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The obesity crisis: don’t blame it on the pyramid
RESEARCH Perspectives in Practice
The Obesity Crisis: Don’t Blame It on the Pyramid JEANNE P. GOLDBERG, PhD, RD; MARTHA A. BELURY, PhD, RD; PEGGY ELAM, PhD; SUSAN CALVERT FINN, PhD, RD, FADA; DAYLE HAYES, MS, RD; ROSEANN LYLE, PhD, MEd; SACHIKO ST. JEOR, PhD, RD; MICHELLE WARREN, MD; JENNIFER P. HELLWIG, MS, RD
ABSTRACT Since its release in 1992, the Food Guide Pyramid has become one of the most recognized nutrition education tools in US history. As such, it has been subject to criticism, particularly in several recent media reports that implicate it as the culprit in America’s current obesity epidemic. What these reports often overlook, however, is that the diets of many Americans do not adhere to the dietary guidelines illustrated by the Pyramid, refuting the notion that the Pyramid is the cause of the nation’s obesity problem. Data indicate that the more likely causes of escalating obesity rates are increased per capita caloric consumption and larger portion sizes, along with a lack of adequate physical activity. Although the Pyramid graphic was designed more than a decade ago, it still communicates three key concepts that continue to be the cornerstone of federal dietary guidance: variety, proportionality, and moderation. As such, it remains a viable and relevant nutrition education tool, especially when used by dietetics professionals as a component of individJ. P. Goldberg is director, Center on Nutrition Communication, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. M. A. Belury is the Carol S. Kennedy professor in nutrition, Department of Human Nutrition, The Ohio State University, Columbus. P. Elam is a clinical and consulting psychologist, Nashville, TN. S. C. Finn is chair, American Council for Fitness and Nutrition, Finn Parks and Associates, Inc, Columbus, OH. D. Hayes is a nutrition consultant, Billings, MT. R. Lyle is a professor of health promotion, Department of Health and Kinesiology, Purdue University, West Lafayette, IN. S. St. Jeor is director, Nutrition Education and Research, University of Nevada School of Medicine, Reno. M. Warren is a professor of obstetrics and gynecology and medicine, Department of Obstetrics and Gynecology, Columbia University, New York, NY. J. P. Hellwig is an adjunct lecturer, Tufts University Friedman School of Nutrition Science and Policy, Boston, MA. Address correspondence to: Jeanne P. Goldberg, PhD, RD, Center on Nutrition Communication, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, 150 Harrison Ave, Boston, MA 02111. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10407-0008$30.00/0 doi: 10.1016/j.jada.2004.04.026
© 2004 by the American Dietetic Association
ualized, comprehensive nutrition education and behavior modification interventions. As the United States Department of Agriculture begins to investigate whether the food intake patterns illustrated by the Pyramid are in need of updating, research is urgently needed to determine how nutrition education tools, including the Pyramid, can be most effectively implemented to help consumers adopt healthful eating behaviors and to improve the public health of America. J Am Diet Assoc. 2004;104:1141-1147.
A
s the science that forms the basis of dietary guidance has evolved over the last century, so, too, have the nutrition education tools used to convey such guidance. Since the early 1900s, the United States Department of Agriculture (USDA) has been issuing food guides designed to help consumers choose diets that meet recommendations based on a comprehensive body of scientific literature (1). In that time, recommendations have evolved to address concerns not only of nutrient adequacy, but more recently, of overconsumption (1,2). Graphics and illustrations that depict the information in these food guides have played an integral role in conveying dietary advice to consumers. Perhaps the most well-known such graphic is the Food Guide Pyramid, issued in 1992 by the USDA and the US Department of Health and Human Services (DHHS). The Pyramid was designed after extensive market research and testing, in which it was found to be the graphic best suited to convey three key concepts with regard to diet: variety, proportionality, and moderation (3,4). These concepts continue to be the cornerstone of the federal dietary guidance contained in the Dietary Guidelines for Americans (5). But with rates of obesity and obesity-related diseases, such as type 2 diabetes and cardiovascular disease, soaring, the Pyramid has come under intense scrutiny in recent months, with several media reports questioning whether consumers should abandon it altogether and, in some cases, follow an alternate pyramid instead (6-15). After the USDA announced plans to review the food intake patterns that the Pyramid illustrates (16), additional media reports appeared, implicating the Pyramid as a cause of obesity (17-19). In one newspaper article, a nutrition researcher is quoted as saying, “I think the Food Guide Pyramid is a recipe for obesity” (17). Because of the widespread nature of these reports, it is possible that not only consumers but nutrition professionals as well may have been misled to believe that an alternate pyramid has replaced or should replace the USDA Food Guide Pyramid.
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This article argues that the Pyramid has not caused America’s obesity epidemic (as many media reports would have readers believe), but rather that a growing trend of large portion sizes and an increase in average caloric consumption without a concomitant increase in physical activity is more likely the root cause of obesity (20). (Although the role of physical activity in weight control is undisputed, an in-depth discussion of that topic is beyond the scope of this article). This article further contends that if the diets of more Americans actually adhered to the Dietary Guidelines that the Pyramid illustrates, obesity might not be as great a public health problem as it currently is. This article also argues that the failure of the majority of Americans to eat according to the Pyramid may also be contributing to micronutrient deficiencies in several groups, leaving much of the population overfed and undernourished. In making this argument, this article traces the history behind the development and implementation of the Pyramid, discusses its role in nutrition education and research, and makes recommendations for its future use by dietetics professionals in conveying current dietary guidance and combating the nutrition-related public health problems currently facing the US population. Finally, this article raises questions for consideration by nutrition educators and policy makers regarding how to help Americans not only to recognize tools such as the Pyramid, but actually to translate that recognition into the adoption of healthful eating behaviors. UNDERSTANDING THE ROLE OF THE PYRAMID As well known as the Pyramid is, many people (consumers and nutrition professionals alike) do not know the history behind its development or understand what it was—and was not—intended to accomplish. It was not originally intended to function as a stand-alone doctrine of nutrition policy. Rather, it was meant to serve as a user-friendly, widely reproducible illustration of the advice contained in the Dietary Guidelines for Americans, which are reviewed and updated as necessary every 5 years by a panel of national experts. The design of the actual graphic was constrained by the fact that it had to be reproducible in both color and in black and white, as well as in a variety of sizes, making it possible to reproduce in several formats, including brochures, posters, and food packages. Although consumers might encounter the Pyramid alone in these formats, it was intended to be most effective when used in conjunction with the detailed booklet (21) that accompanied its release and when used as a complementary teaching tool in individual, in-depth nutrition counseling, as well as in targeted, populationbased nutrition education campaigns. In addition to being based on sound science, the Pyramid was designed to be flexible and adaptable in its use by dietetics professionals in counseling a wide array of clients, including those seeking weight control. It is important to note, however, that the Pyramid was not designed to represent a weight-loss diet, per se, making recent comparisons in the media (8,9) between it and popular weight-loss diets misleading. The Pyramid specifies a range of servings for each food group; eating the minimum number of servings from each group will supply about 1,600 calories; eating at the midpoint of servings for each group will supply about 2,200 calories; and eat-
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ing the maximum number of servings will supply about 2,800 calories (21). The booklet that accompanies the Pyramid explains in detail what a serving size constitutes for foods from each food group (21). To fully understand the usefulness and relevancy of the Pyramid, it is helpful to know a little about the history of US food guidance that led to its development (22). BRIEF HISTORY OF DIETARY GUIDANCE LEADING TO THE PYRAMID Various food guides have been issued to the American public by the USDA since the early 1900s (1). Perhaps the most well known of these for most of the 20th century was the “Basic Four,” which recommended a minimum number of servings from each of four food groups: (a) milk; (b) meat, poultry, fish, eggs, dry beans, and nuts; (c) fruits and vegetables; and (d) breads and cereals. The goal of the guide, which did not make recommendations for total fat, sugar, or calorie consumption, was to help Americans prevent nutrient deficiencies. According to Welsh and colleagues (2), “The ‘Basic Four’ was developed as a foundation diet—that is, it was intended to meet only a portion (although the major portion) of the Recommended Dietary Allowances (RDAs) for nutrients. It was assumed that individuals would eat more food than the guide recommended in order to satisfy their full calorie and nutrient needs.” For the following 2 decades, the “Basic Four” was the basis of nutrition education in the United States (2). New Dietary Concerns Necessitate New Food Guide In the late 1970s, dietary advice began to shift to address concerns not only of nutrient adequacy, but of overconsumption as well. In 1979, the USDA issued a new food guide, the Hassle-free Guide to a Better Diet, which built on the “Basic Four” by adding a fifth group composed of fats, sweets, and alcohol. This guide addressed total fiber and calorie intake as well. When the USDA and DHHS released the first edition of the Dietary Guidelines for Americans in 1980, it became clear that a new food guide would be necessary to help consumers follow the advice contained in the Dietary Guidelines. The new guide was intended to meet the following criteria (2): ● ● ● ● ● ● ● ●
promote overall health; be based on up-to-date research; focus on the total diet; be useful to the target audience; meet nutrition goals in a realistic manner; allow maximum flexibility; be practical; and be evolutionary.
A circular graphic called the “Food Wheel” was released in 1984 to depict the information contained in the new food guide. But market research and testing revealed that American consumers did not, in general, perceive the new food guide as novel or markedly different from the “Basic Four” (2). The USDA therefore set about the task of developing a separate publication that would explain the food guide, as well as a new graphic to depict it. The
graphic had to convey three key messages of the new food guide: variety, proportionality, and moderation (3). The Pyramid Takes Shape In 1988, the USDA’s Human Nutrition Information Service (HNIS) began conducting market research to develop a new food guide booklet and graphic (21). The target audience was adults with at least a high school education, whose eating patterns were typical of the general US population, and for whom food cost was not an overwhelming concern (3). Five different illustrations of the new food guide’s food groups and the recommended number of servings from each group were tested: a circle or “food wheel,” blocks in a row, blocks in a circle, an inverted pyramid, and an upright pyramid. Welsh, Davis, and Shaw have previously done an excellent job of recording in detail the testing process (3). Ultimately, the upright pyramid was deemed the graphic that best communicated the messages of variety, proportionality, and moderation to the target audience. The Food Guide Pyramid was eventually released to the public in April 1992. THE PYRAMID’S IMPACT ON NUTRITION EDUCATION AND RESEARCH After its release, the Pyramid went on to become one of the most widely disseminated nutrition education tools developed in the United States. Surveys have found that it is widely recognized by consumers. Two thirds of consumers surveyed in the 1997 American Dietetic Association Nutrition Trends Survey recognized the Pyramid, and nearly half of them rated it as “valuable” (23,24). In a Gallup survey conducted in 2000 for the Wheat Foods Council, 75% of those surveyed were either “somewhat” or “very” familiar with the Pyramid (25), and in a 2003 Gallup survey conducted for the Wheat Foods Council, 82% of consumers agreed that the Pyramid “is the basis of a sensible, healthful eating plan” (26). It has been reproduced in a variety of formats, including pamphlets, posters, books, and food package labels; it has also been used effectively as a research tool in assessing and evaluating the dietary patterns and attributes of individuals and groups (27-33). THE DISCONNECT BETWEEN CONSUMER KNOWLEDGE AND PRACTICE Many American Diets Fall Short of the Pyramid and the RDAs Despite widespread consumer awareness of the Pyramid, it seems that the majority of Americans do not follow the dietary recommendations it illustrates. According to the 1999-2000 Healthy Eating Index, only 16% of the population ate a “good” diet, whereas the diets of 74% were classified as “needs improvement” (34). The Table illustrates how the average American diet compares with the Pyramid’s recommendations for each food group. Recent findings indicate that the diets of many people are failing to meet the recommended number of servings from many of the Pyramid’s food groups (35,36) and are too high in refined grains and added sugars and fats (20). According to data for 2000, “added fats accounted for 56% of the total fat provided by the food supply” (20). In
Table 1. How the average American diet compares with the Food Guide Pyramid’s recommended number of servings for each food groupa Average number of Recommended range servings consumed per Food group of servings day, 2-day average Grains Vegetables Fruits Dairy Meat (oz)
6 3 2 2 5
to to to to to
11 5 4 3 7
6.7 3.3 1.5 1.5 4.7
a Source: US Department of Agriculture—Food Surveys Research Group. Available at: http://www.barc.usda.gov/bhnrc/foodsurvey/Fsrgfaq.html#pyramid. Accessed May 9, 2004.
addition, Americans are consuming nearly triple the recommended amount of added sugars (20). These trends have occurred along with a concomitant increase in per capita caloric consumption of approximately 300 calories more per day (from 1,985 to 2,000) (20). In addition, portion sizes served in many food service outlets (and, subsequently, consumers’ perceptions of what a “normal” portion size is) far exceed the standard portion sizes recommended in the Pyramid booklet (37,38). Putnam and colleagues point out that the average American’s diet falls short of several of the nutritious foods represented in the Pyramid: The average American dietary style at the beginning of the 21st century resembles an hourglass rather than the federal government’s Food Guide Pyramid. We gobble huge amounts of added fats and sugars from the top tier of the Pyramid (marked “Use Sparingly”) and heaping plates of pasta and other refined grains from the bottom tier, but we are sorely lacking in the vegetables, fruits, low-fat milk products, and other nutritious foods in the middle of the Pyramid (20).
Indeed, women, men, and children are all falling short of the recommended number of daily Pyramid servings from several food groups. Among women over the age of 20, only 16% are consuming the minimum number of Pyramid servings from the dairy group and only 28% are consuming the minimum number of servings from the meat group (Figure 1) (36). Among men, only 27% are meeting Pyramid recommendations for the dairy group and only 28% are meeting recommendations for the fruit group (Figure 1) (36). Among girls aged 12 to 19, 76% are consuming less than the minimum recommended number of Pyramid servings per day for fruit, and 74% are not meeting recommendations for both dairy and meat (Figure 2) (36). In addition to failing to consume the minimum recommendations for many of the Pyramid’s food groups, many Americans are failing to meet the RDAs for several micronutrients. For example, 62% of women over 20 are failing to meet the RDA for iron, 51% are falling short for vitamin B-6, 49% are not getting enough zinc, 41% are not getting enough thiamin, and 39% are not getting enough vitamin B-12 (39). Similarly, men are also not getting enough of several
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Figure 1. Percentage of individuals consuming at least the minimum number of Food Guide Pyramid servings per day. Minimum number of servings from grain group: 6; vegetable group: 3; fruit group: 2; dairy group: 2; meat group: 5 ounces or equivalent. (Source: US Department of Agricultural Research Service, Pyramid Servings Intakes by US Children and Adults 1994-96, 1998, Community Nutrition Research Group, October 2000; http://www.barc.usda.gov/bhnrc.cnrg.)
Figure 2. Percentage of individuals consuming less than the minimum recommended number of Food Guide Pyramid servings per day. Minimum number of servings from grain group: 6; vegetable group: 3; fruit group: 2; dairy group: 2; meat group: 5 ounces or equivalent. (Source: US Department of Agricultural Research Service, Pyramid Servings Intakes by US Children and Adults 1994-96, 1998, Community Nutrition Research Group, October 2000; http://www.barc.usda.gov/bhnrc.cnrg.) micronutrients. Of men over the age of 20, 41% are failing to meet the RDA for zinc, 27% are not getting enough vitamin B-6, 20% are not getting enough thiamin, and 17% are not getting enough riboflavin and vitamin B-12 (39). Inadequate micronutrient consumption is affecting American children as well. Among girls aged 12 to 19, 59.8% do not meet the RDA for iron and 47% do not meet the RDA for zinc (39). Younger children are affected as well: 24.9% of children (boys and girls) age 5 and under do
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not meet the RDA for iron and 4.7% do not meet the RDA for zinc (39). These data are contributing to a disturbing phenomenon—are Americans overfed and undernourished? OBESITY IS A COMPLEX AND MULTIFACTORIAL PUBLIC HEALTH ISSUE As stated in the previous section, Americans’ diets hardly come close to adhering to the Dietary Guidelines for
Americans and to the Food Guide Pyramid. But these dietary trends, although certainly integral to the current obesity epidemic, represent just one of many factors that contribute to obesity on a public health scale. Although a comprehensive discussion of the factors that contribute to obesity—which include environmental, genetic, behavioral, and psychological—are beyond the scope of this article, it is worth noting that the net effect is an increasingly sedentary population, coupled with widespread availability of ever-growing portions of high-calorie, lownutrient foods. Many Americans’ lifestyles, it seems, are engineered perfectly to result in weight gain (40-43). Because obesity is such a complex issue, it is overly simplistic to argue that a single educational device such as the Pyramid offers a root cause for the problem. And because it seems that most Americans do not actually follow the advice illustrated by the Pyramid, it is illogical to blame the Pyramid for our current epidemic of obesity. Still, these alarming trends beg the question: How can we improve nutrition education efforts, including use of the Pyramid, to combat these problems? UTILITY OF THE PYRAMID AND THE TOTAL DIET APPROACH As long as the Pyramid reflects the advice contained in the Dietary Guidelines for Americans, it remains a useful part of nutrition education efforts, especially when used by dietetics professionals in the context of individualized, comprehensive nutrition education and behavior modification interventions. The key concepts conveyed by the Pyramid—variety, proportionality, and moderation—are still important principles on which Americans should base their diets, and nutrition interventions based on overall dietary patterns are advocated (44). Studies have found that nutrition interventions based on overall dietary patterns are effective in improving health-related outcomes, including body mass index (31,45), blood pressure (46), and blood lipid levels (45,47,48). Continuing Survey of Food Intake by Individuals (CSFII) data show that lower body mass indexes were associated with people eating in a Pyramid-based dietary pattern compared with those eating in non-Pyramid patterns (31). With scientific review under way for the next release of the Dietary Guidelines, however, it is prudent for the USDA to consider whether the Pyramid’s design still closely correlates with the science the guidelines are based on and whether revisions to the graphic are necessary. The Pyramid, like any educational tool, is not perfect. For example, some argue that the graphic should better communicate the recommendations that consumers choose low-fat dairy foods over high-fat ones and choose whole grains over refined grains. Some also argue that the recommendation that all fats should be “used sparingly” is outdated, although scientific consensus on the optimal amount and type(s) of fat to recommend to American consumers has yet to be reached. THE FUTURE: A CALL TO ACTION FOR DIETETICS PROFESSIONALS In the meantime, nutrition educators should continue to use the Pyramid as a component of creative interventions designed to help consumers achieve desired health behav-
iors. Because the Pyramid—and all variations of it— depicts simple foods, educators must help consumers to understand how the complex foods they eat relate to the numbers of servings of simple foods the Pyramid recommends (eg, how mixed dishes such as beef stew or Pad Thai translate into Pyramid guidelines).
The abandonment of the USDA Food Guide Pyramid would cause massive confusion among an already confused public. Contrary to what popular media stories may imply, abandoning the USDA Food Guide Pyramid in favor of an alternate pyramid is not necessarily the answer to the nation’s current nutrition problems, particularly in the absence of data to show that most Americans can and will actually eat according to any such alternate pyramid. The abandonment of the USDA Food Guide Pyramid would cause massive confusion among an already confused public. In addition, time, money, and expertise would be better spent studying the reasons why so many Americans seem unable or unwilling to actually put into practice the nutrition information they learn. Until that question is answered, the Food Guide Pyramid continues to fulfill its intended role as an illustration of the advice contained in the Dietary Guidelines. It remains useful as the basis for the development of nutrition education initiatives that can influence behavior, with one important caveat: No nutrition education tool, pyramid or otherwise, will be 100% effective if nutrition educators and policy makers do not recognize and accept that factors such as taste, convenience, and cost are often more likely to influence consumers’ food selections than is health (23,49). As rates of obesity and obesity-related diseases continue to grow, research is urgently needed to address which types of interventions are most likely to be successful at helping consumers not only to recognize, but also to actually adopt, healthful behaviors. Research is also needed to determine the most effective ways of using nutrition education tools, including the Pyramid, to achieve this goal. The current obesity crisis highlights not only the need for further research, but also the need for expanded availability of professional nutrition services in federally funded food and nutrition programs and in governmentand third-party–supported health care delivery systems (50-52). Innovative nutrition interventions, including education, counseling, and behavior modification, are needed at the individual, family, community, and public health levels. To that end, dietetics professionals working in all aspects of the field— clinical nutrition, community nutrition, food service, research, education, communication, and government— can capitalize on one of the major strengths of the Pyramid: it is already a widely recognized and reproduced icon. Dietetics professionals can capitalize on that recognition and seek novel ways to use
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the Pyramid as one component in their efforts to improve public health. Supported in part by the Cattlemen’s Beef Board and the National Cattlemen’s Beef Association. References 1. Welsh S. Atwater to present: Evolution of nutrition education. J Nutr. 1994;124(suppl 9):S1799-S1807. 2. Welsh S, Davis C, Shaw A. A brief history of food guides in the United States. Nutr Today. Nov/Dec 1992;6-11. 3. Welsh S, Davis C, Shaw A. Development of the Food Guide Pyramid. Nutr Today. Nov/Dec 1992;12-23. 4. Davis CA, Britten P, Myers EF. Past, present, and future of the Food Guide Pyramid. J Am Diet Assoc. 2001;101:881-885. 5. Nutrition and Your Health: Dietary Guidelines for Americans. 5th ed. Washington, DC: US Depts of Agriculture and Health and Human Services; 2000. Home and Garden Bulletin No. 232. 6. Yeoman B. Is the food pyramid making you fat? Fitness. June 2003; 133-137. 7. Foltz-Gray D. How to build a better pyramid. Health. April 2002; 126-132. 8. Taubes G. What if it’s all been a big fat lie? New York Times. July 7, 2002. 9. Burros M. The diet pendulum swings again. New York Times. August 14, 2002. 10. Hellmich N. Scales tip in favor of new food pyramid. USA Today. November 5, 2002; page 6D. 11. Weinraub J. The power of the pyramid. The government’s symbol of healthful eating still reigns supreme. But should it? The Washington Post. January 15, 2003; page F01. 12. Lee E. Rebuilding the food pyramid. Atlanta JournalConstitution. January 20, 2003. 13. Cowley G. A better way to eat. Newsweek. January 20, 2003. 14. Cleary AJ. Razing the pyramid. Eating Well. Winter 2003; 17-23. 15. Rice W. Crossroads at the pyramids: Divergent plans reflect the confusion over what Americans should eat for health. Chicago Tribune. March 5, 2003. 16. Department of Agriculture, Center for Nutrition Policy and Promotion. Notice of availability of proposed food guide pyramid daily food intake patterns and technical support data and announcement of public comment period. Federal Register. 2003;68:5353653539. 17. Martin A. US begins remodeling food pyramid: Critics already slicing and dicing. Chicago Tribune. September 24, 2003. 18. Lee E. Food pyramid takes aim at couch potatoes. Atlanta Journal-Constitution. September 11, 2003; page 1A. 19. Hellmich N. Rebuilding the pyramid: Food guide redesign has the experts ruminating. USA Today. September 17, 2003; page 5D. 20. Putnam J, Allshouse J, Kantor LS. US per capita food supply trends: More calories, refined carbohydrates, and fats. USDA, Economic Research Service. Food Rev. 2002;25:2-15.
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The Obesity Crisis: Don’t Blame It on the Pyramid JEANNE P. GOLDBERG, PhD, RD; MARTHA A. BELURY, PhD, RD; PEGGY ELAM, PhD; SUSAN CALVERT FINN, PhD, RD, FADA; DAYLE HAYES, MS, RD; ROSEANN LYLE, PhD, MEd; SACHIKO ST. JEOR, PhD, RD; MICHELLE WARREN, MD; JENNIFER P. HELLWIG, MS, RD
ABSTRACT Since its release in 1992, the Food Guide Pyramid has become one of the most recognized nutrition education tools in US history. As such, it has been subject to criticism, particularly in several recent media reports that implicate it as the culprit in America’s current obesity epidemic. What these reports often overlook, however, is that the diets of many Americans do not adhere to the dietary guidelines illustrated by the Pyramid, refuting the notion that the Pyramid is the cause of the nation’s obesity problem. Data indicate that the more likely causes of escalating obesity rates are increased per capita caloric consumption and larger portion sizes, along with a lack of adequate physical activity. Although the Pyramid graphic was designed more than a decade ago, it still communicates three key concepts that continue to be the cornerstone of federal dietary guidance: variety, proportionality, and moderation. As such, it remains a viable and relevant nutrition education tool, especially when used by dietetics professionals as a component of individJ. P. Goldberg is director, Center on Nutrition Communication, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA. M. A. Belury is the Carol S. Kennedy professor in nutrition, Department of Human Nutrition, The Ohio State University, Columbus. P. Elam is a clinical and consulting psychologist, Nashville, TN. S. C. Finn is chair, American Council for Fitness and Nutrition, Finn Parks and Associates, Inc, Columbus, OH. D. Hayes is a nutrition consultant, Billings, MT. R. Lyle is a professor of health promotion, Department of Health and Kinesiology, Purdue University, West Lafayette, IN. S. St. Jeor is director, Nutrition Education and Research, University of Nevada School of Medicine, Reno. M. Warren is a professor of obstetrics and gynecology and medicine, Department of Obstetrics and Gynecology, Columbia University, New York, NY. J. P. Hellwig is an adjunct lecturer, Tufts University Friedman School of Nutrition Science and Policy, Boston, MA. Address correspondence to: Jeanne P. Goldberg, PhD, RD, Center on Nutrition Communication, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, 150 Harrison Ave, Boston, MA 02111. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10407-0008$30.00/0 doi: 10.1016/j.jada.2004.04.026
© 2004 by the American Dietetic Association
ualized, comprehensive nutrition education and behavior modification interventions. As the United States Department of Agriculture begins to investigate whether the food intake patterns illustrated by the Pyramid are in need of updating, research is urgently needed to determine how nutrition education tools, including the Pyramid, can be most effectively implemented to help consumers adopt healthful eating behaviors and to improve the public health of America. J Am Diet Assoc. 2004;104:1141-1147.
A
s the science that forms the basis of dietary guidance has evolved over the last century, so, too, have the nutrition education tools used to convey such guidance. Since the early 1900s, the United States Department of Agriculture (USDA) has been issuing food guides designed to help consumers choose diets that meet recommendations based on a comprehensive body of scientific literature (1). In that time, recommendations have evolved to address concerns not only of nutrient adequacy, but more recently, of overconsumption (1,2). Graphics and illustrations that depict the information in these food guides have played an integral role in conveying dietary advice to consumers. Perhaps the most well-known such graphic is the Food Guide Pyramid, issued in 1992 by the USDA and the US Department of Health and Human Services (DHHS). The Pyramid was designed after extensive market research and testing, in which it was found to be the graphic best suited to convey three key concepts with regard to diet: variety, proportionality, and moderation (3,4). These concepts continue to be the cornerstone of the federal dietary guidance contained in the Dietary Guidelines for Americans (5). But with rates of obesity and obesity-related diseases, such as type 2 diabetes and cardiovascular disease, soaring, the Pyramid has come under intense scrutiny in recent months, with several media reports questioning whether consumers should abandon it altogether and, in some cases, follow an alternate pyramid instead (6-15). After the USDA announced plans to review the food intake patterns that the Pyramid illustrates (16), additional media reports appeared, implicating the Pyramid as a cause of obesity (17-19). In one newspaper article, a nutrition researcher is quoted as saying, “I think the Food Guide Pyramid is a recipe for obesity” (17). Because of the widespread nature of these reports, it is possible that not only consumers but nutrition professionals as well may have been misled to believe that an alternate pyramid has replaced or should replace the USDA Food Guide Pyramid.
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This article argues that the Pyramid has not caused America’s obesity epidemic (as many media reports would have readers believe), but rather that a growing trend of large portion sizes and an increase in average caloric consumption without a concomitant increase in physical activity is more likely the root cause of obesity (20). (Although the role of physical activity in weight control is undisputed, an in-depth discussion of that topic is beyond the scope of this article). This article further contends that if the diets of more Americans actually adhered to the Dietary Guidelines that the Pyramid illustrates, obesity might not be as great a public health problem as it currently is. This article also argues that the failure of the majority of Americans to eat according to the Pyramid may also be contributing to micronutrient deficiencies in several groups, leaving much of the population overfed and undernourished. In making this argument, this article traces the history behind the development and implementation of the Pyramid, discusses its role in nutrition education and research, and makes recommendations for its future use by dietetics professionals in conveying current dietary guidance and combating the nutrition-related public health problems currently facing the US population. Finally, this article raises questions for consideration by nutrition educators and policy makers regarding how to help Americans not only to recognize tools such as the Pyramid, but actually to translate that recognition into the adoption of healthful eating behaviors. UNDERSTANDING THE ROLE OF THE PYRAMID As well known as the Pyramid is, many people (consumers and nutrition professionals alike) do not know the history behind its development or understand what it was—and was not—intended to accomplish. It was not originally intended to function as a stand-alone doctrine of nutrition policy. Rather, it was meant to serve as a user-friendly, widely reproducible illustration of the advice contained in the Dietary Guidelines for Americans, which are reviewed and updated as necessary every 5 years by a panel of national experts. The design of the actual graphic was constrained by the fact that it had to be reproducible in both color and in black and white, as well as in a variety of sizes, making it possible to reproduce in several formats, including brochures, posters, and food packages. Although consumers might encounter the Pyramid alone in these formats, it was intended to be most effective when used in conjunction with the detailed booklet (21) that accompanied its release and when used as a complementary teaching tool in individual, in-depth nutrition counseling, as well as in targeted, populationbased nutrition education campaigns. In addition to being based on sound science, the Pyramid was designed to be flexible and adaptable in its use by dietetics professionals in counseling a wide array of clients, including those seeking weight control. It is important to note, however, that the Pyramid was not designed to represent a weight-loss diet, per se, making recent comparisons in the media (8,9) between it and popular weight-loss diets misleading. The Pyramid specifies a range of servings for each food group; eating the minimum number of servings from each group will supply about 1,600 calories; eating at the midpoint of servings for each group will supply about 2,200 calories; and eat-
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ing the maximum number of servings will supply about 2,800 calories (21). The booklet that accompanies the Pyramid explains in detail what a serving size constitutes for foods from each food group (21). To fully understand the usefulness and relevancy of the Pyramid, it is helpful to know a little about the history of US food guidance that led to its development (22). BRIEF HISTORY OF DIETARY GUIDANCE LEADING TO THE PYRAMID Various food guides have been issued to the American public by the USDA since the early 1900s (1). Perhaps the most well known of these for most of the 20th century was the “Basic Four,” which recommended a minimum number of servings from each of four food groups: (a) milk; (b) meat, poultry, fish, eggs, dry beans, and nuts; (c) fruits and vegetables; and (d) breads and cereals. The goal of the guide, which did not make recommendations for total fat, sugar, or calorie consumption, was to help Americans prevent nutrient deficiencies. According to Welsh and colleagues (2), “The ‘Basic Four’ was developed as a foundation diet—that is, it was intended to meet only a portion (although the major portion) of the Recommended Dietary Allowances (RDAs) for nutrients. It was assumed that individuals would eat more food than the guide recommended in order to satisfy their full calorie and nutrient needs.” For the following 2 decades, the “Basic Four” was the basis of nutrition education in the United States (2). New Dietary Concerns Necessitate New Food Guide In the late 1970s, dietary advice began to shift to address concerns not only of nutrient adequacy, but of overconsumption as well. In 1979, the USDA issued a new food guide, the Hassle-free Guide to a Better Diet, which built on the “Basic Four” by adding a fifth group composed of fats, sweets, and alcohol. This guide addressed total fiber and calorie intake as well. When the USDA and DHHS released the first edition of the Dietary Guidelines for Americans in 1980, it became clear that a new food guide would be necessary to help consumers follow the advice contained in the Dietary Guidelines. The new guide was intended to meet the following criteria (2): ● ● ● ● ● ● ● ●
promote overall health; be based on up-to-date research; focus on the total diet; be useful to the target audience; meet nutrition goals in a realistic manner; allow maximum flexibility; be practical; and be evolutionary.
A circular graphic called the “Food Wheel” was released in 1984 to depict the information contained in the new food guide. But market research and testing revealed that American consumers did not, in general, perceive the new food guide as novel or markedly different from the “Basic Four” (2). The USDA therefore set about the task of developing a separate publication that would explain the food guide, as well as a new graphic to depict it. The
graphic had to convey three key messages of the new food guide: variety, proportionality, and moderation (3). The Pyramid Takes Shape In 1988, the USDA’s Human Nutrition Information Service (HNIS) began conducting market research to develop a new food guide booklet and graphic (21). The target audience was adults with at least a high school education, whose eating patterns were typical of the general US population, and for whom food cost was not an overwhelming concern (3). Five different illustrations of the new food guide’s food groups and the recommended number of servings from each group were tested: a circle or “food wheel,” blocks in a row, blocks in a circle, an inverted pyramid, and an upright pyramid. Welsh, Davis, and Shaw have previously done an excellent job of recording in detail the testing process (3). Ultimately, the upright pyramid was deemed the graphic that best communicated the messages of variety, proportionality, and moderation to the target audience. The Food Guide Pyramid was eventually released to the public in April 1992. THE PYRAMID’S IMPACT ON NUTRITION EDUCATION AND RESEARCH After its release, the Pyramid went on to become one of the most widely disseminated nutrition education tools developed in the United States. Surveys have found that it is widely recognized by consumers. Two thirds of consumers surveyed in the 1997 American Dietetic Association Nutrition Trends Survey recognized the Pyramid, and nearly half of them rated it as “valuable” (23,24). In a Gallup survey conducted in 2000 for the Wheat Foods Council, 75% of those surveyed were either “somewhat” or “very” familiar with the Pyramid (25), and in a 2003 Gallup survey conducted for the Wheat Foods Council, 82% of consumers agreed that the Pyramid “is the basis of a sensible, healthful eating plan” (26). It has been reproduced in a variety of formats, including pamphlets, posters, books, and food package labels; it has also been used effectively as a research tool in assessing and evaluating the dietary patterns and attributes of individuals and groups (27-33). THE DISCONNECT BETWEEN CONSUMER KNOWLEDGE AND PRACTICE Many American Diets Fall Short of the Pyramid and the RDAs Despite widespread consumer awareness of the Pyramid, it seems that the majority of Americans do not follow the dietary recommendations it illustrates. According to the 1999-2000 Healthy Eating Index, only 16% of the population ate a “good” diet, whereas the diets of 74% were classified as “needs improvement” (34). The Table illustrates how the average American diet compares with the Pyramid’s recommendations for each food group. Recent findings indicate that the diets of many people are failing to meet the recommended number of servings from many of the Pyramid’s food groups (35,36) and are too high in refined grains and added sugars and fats (20). According to data for 2000, “added fats accounted for 56% of the total fat provided by the food supply” (20). In
Table 1. How the average American diet compares with the Food Guide Pyramid’s recommended number of servings for each food groupa Average number of Recommended range servings consumed per Food group of servings day, 2-day average Grains Vegetables Fruits Dairy Meat (oz)
6 3 2 2 5
to to to to to
11 5 4 3 7
6.7 3.3 1.5 1.5 4.7
a Source: US Department of Agriculture—Food Surveys Research Group. Available at: http://www.barc.usda.gov/bhnrc/foodsurvey/Fsrgfaq.html#pyramid. Accessed May 9, 2004.
addition, Americans are consuming nearly triple the recommended amount of added sugars (20). These trends have occurred along with a concomitant increase in per capita caloric consumption of approximately 300 calories more per day (from 1,985 to 2,000) (20). In addition, portion sizes served in many food service outlets (and, subsequently, consumers’ perceptions of what a “normal” portion size is) far exceed the standard portion sizes recommended in the Pyramid booklet (37,38). Putnam and colleagues point out that the average American’s diet falls short of several of the nutritious foods represented in the Pyramid: The average American dietary style at the beginning of the 21st century resembles an hourglass rather than the federal government’s Food Guide Pyramid. We gobble huge amounts of added fats and sugars from the top tier of the Pyramid (marked “Use Sparingly”) and heaping plates of pasta and other refined grains from the bottom tier, but we are sorely lacking in the vegetables, fruits, low-fat milk products, and other nutritious foods in the middle of the Pyramid (20).
Indeed, women, men, and children are all falling short of the recommended number of daily Pyramid servings from several food groups. Among women over the age of 20, only 16% are consuming the minimum number of Pyramid servings from the dairy group and only 28% are consuming the minimum number of servings from the meat group (Figure 1) (36). Among men, only 27% are meeting Pyramid recommendations for the dairy group and only 28% are meeting recommendations for the fruit group (Figure 1) (36). Among girls aged 12 to 19, 76% are consuming less than the minimum recommended number of Pyramid servings per day for fruit, and 74% are not meeting recommendations for both dairy and meat (Figure 2) (36). In addition to failing to consume the minimum recommendations for many of the Pyramid’s food groups, many Americans are failing to meet the RDAs for several micronutrients. For example, 62% of women over 20 are failing to meet the RDA for iron, 51% are falling short for vitamin B-6, 49% are not getting enough zinc, 41% are not getting enough thiamin, and 39% are not getting enough vitamin B-12 (39). Similarly, men are also not getting enough of several
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Figure 1. Percentage of individuals consuming at least the minimum number of Food Guide Pyramid servings per day. Minimum number of servings from grain group: 6; vegetable group: 3; fruit group: 2; dairy group: 2; meat group: 5 ounces or equivalent. (Source: US Department of Agricultural Research Service, Pyramid Servings Intakes by US Children and Adults 1994-96, 1998, Community Nutrition Research Group, October 2000; http://www.barc.usda.gov/bhnrc.cnrg.)
Figure 2. Percentage of individuals consuming less than the minimum recommended number of Food Guide Pyramid servings per day. Minimum number of servings from grain group: 6; vegetable group: 3; fruit group: 2; dairy group: 2; meat group: 5 ounces or equivalent. (Source: US Department of Agricultural Research Service, Pyramid Servings Intakes by US Children and Adults 1994-96, 1998, Community Nutrition Research Group, October 2000; http://www.barc.usda.gov/bhnrc.cnrg.) micronutrients. Of men over the age of 20, 41% are failing to meet the RDA for zinc, 27% are not getting enough vitamin B-6, 20% are not getting enough thiamin, and 17% are not getting enough riboflavin and vitamin B-12 (39). Inadequate micronutrient consumption is affecting American children as well. Among girls aged 12 to 19, 59.8% do not meet the RDA for iron and 47% do not meet the RDA for zinc (39). Younger children are affected as well: 24.9% of children (boys and girls) age 5 and under do
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not meet the RDA for iron and 4.7% do not meet the RDA for zinc (39). These data are contributing to a disturbing phenomenon—are Americans overfed and undernourished? OBESITY IS A COMPLEX AND MULTIFACTORIAL PUBLIC HEALTH ISSUE As stated in the previous section, Americans’ diets hardly come close to adhering to the Dietary Guidelines for
Americans and to the Food Guide Pyramid. But these dietary trends, although certainly integral to the current obesity epidemic, represent just one of many factors that contribute to obesity on a public health scale. Although a comprehensive discussion of the factors that contribute to obesity—which include environmental, genetic, behavioral, and psychological—are beyond the scope of this article, it is worth noting that the net effect is an increasingly sedentary population, coupled with widespread availability of ever-growing portions of high-calorie, lownutrient foods. Many Americans’ lifestyles, it seems, are engineered perfectly to result in weight gain (40-43). Because obesity is such a complex issue, it is overly simplistic to argue that a single educational device such as the Pyramid offers a root cause for the problem. And because it seems that most Americans do not actually follow the advice illustrated by the Pyramid, it is illogical to blame the Pyramid for our current epidemic of obesity. Still, these alarming trends beg the question: How can we improve nutrition education efforts, including use of the Pyramid, to combat these problems? UTILITY OF THE PYRAMID AND THE TOTAL DIET APPROACH As long as the Pyramid reflects the advice contained in the Dietary Guidelines for Americans, it remains a useful part of nutrition education efforts, especially when used by dietetics professionals in the context of individualized, comprehensive nutrition education and behavior modification interventions. The key concepts conveyed by the Pyramid—variety, proportionality, and moderation—are still important principles on which Americans should base their diets, and nutrition interventions based on overall dietary patterns are advocated (44). Studies have found that nutrition interventions based on overall dietary patterns are effective in improving health-related outcomes, including body mass index (31,45), blood pressure (46), and blood lipid levels (45,47,48). Continuing Survey of Food Intake by Individuals (CSFII) data show that lower body mass indexes were associated with people eating in a Pyramid-based dietary pattern compared with those eating in non-Pyramid patterns (31). With scientific review under way for the next release of the Dietary Guidelines, however, it is prudent for the USDA to consider whether the Pyramid’s design still closely correlates with the science the guidelines are based on and whether revisions to the graphic are necessary. The Pyramid, like any educational tool, is not perfect. For example, some argue that the graphic should better communicate the recommendations that consumers choose low-fat dairy foods over high-fat ones and choose whole grains over refined grains. Some also argue that the recommendation that all fats should be “used sparingly” is outdated, although scientific consensus on the optimal amount and type(s) of fat to recommend to American consumers has yet to be reached. THE FUTURE: A CALL TO ACTION FOR DIETETICS PROFESSIONALS In the meantime, nutrition educators should continue to use the Pyramid as a component of creative interventions designed to help consumers achieve desired health behav-
iors. Because the Pyramid—and all variations of it— depicts simple foods, educators must help consumers to understand how the complex foods they eat relate to the numbers of servings of simple foods the Pyramid recommends (eg, how mixed dishes such as beef stew or Pad Thai translate into Pyramid guidelines).
The abandonment of the USDA Food Guide Pyramid would cause massive confusion among an already confused public. Contrary to what popular media stories may imply, abandoning the USDA Food Guide Pyramid in favor of an alternate pyramid is not necessarily the answer to the nation’s current nutrition problems, particularly in the absence of data to show that most Americans can and will actually eat according to any such alternate pyramid. The abandonment of the USDA Food Guide Pyramid would cause massive confusion among an already confused public. In addition, time, money, and expertise would be better spent studying the reasons why so many Americans seem unable or unwilling to actually put into practice the nutrition information they learn. Until that question is answered, the Food Guide Pyramid continues to fulfill its intended role as an illustration of the advice contained in the Dietary Guidelines. It remains useful as the basis for the development of nutrition education initiatives that can influence behavior, with one important caveat: No nutrition education tool, pyramid or otherwise, will be 100% effective if nutrition educators and policy makers do not recognize and accept that factors such as taste, convenience, and cost are often more likely to influence consumers’ food selections than is health (23,49). As rates of obesity and obesity-related diseases continue to grow, research is urgently needed to address which types of interventions are most likely to be successful at helping consumers not only to recognize, but also to actually adopt, healthful behaviors. Research is also needed to determine the most effective ways of using nutrition education tools, including the Pyramid, to achieve this goal. The current obesity crisis highlights not only the need for further research, but also the need for expanded availability of professional nutrition services in federally funded food and nutrition programs and in governmentand third-party–supported health care delivery systems (50-52). Innovative nutrition interventions, including education, counseling, and behavior modification, are needed at the individual, family, community, and public health levels. To that end, dietetics professionals working in all aspects of the field— clinical nutrition, community nutrition, food service, research, education, communication, and government— can capitalize on one of the major strengths of the Pyramid: it is already a widely recognized and reproduced icon. Dietetics professionals can capitalize on that recognition and seek novel ways to use
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the Pyramid as one component in their efforts to improve public health. Supported in part by the Cattlemen’s Beef Board and the National Cattlemen’s Beef Association. References 1. Welsh S. Atwater to present: Evolution of nutrition education. J Nutr. 1994;124(suppl 9):S1799-S1807. 2. Welsh S, Davis C, Shaw A. A brief history of food guides in the United States. Nutr Today. Nov/Dec 1992;6-11. 3. Welsh S, Davis C, Shaw A. Development of the Food Guide Pyramid. Nutr Today. Nov/Dec 1992;12-23. 4. Davis CA, Britten P, Myers EF. Past, present, and future of the Food Guide Pyramid. J Am Diet Assoc. 2001;101:881-885. 5. Nutrition and Your Health: Dietary Guidelines for Americans. 5th ed. Washington, DC: US Depts of Agriculture and Health and Human Services; 2000. Home and Garden Bulletin No. 232. 6. Yeoman B. Is the food pyramid making you fat? Fitness. June 2003; 133-137. 7. Foltz-Gray D. How to build a better pyramid. Health. April 2002; 126-132. 8. Taubes G. What if it’s all been a big fat lie? New York Times. July 7, 2002. 9. Burros M. The diet pendulum swings again. New York Times. August 14, 2002. 10. Hellmich N. Scales tip in favor of new food pyramid. USA Today. November 5, 2002; page 6D. 11. Weinraub J. The power of the pyramid. The government’s symbol of healthful eating still reigns supreme. But should it? The Washington Post. January 15, 2003; page F01. 12. Lee E. Rebuilding the food pyramid. Atlanta JournalConstitution. January 20, 2003. 13. Cowley G. A better way to eat. Newsweek. January 20, 2003. 14. Cleary AJ. Razing the pyramid. Eating Well. Winter 2003; 17-23. 15. Rice W. Crossroads at the pyramids: Divergent plans reflect the confusion over what Americans should eat for health. Chicago Tribune. March 5, 2003. 16. Department of Agriculture, Center for Nutrition Policy and Promotion. Notice of availability of proposed food guide pyramid daily food intake patterns and technical support data and announcement of public comment period. Federal Register. 2003;68:5353653539. 17. Martin A. US begins remodeling food pyramid: Critics already slicing and dicing. Chicago Tribune. September 24, 2003. 18. Lee E. Food pyramid takes aim at couch potatoes. Atlanta Journal-Constitution. September 11, 2003; page 1A. 19. Hellmich N. Rebuilding the pyramid: Food guide redesign has the experts ruminating. USA Today. September 17, 2003; page 5D. 20. Putnam J, Allshouse J, Kantor LS. US per capita food supply trends: More calories, refined carbohydrates, and fats. USDA, Economic Research Service. Food Rev. 2002;25:2-15.
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