least one-half of grain servings should be whole grains. Minimize alcohol use and consumption of foods with added sugar, saturated fat, and sodium. Serving sizes on labels can be used to determine appropriate single portions.

FoodNutrient-denseLess healthy

FormCaloriesFormCalories
Applesauce, 1 cupUnsweetened103Sweetened170
Cod, 4 ozBaked99Breaded, fried230
Ground beef, 3-oz patty97% lean12280% lean209
Milk, 1 cupFat free83Whole146
Mocha, 12 ozFat-free milk110Full-fat milk and chocolate syrup290
Popcorn, 2 cupsAir-popped62Buttered184

These guidelines will be more difficult to follow for people with food insecurity, which is the limited or uncertain access to nutrient-dense foods that affects 10% of households. Most people, even those without limited access, exceed the recommended intake of refined grains, added sugars, sodium, and saturated fats.

Infants and Toddlers

During the first four months of life, breast milk is the optimal sole form of nutrition. Infants fed breast milk as part or all of their diet should get a 400-IU supplement of vitamin D each day. An iron-fortified commercial infant formula is recommended when breast milk is unavailable. Formula should be prepared per the manufacturer's instructions.

Between four and six months of age, infants can begin eating nutrient-dense foods prepared to reduce choking risk. Although dairy products such as yogurt and cheese can be introduced at this time, cow's milk is not a safe replacement for human milk or formula until 12 months of age. Foods high in added sugar or sodium should be limited. Honey and unpasteurized foods (e.g., juices, milk, yogurt, cheeses) are unsafe for infants to consume.

Potentially allergenic foods such as peanuts, tree nuts, egg, soy, and shellfish should be introduced with other complementary foods at six months of age to reduce risk of allergy. There is no evidence that delaying introduction of allergenic foods prevents food allergy, and introducing peanut-containing foods in the first year reduces the risk of developing an allergy.

Children and Adolescents

The same core nutrient-dense foods are recommended for children and adolescents as for adults, because childhood habits guide adult eating patterns. Modeling and supporting healthy dietary patterns during childhood is the best way for parents and caregivers to prevent chronic diseases during adolescence and adulthood. Age-based caloric needs (Table 2) are estimates that should be adjusted by the size and activity level of the child. In childhood, beverages are optimally limited to water, unsweetened reduced fat milk, and juices without added sugars. Cow's milk should be fat free or reduced fat, although lactose-free or soy milk is also acceptable. Sugar-sweetened beverages such as soda, sports drinks, and energy drinks should be avoided.

Life stageFemale caloric needs (kcal)Male caloric needs (kcal)
Early childhood (2 to 4 years of age)1,000 to 1,4001,000 to 1,600
School age (5 to 8 years of age)1,200 to 1,8001,200 to 2,000
Late childhood (9 to 13 years of age)1,400 to 2,2001,600 to 2,600
Adolescence (14 to 18 years of age)1,800 to 2,4002,000 to 3,200
Adulthood (19 to 59 years of age)1,600 to 2,4002,200 to 3,000
Older adults (60 years and older)1,600 to 2,0002,000 to 2,600

Adults

The core dietary elements also guide the adult diet. Standard caloric recommendations (Table 2) can be adjusted by age, activity, and current weight. U.S. adults consistently overconsume added sugars, refined grains, saturated fats, and sodium. Adults should be encouraged to prepare household meals from fresh ingredients, minimizing intake of sugar-sweetened beverages, alcohol, and added sugars. Sandwiches and grain-based dishes such as spaghetti and meatballs are the major sources of saturated fat in the U.S. diet. Increasing dietary fiber intake is particularly important to prevent coronary heart disease. Intake of calcium and vitamin D is particularly important in adults up to 30 years of age because bone mass is actively increasing.

Pregnancy and Lactation

Although caloric requirements increase during pregnancy and lactation (Table 3), many patients experience excessive weight gain during pregnancy. One-half of patients retain at least 10 lb (4.5 kg) of excess weight after pregnancy and one-fourth retain at least 20 lb (9.1 kg). Goal weight gain during pregnancy depends on starting weight (Table 4).

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