Dietary Guidelines Advisory Committee has completed their review of the
evidence on nutrition and health. The final report reflects the Advisory
Committee’s full examination of the evidence using three rigorous approaches:
data analysis, systematic reviews, and food pattern modeling. The Scientific
Report also includes advice to the United States Departments of Agriculture and
Health and Human Services to consider in the development of the next edition of
the Dietary Guidelines for
Americans. The Advisory Committee’s Scientific
Report is not a “draft” of the next edition of the Dietary Guidelines for
Americans. USDA and HHS will consider the Advisory Committee’s
Scientific Report, along with public and agency comments, as the Departments
develop the 2020-2025
Dietary Guidelines for Americans.
The Vegetarian Resource Group submitted the following comment on the Advisory Committee report
To the U.S.
Department of Agriculture and U.S.
Department of Health and Human Services.
August 7, 2020
Thank you for the opportunity
to submit comments on the Scientific
Report of the 2020 Dietary Guidelines Advisory Committee.
We commend the Committee for
their diligence, especially during this challenging time. We appreciate the
inclusion of additional life stages in this report and support the overall
overarching guidelines (pages 43-45/835).
Since the Committee has made
dietary patterns a centerpiece of their report (according to page 14/835), we
have chosen to focus our comments on the Healthy Vegetarian Pattern.
While we strongly support the
inclusion of a Healthy Vegetarian Pattern as a healthy eating pattern for
Americans, we have concerns with the composition of the dietary pattern. The
food choices in the Healthy Vegetarian Pattern were informed by a survey (page
752/835) that is more than 10 years old and that was based on a single day’s
dietary recall of self-described “vegetarians.” A large portion of the
self-identified “vegetarians” consumed meat, fish, or poultry1 which
prevents their diet intake records from being informative about the composition
of a vegetarian diet which does not include meat, fish, seafood, or poultry.
The aforementioned study
reported that 2.1% of the U.S. population identified themselves as “vegetarian”
and that 3% of the vegetarians did not use any animal products on the day of
the survey.1 In contrast, our
most recent polls indicate that between 3.3% and 6% of the adult and
child/adolescent U.S. population “never eats meat, fish, seafood, or poultry”
and thus would be classified as vegetarian.2-5 Approximately half of these adult vegetarians and a quarter of the child/adolescent
vegetarians “never eat meat, fish, seafood, poultry, dairy products, or eggs”
and thus would be classified as vegan.2-5 Table 1 provides details about the
percentages of vegetarians and vegans in our most recent surveys.
We recommend that additional
research be conducted on the food choices of vegetarians (those who do not eat
meat, fish, and poultry) including vegans (no meat, fish, poultry, dairy
products, eggs) in the United
States and that these results be used to
inform the food choices in the Healthy Vegetarian Pattern. Additional support
for the inclusion of food patterns for those using a vegan diet is found in
Table 2 which presents the results of surveys of U.S. adults’ behavior when eating
out. Many adults eat vegetarian, including vegan meals when they eat out. In
our most recent survey, 46% of U.S. adults who ate vegetarian meals when eating
out chose to eat vegan meals.2 In view of the consistent results of
our polls demonstrating that as many as half of vegetarians do not eat dairy
products or eggs and that those Americans sometimes choosing to eat vegetarian
meals frequently choose to eat vegan meals, we urge the Committee to increase
the flexibility of the Healthy Vegetarian Pattern to include vegan diets. An
additional consideration is the potential health benefits of vegan diets.
Vegan diets are associated
with health benefits, in some cases superior to those of lacto-ovo vegetarian
diets and in some cases similar to those of lacto-ovo vegetarian diets.
- A 15%
lower incidence of cancer in vegans and an 8% lower incidence of cancer in
vegetarians overall compared to nonvegetarians.6
have a lower mean BMI than nonvegetarians (Vegetarians: -1.48 kg/m2;
vegans: -1.72 kg/m2).6
had a 27% lower risk of developing diabetes than did nonvegetarians. This
reduced risk was seen in vegans and in lacto-ovo, lacto, and ovo vegetarians.7
have lower total cholesterol (Vegetarian: -28.16 mg/dL; vegans: -31.02 mg/dL)
and LDL cholesterol (Vegetarians: -21.27 mg/dL; Vegans: -22.87 mg/dL) than
diets, especially vegan diets, effectively promote weight reduction.8
from a nonvegetarian to a vegetarian or vegan diet is associated with a mean
decrease in blood cholesterol concentration of 14 mg/dL and a mean decrease in
LDL concentration of 13 mg/dL. Reductions of this scale correspond to an
estimated 9 to 10.6% decrease in risk of heart disease.9
The current Healthy Vegetarian
Pattern does not include options for those who do not eat eggs. There are many
reasons that consumers choose not to eat eggs including taste preference,
allergies, religious or cultural practices, and other considerations. In order
to provide realistic guidance, options should be provided so that eggs do not
appear as an essential component of the Healthy Vegetarian Pattern. This inclusion
of the egg subgroup seems contrary to the Committee’s statement that “… a
strength of the Food Patterns is that it has a tremendous amount of flexibility
that allows it to be tailored to an individual’s cultural and taste
preferences. This flexibility occurs because the resulting Patterns are only
prescriptive for the larger food groups and subgroups amounts but not
the specific types of foods to be consumed, permitting choices and
options for the consumer.” (page 732/835). Eggs are a specific type of food and alternatives are not
presented which would allow the flexibility of other subgroups. We strongly
recommend that eggs not be in a subgroup unless non-animal-based alternatives
are included in this subgroup.
Similarly, guidance is needed
about alternative sources of the nutrients provided by the dairy group for
those who do not use dairy products. While fortified soy milk is included in
the dairy group, many consumers will not use 3 cups of fortified soy milk
daily. We encourage the Committee to offer other options including increased
use of leafy green vegetables and calcium-fortified foods in addition to soy
milk, such as other plant milks and orange juice, as sources of bioavailable
We note that a study of
Seventh-day Adventists found that lacto-ovo vegetarians, pescatarians, and
semi-vegetarians all consumed smaller amounts of dairy products and eggs than
did nonvegetarians10 suggesting that alternatives to dairy products
and eggs are needed in the Healthy Vegetarian Pattern for those consistently
choosing a vegetarian diet and for those who sometimes choose vegetarian or
vegan meals. We recommend greater flexibility in the Healthy Vegetarian
The Healthy Vegetarian Pattern
has limited use of legumes, a food group with numerous health benefits
including cholesterol-lowering, blood glucose control, and anti-inflammatory
effects.11,12 Currently, on a 2000 calorie meal plan, only 1.5 cups
(6 oz eq) of legumes/week are included as a protein food with an additional 1.5
c eq as vegetables (page 750/835). This is less than a half cup of beans daily.
An older survey of self-defined U.S. vegetarians who did not eat meat on the
day of the survey found that their average consumption of dried beans was about
½ cup daily.13 The inclusion of more legumes in the Protein Foods
Group could allow greater flexibility, especially if the subgroups were
eliminated and the foods in the Protein Foods Group
(soy/nuts/seeds/legumes/eggs) could be chosen at will.
We note that in Table D14.3
(pages 750-751/835), that legumes in the Vegetable Group are measured in cup
eq/wk whereas legumes in the Protein Foods Group are measured in oz eq/wk. We are
concerned that the use of different units of measure (c eq and oz eq) depending
on whether legumes are being counted as a protein or a vegetable will be
confusing to consumers.
The Healthy Vegetarian Pattern
for age 12-24 months only includes guidance for those toddlers not receiving
human milk or infant formula. Although the Committee states that “most infants
in the United States (66 percent) are no longer receiving human milk after age
12 months” (page 429/835), a third of the infants in the United States are receiving human milk after age 12
months and require guidance. Guidance is needed for toddlers who are receiving
some human milk or infant formula and who are being fed according to the
Healthy Vegetarian Pattern.
The Healthy Vegetarian Pattern
for age 12-24 months does not include legumes in the Protein Foods Group and
only a small amount of legumes are included in the Vegetable Group. Legumes can
supply significant amounts of protein, iron, and zinc for toddlers.14
Inclusion of legumes in the Protein Foods Group adds additional flexibility and
increases the likelihood that toddlers will become familiar with foods such as
lentils and garbanzo beans that will eventually play a significant role in
The report states (page
467/835), “Without supplements and/or fortified products, it is not possible to
meet all nutrient goals with a vegan diet at this age [12-24 months]. We agree
that supplements and fortified foods are needed to ensure the adequacy of
nutrients such as vitamin B12 and vitamin D. We question, however, why
fortified foods were not used to develop a vegan food pattern for this age
group. The Committee endorses the use of fortified dairy products to supply
vitamin D and fortified infant cereals to supply iron and zinc, suggesting that
fortified foods are acceptable. Given this acceptance of the used of fortified
foods, it seems reasonable to provide guidance for the use of fortified foods
and supplements by parents/caregivers who want to use a vegan diet for
In addition to the preceding
comments that specifically address the Healthy Vegetarian Pattern, we have comments
on other parts of the Report.
We encourage the Committee to
more broadly consider alternatives in all Patterns. For example, the Committee
notes that 88% of people do not meet recommendations for dairy foods (page
136/836). The Report also notes, “The dietary patterns commonly consumed by
racial-ethnic and cultural groups often have unique characteristics (such as
the lack of dairy intake by some groups) that differ from the Healthy
U.S.-Style Pattern. These differences may cause the patterns from these groups
to appear inadequate because some of the unique foods consumed in these
populations that provide the missing nutrients are not represented in the food
item clusters used in food pattern modeling. It is now, and will become even
more, imperative that dietary guidance reflect dietary patterns of growing
demographic groups, particularly LatinX and Asian populations “(page 800/835).
Use of alternatives, such as leafy green vegetables, tofu, fortified plant
milks in addition to soy milks, could allow the nutrition recommendations to be
more acceptable to a greater spectrum of the American population.
Another example of an area
where more consideration of options should be included is the egg subgroup. All
of the three Patterns include eggs as a subgroup. As discussed previously, this
inclusion seems contradictory to the Committee’s statement that Patterns are
not prescriptive for specific types
of foods consumed. We notice that the Food Pattern Modeling Report15
includes an examination of the effect of increasing
the number of eggs included in the Patterns but does not examine the effect
of decreasing or eliminating eggs and
replacing them with plant-based protein sources in all Patterns. Greater
flexibility in food groups and subgroups seems needed in all Patterns to meet
the needs of those with different cultural, religious, and other influences.
Although the Healthy
Vegetarian Pattern includes legumes as a subgroup in the Protein Foods Group,
the other Healthy Patterns fail to emphasize legumes as a protein source.
Legumes have numerous health benefits.11, 12 Some of these benefits
are illustrated in Table D8.1 (page 513/835). Legumes should be included in all
food patterns as a protein source.
We note that Table D1.4 (page
185/835) should include some additional foods in the last column. Fortified
plant milks and fortified orange juice supply vitamin D and are more readily
available than mushrooms exposed to UV light. Fortified plant milks and dark
green leafy vegetables supply bioavailable calcium. Seaweed is not typically
recommended as an iodine source because their content is variable, and some sea
vegetables provide large amounts of iodine.16
The Report repeatedly
recommends seafood consumption in pregnancy due to the high DHA content of some
seafood. Since DHA consumption is what underlies the potential benefits of
seafood consumption, research that included DHA supplementation can be used to
examine whether increased DHA consumption offers benefits. Benefits of DHA
supplementation in pregnancy are primarily associated with gestational duration
and birth weight. A meta-analysis of 70 randomized controlled trials (RCTs)
found that omega-3 interventions in pregnancy consisting of either supplements
(mainly DHA) or food were associated with a reduced risk of preterm birth
(<37 weeks) and early preterm birth (<34 weeks), a slightly longer
gestational length, and a reduced risk of having a low birthweight infant.17
Omega-3 supplementation in pregnancy was not
associated with significantly improved cognition, IQ, vision, or other
developmental or growth outcomes.16 Approximately 20% of people in
the United States reported no fish or seafood consumption over a 30-day period.18
Guidance is needed throughout the Report for those who avoid fish due to allergies,
cultural influences, preference, or because they are vegetarian or vegan. This
is especially the case for pregnancy and lactation where this Report seemed to
emphasize the consumption of fish.
The Report includes many
excellent ideas for further research including expansion of diversity among
populations studied and the expansion of USDA databases to incorporate
additional foods and beverages from diverse populations” (pages 766-767/835).
We encourage increased sampling of those choosing vegetarian, including vegan,
dietary patterns and the expansion of the USDA databases to incorporate
additional foods commonly eaten by vegetarians, including vegans, especially
fortified foods and replacements for animal-derived products. Additional
research should be conducted, which could be used to inform future vegetarian
food patterns, on the food choices of vegetarians who do not consume meat,
fish, seafood, or poultry and those vegetarians who also do not consume dairy
products and eggs.
We noted the statement in the
Committee’s letter to the Secretaries, “In addition, comments identified the
importance of evaluating sustainability of recommended dietary patterns,
addressing the social and economic aspects of access to foods that are
components of healthy dietary patterns, and considering systemic changes to
encourage behavior change consistent with the guidelines. These comments point
to areas that are important for USDA and HHS to address through appropriate
mechanisms, and their consideration may provide useful approaches for
implementing the recommendations in the Dietary Guidelines for Americans” (page 3/835). We support these comments and
strongly encourage USDA and HHS to address the issues of social and economic
access to foods that are components of healthy dietary patterns and of
including sustainability as an important consideration when recommending
- Juan W, Yamini S, Britten P. Food intake
patterns of self-identified vegetarians among the U.S. population, 2007-2010. Procedia
Food Sci. 2015;4:86-93. doi:10.1016/j.profoo.2015.06.013.
Many Adults in the U.S.
are Vegan? Vegetarian Resource Group. https://www.vrg.org/blog/2020/08/07/how-many-adults-in-the-u-s-are-vegan-how-many-adults-eat-vegetarian-when-eating-out-asks-the-vegetarian-resource-group-in-a-national-poll/ Published August 7, 2020.
- Stahler C. How Many
People are Vegan? How Many Eat Vegan When Eating Out? Vegetarian Resource Group.
https://www.vrg.org/nutshell/Polls/2019_adults_veg.htm Published 2019.
Many Adults in the U.S.
are Vegetarian and Vegan? Vegetarian Resource Group. https://www.vrg.org/nutshell/Polls/2016_adults_veg.htm Published 2016.
Many Teens or Other Youth are Vegetarian or Vegan? Vegetarian Resource Group. https://www.vrg.org/blog/2014/05/30/how-many-teens-and-other-youth-are-vegetarian-and-vegan-the-vegetarian-resource-group-asks-in-a-2014-national-poll/ Published May 30, 2014.
M, Abbate R, Gensini GF, Casini A, Sofi F. Vegetarian, vegan diets and multiple
health outcomes: a systematic review with meta-analysis of observational
studies. Crit Rev Food Sci Nutr.
Y, Park K. Adherence to a vegetarian diet and diabetes risk: a systematic
review and meta-analysis of observational studies. Nutrients. 2017 Jun 14;9(6). pii: E603.
RY, Huang CC, Hu FB, Chavarro JE. Vegetarian diets and weight reduction: a
meta-analysis of randomized controlled trials. J Gen Intern Med.
F, Zheng J, Yang B, Jiang J, Fu Y, Li D. Effects of vegetarian diets on blood
lipids: A systematic review and meta-analysis of randomized controlled trials. J
Am Heart Assoc. 2015;4(10):e002408.
- Orlich MJ, Jaceldo-Siegl K, Sabaté J, Fan J,
Singh PN, Fraser GE. Patterns of food consumption among vegetarians and
non-vegetarians. Br J Nutr. 2014;112(10):1644-1653.
- Messina V. Nutritional and health benefits of
dried beans. Am J Clin Nutr. 2014;100 Suppl 1:437S-42S.
- Pribis P. The role of
legumes in maintaining health. In Craig W, ed. Vegetarian Nutrition and Wellness. Boca Raton, FL:
CRC Press; 2018:1-9.
- Haddad EH, Tanzman JS. What do vegetarians in
the United States
eat? Am J Clin Nutr. 2003;78(3 Suppl):626S-632S. doi:10.1093/ajcn/78.3.626S
- Mangels R, Driggers J. The youngest vegetarians:
Vegetarian infants and toddlers. ICAN:
Infant, Child & Adolescent Nutrition. 2012; 4:8-20.
Dietary Guidelines Advisory Committee and Food Pattern Modeling Team. Food Pattern Modeling: Ages 2 Years and
Older. 2020 Dietary Guidelines Advisory Committee Project. Washington, D.C: U.S. Department of Agriculture.
J, Pino S, Critchley A, Braverman LE. Variability of iodine content in common
commercially available edible seaweeds. Thyroid.
- Middleton P, Gomersall JC, Gould JF, Shepherd E,
Olsen SF, Makrides M. Omega-3 fatty acid addition during pregnancy. Cochrane
Database Syst Rev. 2018;11(11):CD003402. doi:
- Jahns L, Raatz SK, Johnson LK, Kranz S,
Silverstein JT, Picklo MJ. Intake of seafood in the US varies by age, income, and
education level but not by race-ethnicity. Nutrients.