Modeling Qeustion:

Appendix E-3.7: Developing Vegetarian and Mediterranean-style Food Patterns

Scientific Report of the 2015 Dietary Guidelines Advisory Committee 1

Developing Vegetarian and Mediterranean-style Food Patterns

RESEARCH QUESTION

Using the Food Pattern Modeling process, can healthy eating patterns for vegetarians and for

those who want to follow a Mediterranean-style diet be developed? How do these patterns differ

from the USDA Food Patterns previously updated for the 2015 DGAs?

BACKGROUND

Over time, the USDA Food Patterns have represented the types and amounts of foods that will

provide sufficient nutrients to meet IOM nutrient recommendations and Dietary Guidelines for

Americans recommendations, within calorie needs, for all age/sex groups 2 years of age and

older. They are updated every five years during the deliberations of the Dietary Guidelines

Advisory Committee, and are presented to the Committee for their assessment of how well the

Patterns meet their goals. As part of the update, amounts recommended from each food group

may be modified to reach all or most of the specified goals. See the food pattern modeling report

Adequacy of the USDA Food Patterns (Appendix E3.1 of the 2015 Dietary Guidelines Advisory

Committee Report) for detailed information on the development and evaluation of the overall

USDA Food Patterns.

In 2010, vegetarian adaptations of the Patterns were developed at the request of the DGAC and

included in the 2010 DGA policy document. These did not modify the underlying structure of

the patterns, but rather substituted plant-based foods for animal-based foods at the same overall

intake level for each food group.

For 2015 an emphasis of the DGAC has been on identifying evidence-based dietary patterns.

The 2010 DGA stated that there is more than one way in which to consume a healthful diet, and

the evidence to support this message has expanded with time. In keeping with this growing

emphasis in the DGA, the recommended food patterns should illustrate more than one approach

to consuming a healthful diet. The dietary patterns reviewed by the 2015 DGAC, including

those identified in the NEL Dietary Patterns Systematic Review Project, has indicated evidence

for health benefits of following a Mediterranean-style diet (Med-style) and for following a

vegetarian diet, in addition to following a Healthy US-style pattern typified by the DASH diet

and the USDA Food Patterns (Nutrition Evidence Library, 2014). The 2015 DGAC has explored

quantitative information about the food group content of the Med-style and vegetarian patterns,

making it feasible, for the first time, to use that information as the basis of food patterns that

reflect Vegetarian and Med-style diets.

Plan for Food Pattern Modeling Analysis

Therefore, this modeling analysis will identify Vegetarian and Med-style eating patterns and use

them as the basis for 2 new Patterns related to but different from the original USDA Food

Patterns (the Healthy US-style Patterns): Healthy Vegetarian Patterns, and Healthy Med-style

Patterns. All 3 patterns are considered to be USDA Food Patterns

Appendix E-3.7: Developing Vegetarian and Mediterranean-style Food Patterns

Scientific Report of the 2015 Dietary Guidelines Advisory Committee 2

1. Healthy U.S.-style Patterns. The existing USDA Food Patterns are very similar to DASH

diets, which have been studied extensively in the U.S. The current USDA Food Patterns

will be called “Healthy U.S.-style Patterns” to more clearly identify them. They are similar

to evidence-based diets and have been shown to meet almost all nutrient

recommendations. They are based on nutrient-dense versions of current consumption patterns

in the US, and recommendations for food group intake remain within the broad distribution

of current consumption.

2. Healthy Vegetarian Patterns. Vegetarian diets have been documented to provide health

benefits, but are often described by what is not consumed, and so it has been difficult to

identify what actually is consumed. Recent analysis of self-identified (SI) vegetarians in

NHANES allows us to build a vegetarian food pattern based on evidence rather than

conjecture. These Patterns will build on reported intakes of vegetarians in NHANES rather

than on descriptions from research studies considered by the DGAC. As such, these specific

intake levels have not been identified as having health benefits. Therefore, adequacy of the

Healthy Vegetarian Patterns will be based on meeting the same nutrient standards met by the

Healthy US-style Patterns.

3. Healthy Med-style Patterns. The diets characterized by research as “Mediterranean” have

some similarities to the Healthy US-style Patterns but some notable differences as well.

These Patterns will be based on studies that have reported estimates of food group intake

from population groups scoring high on Mediterranean-diet (Med-diet) indexes. While

nutrient levels will be calculated, determining the adequacy of the Med-style Patterns will

primarily be based on similarity to food group intakes of the population groups with positive

health outcomes.

METHODS

The types of information about food group intakes by vegetarians and those following a Med-

style diet differ, so the approaches to creating these patterns will be presented separately.

Healthy Vegetarian Food Patterns

 Review data on food group intakes from analysis of SI vegetarian’s diets, from NHANES

2007-10, to select foods to include/exclude in Vegetarian Patterns (Juan et al., 2014). Select

the types of foods to include and exclude based on the most typical choices of SI vegetarians.

Identify how the average amounts consumed of each food group or subgroup differ from the

non-vegetarians in the NHANES sample.

 Using an iterative process and the information above, determine amounts from each food

category that could be included to meet nutrient goals in the Food Patterns at 12 calorie

levels. Balance calories by adjusting amounts of oils, solid fats, and added sugars as

appropriate.

Appendix E-3.7: Developing Vegetarian and Mediterranean-style Food Patterns

Scientific Report of the 2015 Dietary Guidelines Advisory Committee 3

 Assess nutrient adequacy of the Food Patterns in comparison to Dietary Reference Intakes

and 2010 Dietary Guidelines recommendations.

Med-Style Food Patterns

 Review data from Dietary Patterns Composition project on food group intakes for studies

assessing diets with a Med-diet index. Compare range of food group intakes to the food

group amounts in the Healthy US-Style Food Patterns.

 Select food groups for modification and the range of amounts of each food group to include

in initial analysis. Using an iterative process, adjust the amounts to provide smooth

transitions across calorie levels Determine the calories and nutrients in the Patterns at 12

calorie levels with varying amounts from each food group. Balance calories by adjusting

amounts of oils, solid fats, and added sugars as appropriate.

 Compare nutrients in the Food Patterns to Dietary Reference Intakes and 2010 Dietary

Guidelines. Working with the DGAC, determine to what extent nutrient standards for

Patterns may be modified for Med-Style patterns.

RESULTS

Development of the Healthy Vegetarian Patterns

Over 90% of SI vegetarians consumed dairy products on the day of the NHANES survey, and

65% of them consumed eggs. Dairy and egg quantities consumed did not differ significantly

between SI vegetarians and non-vegetarians. As such, a lacto-ovo vegetarian pattern was

modeled. Much smaller percentages reported consuming other animal products, and those who

did report consumption ate significantly less than non-vegetarians (Juan et al., 2014) Food group

intake of SI vegetarians from NHANES 2007-10, in comparison to non-vegetarians and amounts

in the USDA Food Patterns, is shown in table 1 and figure 1.

Table 1. Reported food group intake by SI vegetarians and non-vegetarians, from NHANES

2007-10, in comparison to amounts in USDA Food Pattern at 2000 calories. (Juan et al., 2014)

Food groups and

subgroups (unit)

% of SI

vegetarians

reporting food

from group

Amounts

reported by SI

vegetarians

Amounts

reported by Non-

vegetarians

Amount in

USDA 2000

kcal pattern

Meat (oz equiv.)

27%

0.67*

2.57

1.8

Poultry (oz equiv.)

21%

0.68*

1.45

1.5

Seafood (oz equiv.)

18%

0.42

0.53

1.2

Eggs (oz equiv.)

65%

0.41

0.47

0.4

Dairy (cup equiv.)

93%

1.65

1.79

Fruits (cup equiv.)

1.21

1.05

Appendix E-3.7: Developing Vegetarian and Mediterranean-style Food Patterns

Scientific Report of the 2015 Dietary Guidelines Advisory Committee 4

Vegetables (cup equiv.)

1.49

1.4

2.5

Legumes (cup equiv.)

0.2*

0.1

0.21

Soy (oz equiv.)

0.32*

0.1

Nuts and Seeds

0.64

0.55

0.6

Grains (oz equiv.)

7.05

6.43

Whole grains (oz equiv.)

1.23*

0.7

Solid fats (grams)

28.9*

38.13

Added sugars (grams)

63.2*

76.9

*Significantly different from non-vegetarians p< 0.05

Figure 1. Mean reported intake from Protein Foods subgroups by SI vegetarians in comparison

to non-vegetarians (Juan et al., 2014)

Although SI vegetarians did report consuming some meat, poultry, and seafood, these foods were

not included in the Patterns. SI vegetarians consumed significantly more soy products and

legumes than non-vegetarians. Amounts of these foods were increased substantially. They also

reported slightly more nuts and seeds, and whole and total grains, so amounts in the Patterns

were increased to a lesser extent. Amounts of fruits, vegetables, and dairy consumed by SI

0.5

1.5

2.5

Meat (oz

equiv.)

Poultry (oz

equiv.)

Seafood (oz

equiv.)

Eggs (oz

equiv.)

Soy (oz

equiv.)

Legumes (oz.

equiv.)

Nuts and

seeds

Ounce equivalents

Self-identified

vegetarians

Non-vegetarians

USDA 2000 kcal pattern

Appendix E-3.7: Developing Vegetarian and Mediterranean-style Food Patterns

Scientific Report of the 2015 Dietary Guidelines Advisory Committee 5

vegetarians were only slightly different from non-vegetarians, and amounts in the Patterns were

already considerably higher than amounts reported by SI vegetarians, and so were not changed.

In the soy foods subgroup, most consumption by non-vegetarians is from processed soy

products, such as soy protein isolate, incorporated into a wide variety of manufactured foods.

For the Vegetarian Patterns, increased consumption of tofu was used to increase the total amount

of soy products in the Patterns, rather than increasing the processed soy component.

Development of the Med-style Patterns

Quantitative data on food group consumption from studies using a Mediterranean dietary index

score was available for 7 cohorts and 2 interventions, almost all in Europe. For use in the Dietary

Patterns Composition analysis, consumption data was selected for the groups with a high Med-

diet index score and positive health outcomes. These data were converted into grams of food

group intake per 1000 calories, to standardize them. For most food groups, the range of intakes

was wide. Table 2 presents the range of intakes and the median intake for each food group from

the studies that assessed dietary patterns using a Med-diet index. It also shows the amounts in

USDA Food Patterns for adults, also converted to grams per 1000 calories, for comparison.

Table 2. Reported food group intake by populations with positive health outcomes, from studies

using Med-Diet indexes to assess intake, in comparison to amounts in USDA Food Pattern, in

grams per 1000 calories.

Food groups and

subgroups

Range of intakes

across studies

Median intake

in studies

Amounts in USDA

Food Pattern

g/1000 kcal

Vegetables (incl. legumes)

121-195

161

156-174

Fruits

88-185

156

96-125

Grains/ cereals

20-135

89-101

Red/processed meat

41-89

25-28

Fish and seafood

22-49

16-20

Total dairy

99-214

152

194-258

Oils

10-24

13-14

Amounts of fruit, seafood and red/processed meats are notably higher in the diets with high Med

diet scores than in the USDA Patterns. Amounts of dairy are notably lower. While grains are

somewhat lower, there is little consistency in what may have been included in this category

among the studied diets. Therefore, this food group was not considered for change. Also, the

red and processed meat category intakes are notably higher than in the current USDA Patterns,

but these were not considered for change. The saturated fat and sodium (in processed meats) in

the US make this category inappropriate to increase. However, because of the increase in

seafood, the overall amount of Protein Foods was increased in the Med-Style Patterns. In

Appendix E-3.7: Developing Vegetarian and Mediterranean-style Food Patterns

Scientific Report of the 2015 Dietary Guidelines Advisory Committee 6

contrast, the total amount of Protein Foods in the Vegetarian Patterns was substantially less than

in the other Patterns.

Healthy Vegetarian and Healthy Med-style Patterns

Using the information summarized above, Healthy Vegetarian and Healthy Med-style Patterns

were developed at 12 calorie levels. These Patterns, and the Healthy US Style Patterns, reflect

three different approaches to consuming a healthy diet. The food group composition of these

Patterns at the 2000 calorie level are shown in Table 3. The composition of the Patterns at all

calorie levels are provided in additional Tables E3.7.A1 and E3.7.A2.

Table 3. Composition of the Healthy Vegetarian and Healthy Med-style Patterns, and Healthy

US Patterns, at the 2000 calorie level. Food group amounts per day, unless noted per week.

Food Group/subgroup

(units)

Healthy US

Patterns

Healthy Vegetarian

Patterns

Healthy Med-style

Patterns

Fruits (cup eq)

2.5

Vegetables (cup eq)

2.5

Dark Green

1.5/wk

Red/Orange

5.5/wk

Starchy

5/wk

Legumes

1.5/wk

3/wk*

1.5/wk

Other

4/wk

Grains (oz eq)

6.5

Whole

3.5

Refined

Dairy (cup eq)

Protein Foods (oz eq)

5.5

3.5

6.5

Meats (red and processed)

12.5/wk

Poultry

10.5/wk

Seafood

8/wk

15/wk

Eggs

3/wk

Nuts/seeds

4/wk

7/wk

4/wk

Processed Soy (incl. tofu)

0.5/wk

8/wk

0.5/wk

Oils (grams)

Solid fats limit (grams)

Added sugars limit (grams)

*Total amount, includes amount counted toward protein foods.

The nutrient content of these Patterns at the 2000 calorie level is presented in table 4. Nutrient

content of the Patterns at all calorie levels are in additional Tables E3.7.B1 and E3.7.B2. For

many nutrients, the amounts in all three Patterns are similar and meet nutritional

recommendations. The comparison of the nutrients to goals and limits for each calorie level are

in additional Tables E3.7.C1 and E3.7.C2.

Appendix E-3.7: Developing Vegetarian and Mediterranean-style Food Patterns

Scientific Report of the 2015 Dietary Guidelines Advisory Committee 7

Table 4. Selected nutrients in the Healthy Vegetarian, Healthy Med-Style, and Healthy US-

Style Patterns, at the 2000 calorie level as a percent of the RDA for a female 19-50 years of age.

Pattern

Healthy Vegetarian

Healthy Med-style

Healthy US-style

Macronutrients

Protein

71g

89 g

91 g

% of RDA

155%

194%

198%

% of calories

14%

18%

Total lipid (fat)

75 g

72 g

% of calories

34%

32%

33%

Carbohydrate

274g

259 g

256 g

% of RDA

211%

199%

197%

% of calories

55%

52%

51%

Fiber, total dietary

35g

31 g

% of goal (14 g/1000 kcal)

126%

112%

109%

Minerals

Calcium

1333mg

1001 mg

1274 mg

% of RDA

133%

100%

127%

Iron

17 mg

% of RDA

96%

95%

93%

Magnesium

374mg

352 mg

% of RDA

121%

113%

114%

Potassium

3311 mg

3353 mg

3348 mg

% of AI

70%

71%

Sodium

1405 mg

1685 mg

1787 mg

% of UL

61%

73%

78%

Vitamins

Vitamin A (in µg RAE)*

869 µg

815 µg

898 µg

% of RDA

124%

116%

128%

Vitamin E (in mg AT)

10.8mg

10.5 mg

10.2 mg

% of RDA

72%

70%

68%

Vitamin C

116mg

134 mg

117 mg

% of RDA

155%

178%

155%

Vitamin D (in IU)

223 IU

251 IU

274 IU

% of RDA

37%

42%

46%

Folate (in µg DFE)

667 µg

592 µg

586 µg

% of RDA

167%

148%

146%

Choline

283 mg

345 mg

349 mg

% of AI

66%

81%

82%

Fatty Acids

Saturated fatty acids

18.6 g

18.0 g

18.7 g

% of calories

*Includes vitamin A precursors

Appendix E-3.7: Developing Vegetarian and Mediterranean-style Food Patterns

Scientific Report of the 2015 Dietary Guidelines Advisory Committee 8

Note: Results for all nutrients at all calorie levels are provided in additional Tables E3.7.B1,

E3.7.B2, E3.7.C1, and E3.7.C2.

In the Healthy Vegetarian Pattern at 2000 calories, amounts of protein, vitamin D, sodium,

cholesterol, and choline are lower than the Healthy US Pattern, while fiber and folate are higher,

mainly due to the increased amount of legumes. Calcium is also somewhat higher in the

Vegetarian Pattern. This is because in addition to the calcium from dairy and other food groups,

the nutrient profile for processed soy products reflects an increased amount of tofu, which is

often precipitated with a calcium salt. The increased amounts of calcium are not large, however.

The calcium level in Healthy Vegetarian Patterns for adolescent girls is from 96% to 100% of the

RDA, and for women over 50, 104% of the RDA. If Dairy intake had been lowered in the

Vegetarian Patterns, the calcium levels would be below RDA standards.

In the Med-Style Pattern at 2000 calories, amounts of calcium are lower, and vitamin A, vitamin

D, and sodium are somewhat lower than the Healthy US Style Patterns. This reflects the lower

amount of Dairy in the Med-Style Pattern. Vitamin C is higher, reflecting the higher amount of

fruit in the Pattern. Cholesterol is also somewhat higher, due to the higher amount of seafood in

the Patterns.

Note that the Med-Style Pattern at 2000 calories does meet the calcium RDA for a woman 19 to

50, but it would not meet the higher RDA for an adolescent 9 to 18 or an adult over the age of

50, whose RDA is higher. For adolescents, the amount of calcium in the Med-Style Patterns,

depending on the specific calorie level required, ranges from 71% to 82% of their RDA, and for

adults over the age of 50, calcium levels range from 77% to 83% of their RDA. (See additional

Tables E3.7.B2 and E3.7.C2 for all results.) The USDA Food Patterns have traditionally used

meeting RDA and other nutrition goals as their standard; the Med-Style Patterns do not fully

meet the RDAs. However, these diets have been shown to have health benefits, and the entire

dietary pattern may modify requirements for specific nutrients.

SUMMARY

The 2015 DGAC placed an emphasis on identifying and describing evidence-based healthful

dietary patterns, and identified evidence for health benefits of following a Med-style diet and a

vegetarian diet, in addition to following a Healthy US-style pattern typified by the DASH diet

and the 2010 USDA Food Patterns. The 2015 DGAC also explored quantitative information

about the food group content of the Med-style and vegetarian patterns, making it feasible, for the

first time, to use that information as the basis of USDA Food Patterns that reflect Vegetarian and

Med-style diets.

The 2010 DGA stated that there is more than one way in which to consume a healthful diet, and

the evidence to support this message has expanded with time. In keeping with this growing

emphasis, the USDA Food Patterns have been modified to illustrate more than one approach to

consuming a healthful diet. Based on the work of the 2015 DGAC, the USDA Food Patterns

have been expanded to include three different approaches to consuming a healthful diet: Healthy

Appendix E-3.7: Developing Vegetarian and Mediterranean-style Food Patterns

Scientific Report of the 2015 Dietary Guidelines Advisory Committee 9

US-Style Patterns, Healthy Vegetarian Patterns, and Healthy Med-Style Patterns. In comparison

to the Healthy US-Style Patterns, the Healthy Vegetarian Patterns include more legumes,

processed soy products, nuts and seeds, and whole grains. They contain no meat, poultry, or

seafood, and are identical to the Healthy US-Style Patterns (the original USDA Food Patterns) in

amounts of all other food groups. The Healthy Med-Style Patterns contain more fruit and

seafood and less dairy than the Healthy US-Style Patterns.

All of the Patterns meet nutritional goals for almost all nutrients with some notable exceptions.

With a few exceptions, the nutrient goals not met are the same as for the original USDA Food

Patterns. Levels of calcium are highest in the Vegetarian Patterns, because in addition to Dairy

they contain larger amounts of tofu, which is often precipitated with a calcium salt, although

amounts of calcium vary widely across tofu types. Levels of calcium are lowest in the Healthy

Med-Style Patterns, because the amounts of Dairy in those patterns have been decreased.

References:

Juan, WY, Yamini, S, Britten, P. Food Intake Patterns of Self-Identified Vegetarians among the

U.S. Population, 2007-2010. Presentation at National Nutrient Databank meeting, May 14-17,

2014, Portland OR.

Institute of Medicine. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin d,

and fluoride. Washington DC: National Academies Press, 1997.

Nutrition Evidence Library. A series of systematic reviews on the relationship between dietary

patterns and health outcomes. Alexandria, VA: U.S. Department of Agriculture, Center for

Nutrition Policy and Promotion, March 2014. Available at [URL]

Additional Tables available as Resources on Dietary Guidelines 2015 website

(http://www.health.gov/dietaryguidelines/2015.asp):

E3.7.A1 Food group amounts in USDA Healthy Vegetarian Patterns at all Calorie levels

E3.7.A2 Food group amounts in USDA Healthy Mediterranean-style Patterns at all Calorie

levels

E3.7.B1 Nutrients in USDA Healthy Vegetarian Patterns at all Calorie levels

E3.7.B2 Nutrients in USDA Healthy Mediterranean-style Patterns at all Calorie levels

E3.7.C1 Comparison of nutrient content of each USDA Healthy Vegetarian Pattern to the

nutritional goals for that pattern.

E3.7.C2 Comparison of nutrient content of each USDA Healthy Mediterranean-Style Pattern

to the nutritional goals for that pattern.