Table of Contents
- Introduction: The Best Guides to a Healthy Diet
- Building MyPyramid and MyPlate
- Dietary Guidelines in the 21st Century: Progress, Not Perfection
- The Problems with MyPyramid and MyPlate
- Building a Better Pyramid and Plate
• The Healthy Eating Pyramid
• The Healthy Eating Plate
- Using the Healthy Eating Pyramid and the Healthy Eating Plate
- Other Alternatives to MyPlate
- Evidence that Following the Healthy Eating Pyramid and Healthy Eating Plate Lowers Disease Risk
Nearly two decades ago, the U.S. Department of Agriculture (USDA) created a powerful icon: the Food Guide Pyramid. This simple illustration conveyed in a flash what the USDA said were the elements of a healthy diet. The Pyramid was taught in schools, appeared in countless media articles and brochures, and was plastered on cereal boxes and food labels.
Tragically, the information embodied in this pyramid didn’t point the way to healthy eating. Why not? Its blueprint was based on shaky scientific evidence, and it barely changed over the years to reflect major advances in our understanding of the connection between diet and health.
The USDA retired the Food Guide Pyramid in 2005 and replaced it with MyPyramid—basically the old Pyramid turned on its side, sans any explanatory text. Critics lambasted the symbol from the get-go for being vague and confusing. So in June 2011, with great fanfare, the USDA replaced its much-maligned MyPyramid with a new simpler food icon, the fruit-and-vegetable rich MyPlate.
The good news is that these changes have dismantled and buried the original, flawed Food Guide Pyramid and its underwhelming MyPyramid successor. The bad news is that the new MyPlate icon, while an improvement over the Food Guide Pyramid and MyPyramid, still falls short on giving people the nutrition advice they need to choose the healthiest diets.
As an alternative to the USDA’s nutrition advice, faculty members at the Harvard School of Public Health built the Healthy Eating Pyramid. It resembles the USDA’s old pyramids in shape only. The Healthy Eating Pyramid takes into consideration, and puts into perspective, the wealth of research conducted during the last 20 years that has reshaped the definition of healthy eating.
Now it’s time to translate that research to your dinner plate: the Healthy Eating Plate. Just as the Healthy Eating Pyramid rectifies the mistakes of the USDA’s food pyramids, the Healthy Eating Plate fixes the flaws in USDA’s MyPlate. Both the Healthy Eating Pyramid and the Healthy Eating Plate are based on the latest science about how our food, drink, and activity choices affect our health.
In the children’s book Who Built the Pyramid?, (1) different people take credit for building the once-grand Egyptian pyramid of Senwosret. King Senwosret, of course, claims the honor. But so does his architect, the quarry master, the stonecutters, slaves, and the boys who carried water to the workers.
The USDA’s pyramids and MyPlate also had many builders. Some are obvious—USDA scientists, nutrition experts, staff members, and consultants. Others aren’t. Intense lobbying efforts from a variety of food industries also helped shape the pyramid and the plate.
In theory, the USDA’s food icons should reflect the nutrition advice assembled in the Dietary Guidelines for Americans. According to the USDA, the guidelines “provide authoritative advice for people two years and older about how good dietary habits can promote health and reduce risk for major chronic diseases.”
This document, which by law must be considered for revision every five years, aims to offer sound nutrition advice that corresponds to the latest scientific research. The government seeks advice from a scientific panel, one that must include nutrition experts who are leaders in pediatrics, obesity, cardiovascular disease, and public health. Selecting the panelists is no easy task, and is subject to intense lobbying from organizations such as the National Dairy Council, the United Fresh Fruit and Vegetable Association, the Soft Drink Association, the American Meat Institute, the National Cattlemen’s Beef Association, the Salt Institute, and the Wheat Foods Council. (2)
The scientific panel generates a report of 400 or so pages of dense nutrition-speak. The USDA and US Department of Health and Human Services use this report to prepare the 100-page Dietary Guidelines for Americans. The process, however, is less than transparent. And the folks who actually write the final guidelines don’t always hew to the scientific panel’s recommendations.
The hefty Dietary Guidelines for Americans document is translated into a reader-friendly brochure aimed at helping the average person choose a balanced and healthy diet. Of far greater importance, the Dietary Guidelines for Americans set the standards for all federal nutrition programs, including the school lunch program, and help determine what food products Americans buy. In other words, the guidelines influence how billions of dollars are spent each year. So even minor changes can hurt or help a food industry and can also have a substantial impact on the health of Americans.
The Dietary Guidelines for Americans evolve with each new version. The Dietary Guidelines for Americans 2010 continues this trend of routine updates. (3) It also continues to reflect the tense interplay of science and the powerful food industry.
Several of the recommendations in the current version represent important steps in the right direction:
- Move to a plant-based diet. The guidelines emphasize eating more foods from plants, such as vegetables and beans, whole grains, and nuts.
- Choose fish twice a week. They encourage Americans to eat more seafood in place of red meat or poultry, acknowledging its special benefits for the heart.
- Not all proteins are equally healthy. They recognize that some protein-rich foods, such as meat, poultry, and eggs, are higher in so-called “solid fats”—the saturated and trans fats that Americans need to cut back on—and recommend replacing them with fish and nuts, or choosing leaner forms of protein.
Other recommendations do not go far enough to reflect the latest nutrition science—or bury key messages:
- Too lax on refined grains. The guidelines say that it’s okay to eat up to half of our bread, cereal, rice, pasta, and other grain foods in their fiber- and nutrient-depleted, refined forms. That’s unfortunate, because in the body, refined grains like white bread and white rice act just like sugar. Over time, eating too much of these refined grain foods can make it harder to control weight, and can raise the risk of heart disease and diabetes.
- Too lenient on red meat and processed meat. High intakes of red meat, such as beef, pork, and lamb, are associated with a higher risk of heart disease, diabetes, and colon cancer. (4–6) Yet nowhere in the guidelines does it say to limit red meat. The guidelines also don’t give adequate warning about the hazards of processed meats, such as bacon and hot dogs, which are even more strongly linked to heart disease and diabetes.
- Too much dairy. The guidelines’ recommendation to increase the intake of low-fat milk and dairy products seems to reflect the interests of the powerful dairy industry more so than the latest science. There is little, if any, evidence that eating dairy prevents osteoporosis or fractures, and there is considerable evidence that high dairy product consumption is associated with increased risk of fatal prostate and maybe ovarian cancers. (Read more about calcium, milk and health.)
Distilling nutrition advice into a pyramid has its merits: The shape immediately suggests that some foods are good and should be eaten often, and that others aren’t so good and should be eaten only occasionally. The layers represent major food groups that contribute to the total diet. MyPyramid tried to do this in an abstract way, without any text or food images on it, and failed. And it forced people to go to a Web site to learn what they should eat. (Read more about the problems with MyPyramid and its predecessor, the original Food Guide Pyramid.)
The MyPlate icon is an improvement over MyPyramid: It shows a circle divided into four brightly-colored wedges, each labeled with the name of a food group. Vegetables (green) and fruits (red) take up half the plate. Proteins (purple) and grains (brown) each get one quarter of the plate. Just off to the side is a smaller blue circle for dairy products, looking a bit like a glass of milk or a cup of yogurt. A fork and placemat complete the place setting.
The MyPlate icon nudges Americans to put more produce on their plates, but it still falls short on giving people all the nutrition advice they need to choose the healthiest diets. And as a shorthand version of the US government’s nutrition advice, MyPlate suffers from the Dietary Guidelines for Americans 2010’s shortcomings, as well.
MyPlate does not show that whole grains are a better choice than refined grains, for example, or that beans, nuts, fish, and chicken are healthier choices than red meat. Healthy fats—key to heart health and to lowering the risk of diabetes—do not appear at all on the plate or the table. Yet dairy is given a prominent place right next to the plate, despite evidence that high intakes of dairy products do not reduce the risk of osteoporosis and may increase the risk of some chronic diseases. Perhaps the greatest problem is that MyPlate is silent on the large portion of the US diet that’s junk: sugary drinks, sweets, salty processed foods, refined grains, and the like.
If the only goal of the USDA’s food icons is to give us the best possible advice for healthy eating, then they should be grounded in the evidence and be independent of commercial interests.
Instead of waiting for this to happen, nutrition experts from the Harvard School of Public Health created the Healthy Eating Pyramid, and updated it in 2008. And in September 2011, working with colleagues at Harvard Health Publications, they created the Healthy Eating Plate.
The Healthy Eating Pyramid and the Healthy Eating Plate are based on the best available scientific evidence about the links between diet and health. They fix fundamental flaws in the USDA food pyramids and plate and offer sound information to help people make better choices about what to eat. (View a large PDF image of the Healthy Eating Pyramid, in a separate window; view a large PDF image of the Healthy Eating Plate, in a separate window.)
The Healthy Eating Pyramid sits on a foundation of daily exercise and weight control. Why? These two related elements strongly influence your chances of staying healthy. They also affect what you eat and how your food affects you.
Exercise and weight control are also linked through the simple rule of energy balance: Weight change = calories in – calories out. If you burn as many calories as you take in each day, there’s nothing left over for storage in fat cells, and weight remains the same. Eat more than you burn, though, and you end up adding fat and pounds. Regular exercise can help you control your weight, and it is a key part of any weight-loss effort.
The other bricks of the Healthy Eating Pyramid include the following:
The body uses carbohydrates mainly for energy, and it can get them from many sources—some healthful (beans, vegetables, fruit, whole grains), and some not (sugary sodas and other drinks, sweets). The best grain sources of carbohydrates are whole grains such as oatmeal, whole wheat bread, and brown rice. They deliver the outer (bran) and inner (germ) layers along with energy-rich starch. The body can’t digest whole grains as quickly as it can highly processed carbohydrates such as white flour. This keeps blood sugar and insulin levels from rising, then falling, too quickly. Better control of blood sugar and insulin can keep hunger at bay and prevent the development of type 2 diabetes and heart disease.
Healthy Fats and Oils
Surprised that the Healthy Eating Pyramid puts some fats near the base, indicating they are okay to eat? Although this recommendation seems to go against conventional wisdom, it’s exactly in line with the evidence and with common eating habits. The average American gets one-third or more of his or her daily calories from fats, so placing them near the foundation of the pyramid makes sense. Note, though, that it specifically mentions healthy fats and oils, not all types of fat. Good sources of healthy unsaturated fats include olive, canola, soy, corn, sunflower, peanut, and other vegetable oils; trans fat–free margarines; nuts, seeds, and avocados; and fatty fish such as salmon. These healthy fats not only improve cholesterol levels (when eaten in place of highly processed carbohydrates), but the fats in fish can also protect the heart from sudden and potentially deadly rhythm problems.
Vegetables and Fruits
A diet rich in vegetables and fruits has bountiful benefits. Among them: It can decrease the chances of having a heart attack or stroke; possibly protect against some types of cancers; lower blood pressure; help you avoid the painful intestinal ailment called diverticulitis; guard against cataract and macular degeneration, the major causes of vision loss among people over age 65; and add variety to your diet and wake up your palate. On the Healthy Eating Pyramid, potatoes don’t count as a vegetable, since they are chock full of rapidly digested starch, and they have the same effect on blood sugar as refined grains and sweets. That’s why potatoes are in the “Use Sparingly” tip.
Nuts, Seeds, Beans, and Tofu
These plant foods are excellent sources of protein, fiber, vitamins, and minerals. Beans include black beans, navy beans, garbanzos, lentils, and other beans that are usually sold dried. Many kinds of nuts contain healthy fats, and packages of some varieties (almonds, walnuts, pecans, peanuts, hazelnuts, and pistachios) can carry a label saying they’re good for your heart. Eating nuts and beans in place of red meat or processed meat can lower the risk of heart disease and diabetes.
Fish, Poultry, and Eggs
These foods are also important sources of protein. A wealth of research suggests that eating fish can reduce the risk of heart disease, since fish is rich in heart-healthy omega-3 fats. Chicken and turkey are also good sources of protein and can be low in saturated fat. Eggs, which have long been demonized because they contain fairly high levels of cholesterol, aren’t as bad as they’ve been cracked up to be. In fact, an egg is a much better breakfast than a doughnut cooked in an oil rich in trans fats or a bagel made from refined flour. People with diabetes or heart disease should limit their egg yolk consumption to no more than three a week; they can try egg whites, instead, which are very high in protein and are a fine substitute for whole eggs in omelets and baking.
Dairy (1 to 2 Servings Per Day) or Vitamin D/Calcium Supplements
Building bone and keeping it strong takes calcium, vitamin D, exercise, and a whole lot more. So why does the Healthy Eating Pyramid recommend limiting dairy products, which have traditionally been Americans’ main source of calcium and vitamin D? Because most people need more vitamin D than they can get from drinking three glasses of milk—and they need less calcium than three glasses of milk provide. Though there are some health benefits from modest dairy intake, high dairy intakes are associated with increased risk of fatal prostate and maybe ovarian cancers. There are other healthier ways to get calcium than from milk and cheese, which can contain a lot of saturated fat; cheese is also high in sodium. If you enjoy dairy foods, stick to one to two servings a day; you may also need to take a multivitamin or vitamin D supplement to get enough vitamin D. If you don’t like dairy products, taking a vitamin D and calcium supplement (or taking the right multivitamin) offers an easy and inexpensive way to meet your needs for these micronutrients.
Use Sparingly: Red Meat, Processed Meat, and Butter
These foods sit at the top of the Healthy Eating Pyramid because they contain lots of saturated fat. Processed meats, such as bacon, hot dogs, and deli meats are also very high in added sodium. Eating a lot of red meat and processed meat has been linked to increased risk of heart disease, diabetes, and colon cancer. So it’s best to avoid processed meat, and to limit red meat to no more than twice a week. Switching to fish, chicken, nuts, or beans in place of red meat and processed meat can improve cholesterol levels and can lower the risk of heart disease and diabetes. So can switching from butter to olive oil. And eating fish has other benefits for the heart.
Use Sparingly: Refined Grains—White Bread, Rice, and Pasta; Potatoes; Sugary Drinks and Sweets; Salt
Why are these all-American staples at the top, rather than the bottom, of the Healthy Eating Pyramid? White bread, white rice, white pasta, other refined grains, potatoes, sugary drinks, and sweets can cause fast and furious increases in blood sugar that can lead to weight gain, diabetes, heart disease, and other chronic disorders. Whole grains cause slower, steadier increases in blood sugar that don’t overwhelm the body’s ability to handle carbohydrates.
The salt shaker should be used sparingly, based on extensive research linking high-sodium diets to increased risk of heart attack and stroke. Since most of the sodium in our diets comes from processed foods, such as cheese, breads, deli meats, spaghetti with sauce, and food prepared away from home, make sure to compare food labels and choose foods with the lowest sodium values.
Multivitamin with Extra Vitamin D (for Most People)
A daily multivitamin, multimineral supplement offers a kind of nutritional backup, especially when it includes some extra vitamin D. While a multivitamin can’t in any way replace healthy eating, or make up for unhealthy eating, it can fill in the nutrient holes that may sometimes affect even the most careful eaters. You don’t need an expensive name-brand or designer vitamin. Look for a multivitamin that meets the requirements of the USP (U.S. Pharmacopeia), an organization that sets standards for drugs and supplements. A standard, store-brand, RDA-level one is fine for most nutrients—except vitamin D. In addition to its bone-health benefits, there’s growing evidence that getting some extra vitamin D can help lower the risk of colon and breast cancer. Aim for getting at least 800 to 1,000 IU (international units) of vitamin D per day; multiple vitamins are now available with this amount. (Many people, especially those who spend the winter in the northern U.S. or have darker skin, will need extra vitamin D, often a total of 2,000 IU per day or more, to bring their blood levels up to an adequate range. If you fall into one of these groups, which would include most of the U.S. population, taking 2,000 IU is reasonable and well within the safe range. As always, it’s a good idea to discuss use of supplements with your doctor, and he or she may want to order a vitamin D blood test.)
Optional: Alcohol in Moderation (Not for Everyone)
Scores of studies suggest that having an alcoholic drink a day lowers the risk of heart disease. Moderation is clearly important, since alcohol has risks as well as benefits. For men, a good balance point is one to two drinks a day; in general, however, the risks of drinking, even in moderation, exceed benefits until middle age. For women, it’s at most one drink a day; women should avoid alcohol during pregnancy.
Focus on Food Quality
You’ll notice that the Healthy Eating Pyramid does not give specific advice about the numbers of cups or ounces to have each day of specific foods. That’s because it’s not meant to be a rigid road map, and the amounts can vary depending on your body size and physical activity. It’s a simple, general, flexible guide to how you should eat when you eat.
To follow the Healthy Eating Pyramid, there’s just one basic guideline to remember: A healthy diet includes more foods from the base of the pyramid than from the higher levels of the pyramid. Within this guideline, however, there’s plenty of flexibility for different styles of eating and different food choices. A vegetarian can follow the Healthy Eating Pyramid by emphasizing nuts, beans, and other plant sources of protein, and choosing non-dairy sources of calcium and vitamin D; someone who eats animal products can choose fish or chicken for protein, with occasional red meat.
Choosing a variety of fresh, whole foods from all the food groups below the “Use Sparingly” category in the Healthy Eating Pyramid will ensure that you get the nutrients you need. It will also dramatically lower your salt intake, since most of the salt in the U.S. diet lurks in processed food—canned soups, frozen dinners, deli meats, snack chips, and the like.
Perhaps the only foods that are truly off-limits are foods that contain trans fat from partially hydrogenated oils. Luckily, in the U.S. and Canada, trans fats must be listed on nutrition labels. More and more food manufacturers, restaurants, and even entire communities are going trans fat–free, making it easier to avoid this health-damaging type of fat.
When it’s time for dinner, most of us eat off of a plate. So think of the Healthy Eating Plate as a blueprint for a typical meal, for yourself and your family. It’s similar in concept to MyPlate, with colorful quadrants reserved for vegetables (green), fruits (red), protein (orange), and grains (brown). But unlike MyPlate, it offers important messages about diet quality, not just quantity:
- Fill half of your plate with vegetables and fruits. The more color, and the more variety, the better. Most Americans don’t get enough vegetables, especially the dark green and red-orange types, or fruits. On the Healthy Eating Plate, just like the Healthy Eating Pyramid, potatoes and French fries don’t count as vegetables.
- Save a quarter of your plate for whole grains—not just any grains: MyPlate tells you to reserve a quarter of your plate for grains. But grains are not essential for good health. What’s essential is to make any grains you eat whole grains, since these have a gentler effect on blood sugar and insulin than refined grains. Whole grains include whole wheat, brown rice, oats, barley, and the like, as well as foods made with them, such as whole wheat pasta. The less processed the whole grains, the better: Finely ground grain is more rapidly digested, and in turn, has a greater impact on blood sugar than more coarsely ground or intact grains. So choose steel cut oats instead of instant, sugared oats or choose whole wheatberries instead of whole wheat bread.
- Pick a healthy source of protein to fill one quarter of your plate: On MyPlate, the “protein” quadrant of the plate could be filled with a hamburger or hot dog. The Healthy Eating Plate, in contrast, acknowledges that some protein sources (fish, chicken, beans, nuts) are healthier than others (red meat and processed meat).
- Enjoy healthy fats. The glass bottle near the Healthy Eating Plate is a reminder to use healthy oils, like olive and canola, in cooking, on salad, and at the table. Limit butter, and avoid unhealthy trans fats. Though the Dietary Guidelines for Americans 2010 acknowledges that Americans need to consume more plant oils, these healthy oils are nowhere to be found on MyPlate.
- Drink water, coffee or tea. On the Healthy Eating Plate, complete your meal with a glass of water, or if you like, a cup of tea or coffee (which also are low calorie and have health benefits)—not the glass of milk that MyPlate recommends. (Questions about caffeine and kids? Read more.) Limit milk and dairy products to one to two servings per day and limit juice to a small glass per day. Skip the sugary drinks.
- Stay active. The figure scampering across the bottom of the Healthy Eating Plate’s placemat is a reminder that staying active is half of the secret to weight control. The other half is eating a healthy diet with modest portions that meet your calorie needs. Since two out of three U.S. adults and one in three children are overweight or obese, one thing is clear: Many of us have been choosing plates that are too large.
The Healthy Eating Pyramid and the Healthy Eating Plate complement each other. Both emphasize foods that promote good health. And both encourage people to limit or avoid foods and drinks that are harmful, or that provide lots of calories but have little nutritional value.
Think of the Healthy Eating Pyramid as your grocery list: Vegetables, fruits, whole grains, healthy oils, and healthy proteins like nuts, beans, fish, and chicken should make it into your shopping cart every week. Add a little yogurt or milk if you like. Skip the soda and snack food aisle, the deli counter, and the steaks and chops at the butcher counter.
Let the Healthy Eating Plate be your guide to planning a healthy, balanced meal and serving it on a dinner plate—or packing it in a lunch box. Put a copy on the refrigerator at home or at work, to give you a visual guide to portioning out a healthy plate, and a reminder to pump up the produce.
The Healthy Eating Pyramid also addresses other aspects of a healthy lifestyle—exercise, weight control, vitamin D and multivitamin supplements, and moderation in alcohol for people who drink—so it’s a useful tool for health professionals and health educators.
The Healthy Eating Pyramid and the companion Healthy Eating Plate summarize the best dietary information available today. They aren’t set in stone, though, because nutrition researchers will undoubtedly turn up new information in the years ahead. The Healthy Eating Pyramid and the Healthy Eating Plate will change to reflect important new evidence.
The Healthy Eating Pyramid and the Healthy Eating Plate aren’t the only alternatives to the USDA’s MyPlate. The Asian, Latin, Mediterranean, and vegetarian pyramids promoted by Oldways Preservation and Exchange Trust are also good, evidence-based guides for healthy eating. The Healthy Eating Pyramid and the Healthy Eating Plate take advantage of even more extensive research and offer a broader guide that is not based on a specific culture. The original Healthy Eating Pyramid is described in greater detail in Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy Eating, by Walter C. Willett, M.D. (the Fredrick John Stare Professor of Epidemiology and Nutrition in the Departments of Nutrition and Epidemiology at Harvard School of Public Health) with Patrick J. Skerrett (published by Simon & Schuster, 2001, and Free Press, 2005).
What’s the payoff for following the Healthy Eating Pyramid and Healthy Eating Plate? A lower risk of heart disease and premature death, according to research done at Harvard School of Public Health and elsewhere. (7–9)
Back in the 1990s, the USDA’s Center for Nutrition Policy and Promotion created the Healthy Eating Index “to measure how well American diets conform to recommended healthy eating patterns.” (10) A score of 100 meant following the federal recommendations (including those of the original USDA Food Guide Pyramid) to the letter while a score of 0 meant totally ignoring them.
To see how well the principles embodied in the Healthy Eating Pyramid stacked up against the government’s advice, Harvard School of Public Health researchers created an Alternate Healthy Eating Index with a scoring system similar to the USDA’s index. They then compared the two indexes, using information about daily diets collected from more than 100,000 female nurses and male health professionals taking part in two long-term studies.
Men who scored highest on the USDA’s original Healthy Eating Index (meaning their diets most closely followed federal recommendations) reduced their overall risk of developing heart disease, cancer, or other chronic disease by 11 percent over 8 to 12 years of follow-up compared to those who scored lowest. Women who most closely followed the government’s recommendations were only 3 percent less likely to have developed a chronic disease. (6) In comparison, scores on the Alternate Healthy Eating Index created at the Harvard School of Public Health did appear to correlate more closely with better health in both sexes. Men with high scores (those whose diets most closely followed the Healthy Eating Pyramid guidelines) were 20 percent less likely to have developed a major chronic disease than those with low scores. Women with high scores lowered their overall risk by 11 percent. Men whose diets most closely followed the Healthy Eating Pyramid lowered their risk of cardiovascular disease by almost 40 percent; women with high scores lowered their risk by almost 30 percent.
Two recent studies offer further evidence of the disease prevention benefits that accrue from following a diet similar to the Healthy Eating Pyramid: A study that tracked 7,319 British civil servants for 18 years found that men and women with the highest scores on the Alternate Healthy Eating Index had a 25 percent lower risk of dying from any cause, and a 42 percent lower risk of dying from heart disease, than people with the lowest scores. (7) Another observational study in 93,676 post-menopausal women found that following a Healthy Eating Pyramid–style diet (as measured by adherence to the Alternative Healthy Eating Index) was superior to following a low-fat diet at lowering cardiovascular disease and heart failure risk. (8)
1. Hooper M, Heighway-Bury R. Who Built the Pyramid? Cambridge, Mass.: Candlewick Press, 2001.
2. Abboud L. Expect a food fight as U.S. sets to revise diet guidelines. Wall Street Journal: August 8, 2003, B1
3. U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010. Accessed September 7, 2011.
4. Bernstein AM, Sun Q, Hu FB, Stampfer MJ, Manson JE, Willett WC. Major dietary protein sources and risk of coronary heart disease in women. Circulation. 2010;122:876–83.
5. Pan A, Sun Q, Bernstein AM, et al. Red meat consumption and risk of type 2 diabetes: 3 cohorts of U.S. adults and an updated meta-analysis. Am J Clin Nutr. 2011 Aug 10. [Epub ahead of print]
6. World Cancer Research Fund, American Institute for Cancer Research. Continuous Update Project Report Summary. Food, Nutrition, Physical Activity, and the Prevention of Colorectal Cancer. 2011.
7. McCullough ML, Feskanich D, Stampfer MJ, et al. Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance. Am J Clin Nutr. 2002;76:1261–71.
8. Akbaraly TN, Ferrie JE, Berr C, et al. Alternative Healthy Eating Index and mortality over 18 y of follow-up: results from the Whitehall II cohort. Am J Clin Nutr. 2011;94:247–53.
9. Belin RJ, Greenland P, Allison M, et al. Diet quality and the risk of cardiovascular disease: the Women’s Health Initiative (WHI). Am J Clin Nutr. 2011;94:49–57.
10. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. The Healthy Eating Index (PDF). 1995. Accessed on September 7, 2011.
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