The Dietary Guidelines for Americans (DGA) are a set of guidelines and eating recommendations intended for the average American. However, when the committee that reviewed the evidence for the DGA, they failed to include studies that represent the ethnic make-up of the United States and failed to include studies on the largely unhealthy American population, and especially the health disparities among minority groups. One issue that received little attention is the fact that a large percentage of minority groups in the U.S. are lactose intolerant, yet the DGA still includes three servings of dairy foods without considering the dietary needs of these groups.   A change to the DGA that addresses systemic racism and specifically does not include dairy foods is necessary to make them inclusive and representative of the whole U.S. populations’ dietary needs.

Lactose intolerance, sometimes called lactose malabsorption or hypolactasia is often thought of as a deficiency in the lactase enzyme needed to digest lactose which is found in dairy products (Bhatnagar, 2007). However, 68% of the world population does not have this enzyme because they are not of Northern European descent (Storhaug, 2017). White Europeans and their descendants are the exception and not the rule in their ability to digest lactose.  Dr. Christian Storhaug from the Centre for International Health estimates that lactose intolerance prevalence in the United States is “95% of Asians, 60% to 80% of African Americans and Ashkenazi Jews, 80% to 100% of American Indians, and 50% to 80% percent of Hispanics” (2017). The National Institute of Diabetes and Digestive and Kidney Diseases indicates that 36% of the U.S. population is lactose intolerant (2022). Over one third of Americans cannot digest diary. Why, then, does the DGA recommend three daily servings of dairy to all Americans when there are other equally healthful alternatives?

Just prior to the USDA committee conducting their 5-year review of the DGA for 2020-2025, The American Medical Association called on them to adopt culturally responsive dietary and nutrition guidelines.  The AMA specifically requested that they “recognize that lactose intolerance is a common and normal condition among many Americans, especially African Americans, Asian Americans, and Native Americans, with a lower prevalence in whites” (2018).  In addition, Dr. R. Milton Mills spoke to the review committee about dairy and intolerance among people of color and stated that he was there to “call out the racism that is inherent in the U.S. Dietary Guidelines” (Red Pill Vegan, 2019). The scientific report that the committee published concerning the determination of the DGA stated multiple times that “People with lower socioeconomic status, adolescents, and racially and ethnically diverse populations were underrepresented in the body of evidence” (Dietary Guidelines Advisory Committee, 2020).  The report mentions lactose intolerance precisely one time.  The committee was aware of the racial disparities in the previous guidelines yet chose to include three servings of dairy daily to all Americans anyway and ignore the prevalence of lactose intolerance.  This is systemic racism.  What would cause an American institution to make these recommendations given these facts?

Multiple health and nutrition advocates like Marion Nestle have criticized the committee for its ties to the food industry, and their lack of adherence to the scientific evidence surrounding various foods and alcohol. One scientific analysis found that that 95% of the committee members had conflicts of interest with the food, and/or pharmaceutical industries (Mialon, 2022).  In 2019, the dairy industry spent $7.49 million dollars lobbying the federal government (Open Secrets, 2022).  Many of those efforts are aimed at influencing the DGA.  The oral and written comments submitted by the International Dairy Foods Association were followed exactly by the committee to include three servings of dairy, and to include dairy as a separate food group (Frye, 2019).  Conflicts of interest and undue influence by the dairy industry undoubtedly played a role in the formation of the DGA’s recommendations.

The solution to addressing the racial inequality in the DGA is to first limit all food industry influence and conflicts of interest within the committee. The second step is simply to change the guidelines to not include three servings of dairy products and not have dairy as a separate food group. Both tasks are not difficult to undertake, but policy makers would need to start with policy changes within the USDA’s Food and Nutrition Services.  

Canada has performed an extraordinary task of developing its guidelines independent from industry.  As a result, Canada’s Dietary Guidelines discuss reducing dairy but do not include dairy as part of its recommendations for daily intake or include dairy as a food group (Bacon, 2019). The World Health Organization’s recommendations for a healthy diet includes reducing dairy products and does not recommend three servings of dairy daily or include dairy as a separate food group (WHO, 2020).  If Canada and the World Health Organization can suggest healthy dietary patterns that are culturally sensitive and more widely digestible for the entire population, so can the U.S.

Many believe that dairy foods are necessary to obtain Vitamin D, potassium, and calcium.  Vitamin D in dairy is from fortification but is only found in fluid milk.  Vitamin D comes from absorbing it from the sun, so perhaps recommending outdoor activity should be included to obtain this essential nutrient.  Calcium and potassium are easily obtained from many other food sources including beans, greens, and fortified foods like cereals. The International Dairy Foods Association commenter stated that there are many lactose free dairy products available, but those products are at a premium price and not readily available to all socioeconomic classes.  There is nothing naturally in dairy products that are essential to human health.

This change is straightforward, but several nutrition programs would need some changes as they have relied heavily on dairy products to meet nutritional needs.  Many nutrition programs for schools and state funded nutrition programs include substitution for milk with fortified soy milk. The Child and Adult Care Food Program (CACFP), National School Lunch Program, School Breakfast Program, and Women and Infant Children (WIC) nutrition program, have the option under a 2008 ruling by the Food and Nutrition Service to substitute fluid milk with other beverages that are fortified with calcium, protein, vitamin A, and vitamin D, riboflavin, vitamin B-12, magnesium, phosphorus, and potassium. Most fortified soy milk products meet this substitution requirement.  The ruling states that “optional substitution of nondairy beverage for fluid milk for children with medical or special dietary needs” is allowable, but that parents or guardians must request in writing for non-dairy milk substitutions. However, substitutions are at the option of the facility (Food and Nutrition Service, 2008).  The CACFP and WIC program updated their guidelines in the same manner. The ruling is already in place, so it is only a matter of changing recommendations to not include three servings of dairy daily, remove diary as a food group, make substitution mandatory instead of optional, and remove the written request requirement barrier. Advising nutrition program administrators of the serious lactose intolerance issue amongst non-white people would also be beneficial.

Conclusion

Again, over one third of Americans cannot digest lactose, especially minorities so being mindful of these dietary limitations when advising average Americans on what they should be eating is imperative. Studies that represent the racial make-up of America and the prevalence of lactose intolerance need to be included when assessing the DGA.  Industry influence and powerful lobbies must be removed when considering what is best for all Americans. If Canadians were able to achieve this, Americans certainly can as well. Dairy foods are not necessary for human health and recommending them to some groups is harmful to their health.  Alternatives are readily available. Thus, dairy recommendations must be changed to be more inclusive and not systemically racist in the Dietary Guidelines for Americans if all Americans are expected to adhere to them. 

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References

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Bacon, S. L., Campbell, N., Raine, K. D., Tsuyuki, R. T., Khan, N. A., Arango, M., & Kaczorowski, J. (2019). Canada’s new healthy eating strategy: Implications for health care professionals and a call to action. Canadian pharmacists journal: RPC, 152(3), 151–157. https://doi.org/10.1177/1715163519834891

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