A Healthy Diet and the New Food Pyramid

By Paul E. Lemanski, MD, MS, FACP

Editor’s Note: This is the 126th in a series on optimal diet and lifestyle to help prevent and treat disease. Any planned change in diet, exercise or treatment should be discussed with and approved by your personal physician before implementation. The help of a registered dietitian in the implementation of dietary changes is strongly recommended.

Medicines are a mainstay of American life and the healthcare system not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of Type 2 diabetes, heart attacks, strokes, cardiovascular death and even some cancers.

In the first 125 installments of the Non-Medicated Life, a healthy diet and lifestyle have been shown to accomplish naturally for the majority of individuals most of the benefits of medications in the prevention of the chronic medical conditions mentioned above. With respect to a healthy diet this column has championed a predominantly whole foods, plant-based diet such as the Mediterranean diet. The rationale for such a diet rests on both epidemiological evidence and randomized placebo controlled trials proving superior health outcomes in preventing disease. 

Recently, the US Department of Agriculture and the US Department of Health and Human Services released a new edition of “Dietary Guidelines for Americans.” This 10 page document can be summarized pictorially as an inverted food pyramid with the “base” suggesting foods to consume proportionately more of and the “peak” proportionately less of. Some of the recommendations in the pyramid would seem to contradict our recommendations and the recommendations of previous editions of the guidelines. The purpose of this month’s column is to examine the apparent contradictions as well as the available medical evidence, so as to encourage you to make the best health choices.

The new edition of Dietary Guidelines for Americans was preceded by an edition published in 1992 which also had an associated food pyramid. That pyramid based on the available evidence at the time had at the base of the pyramid a foundation of grains including 6-11 servings per day of bread, cereal, rice and/or pasta. The next “level up” the pyramid suggested 3-5 servings per day of vegetables, and 2-4 servings per day of fruit. Next up the pyramid suggested 2-3 servings per day of milk, yogurt and cheese, and 2-3 servings per day of meat, poultry, eggs, beans, and nuts. At the peak, the use of fats, oils and sweets was recommended only sparingly. 

This recommended frequency of consumption limited the intake of saturated fat by restricting animal derived foods and suggesting non-fat or low fat versions of milk, yogurt, and cheese. Such a limitation would result in lower levels of LDL, the bad cholesterol, and as shown in clinical trials would result primarily in reduced risk of heart attacks and strokes. Protein in the pyramid would be set at 0.8 grams per kilogram of bodyweight and consist of both plant-based and animal sources. This pictorial representation of type and relative amounts of food consumption is perhaps best exemplified by the Mediterranean diet, a predominantly whole food, plant-based diet.

The new edition’s food pyramid literally turns the pyramid on its head or more appropriately its peak. Under the heading of “Eat Real Food” the base of the pyramid-indicating an increased frequency of consumption – places high quality, nutrient dense protein (primarily from animals), healthy fats, and whole fat dairy as a top priority. The center of the pyramid consists of three servings a day of vegetables, two servings a day of fruit, nuts and seeds. The peak of the pyramid-indicating a reduced frequency of consumption-consists of 2-4 servings a day of whole grains, and general avoidance of simple sugars and refined carbohydrates. 

The emphasis to eat real food suggests that highly processed food products or those that contain unnatural ingredients including excess sodium, chemical additives, food dyes and thickeners be avoided. Moreover, the new pyramid emphasizes a significantly higher intake of protein (1.2-1.6 grams per kilogram of bodyweight) primarily from animal sources.

From my perspective, there is more medical evidence supporting a predominately whole food, plant-based diet like the Mediterranean diet for optimizing cardiovascular outcomes. This evidence is both epidemiological from population-based studies and randomized placebo controlled trials like the Lyon Diet Heart Study, which showed 70% reduction in fatal and non-fatal heart attack on a high omega-3 Mediterranean diet, compared to a “prudent” Western diet. Part of the benefit of such a diet may be due to a restriction in saturated fat achieved by reduced meat, an increase in monounsaturated oils like olive oil, and the consumption of a larger proportion of vegetables, fruits and whole grains. 

The new dietary recommendations would seem to suggest an increase in saturated fat from meat and whole fat dairy. Interestingly, however, the new guidelines at the same time suggest that saturated fat should be no more than 10% of total calories, which on a 2,000 calorie diet should be about 22 grams of saturated fat per day. This is actually a relatively low amount saturated fat and about the same you would get on a Mediterranean diet.

An increase in meat, fish, and poultry can still have relatively low saturated fat depending on the cuts of meat, the type of fish, the parts of poultry as well as the amount consumed. For example, filet mignon, flank steak and London broil are all relatively low in saturated fat, as is chicken breast, turkey breast, and fish. By also emphasizing the vegetables and fruits in the middle of the pyramid and restricting carbohydrates to whole grains, while avoiding sugar and refined carbohydrates the new pyramid is really not that far removed from the old. Moreover, the admonition to eat real food and avoid highly processed and refined foods means fast foods, boxed and canned food products with higher salt content would be consumed less. This is all to the good. The recommendation for more protein also makes sense to maintain muscle mass as the population ages.

In summary the new edition of Dietary Guidelines for Americans does appear a departure from prior editions in the encouragement of an increased proportion of meat, chicken, fish, and whole fat dairy potentially resulting in a higher saturated fat intake. However, with specific cuts of meat, poultry, and portion control, the guidelines stated a low target of 22 grams of saturated fat per day may potentially be met. The increased animal protein may also benefit maintaining muscle mass with age. The admonition to eat real food and avoid ultra-processed and refined food products, chemical additives, food dyes, and increased sodium would mean less fast foods and a healthier diet overall.

Bottom line: If you restrict saturated fat to under 20 grams a day, eat lots of fruits and vegetable, avoid sugar, refined carbohydrates, and ultra-processed foods, either guideline would help optimize the health impact of your diet.

Paul E. Lemanski, MD, MS, FACP (plemanski3@gmail.com) is a board-certified internist practicing internal medicine and lifestyle medicine in Albany, NY. Paul has a master’s degree in human nutrition, he’s an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.