Consume only moderate amounts of sugars and foods containing added sugars

Full text

i
CONTENTS
Dietary Guidelines for Australian Adults
Dietary Guidelines for Australian Adults
Endorsed 10 April 2003

ii Dietary Guidelines for Australian Adults
CONTENTS
© Commonwealth of Australia 2003
ISBN Print: 1864961414 Online:186496135X
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The strategic intent of the NHMRC is to provide leadership and work with other relevant
organisations to improve the health of all Australians by:
• fostering and supporting a high quality and internationally recognised research base;
• providing evidence based advice;
• applying research evidence to health issues thus translating research into better health
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Disclaimer
This document is a general guide to appropriate practice, to be followed only subject to the
clinician’s judgement in each individual case.
The guidelines are designed to provide information to assist decision–making and are based on
the best information available at the date of compilation.
It is planned to review this Guideline in 2008. For further information regarding the status of this
document, please refer to the NHMRC web address: http://www.nhmrc.gov.au
Materials including a poster, booklet and brochure for the general public and nutrition
educators are available by contacting the Population Health Publications Officer,
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email: phd.publications@health.gov.au
The Australian dietary guidelines and Food for Health information can also be found on the
internet at http://www.nhmrc.gov.au/publications/nhome.htm
Reliable information about food, nutrition and health is also available from:
• Nutrition Australia — www.nutritionaustralia.org
• Dietitians Association of Australia (DAA) — www.daa.asn.au
• Food Standards Australia New Zealand (FSANZ) — www.foodstandards.gov.au who also
produce The official shopper’s guide to food additives and labels: know what you are eating
at a glance (published by Murdoch)
• Local community health centres
• State Departments of health
• Baby, child and youth health centres
• Accredited practising dietitians in private practice (look in the yellow pages)or in hospitals
and community centres
• National Heart Foundation of Australia — www.heartfoundation.com.au
• Diabetes Australia — www.diabetesaustralia.com.au

iii
CONTENTS
Dietary Guidelines for Australian Adults
CONTENTS
Preface vii
The Working Party xi
Assessing the evidence xiii
The consultation process xv
The Dietary Guidelines for Australian Adults xvii
BACKGROUND INFORMATION
1 Enjoy a wide variety of nutritious foods 1
Terminology 1
Background 1
Scientific basis 8
Practical aspects of this guideline 10
Relationship to other guidelines 12
Conclusion 12
Evidence 13
References 13
1.1 Eat plenty of vegetables, legumes and fruits 17
Terminology 17
Background 18
Scientific basis 19
Practical aspects of this guideline 23
Relationship to other guidelines 24
Conclusion 25
Evidence 26
References 26
1.2 Eat plenty of cereals (including breads, rice, pasta and
noodles), preferably wholegrain 31
Terminology 31
Background 32
Scientific basis 33
Practical aspects of this guideline 39
Relationship to other guidelines 41
Conclusion 41
Evidence 42
References 42

iv Dietary Guidelines for Australian Adults
CONTENTS
1.3 Include lean meat, fish, poultry and/or alternatives 51
Terminology 51
Background 52
Scientific basis 56
Practical aspects of this guideline 65
Relationship to other guidelines 66
Conclusion 67
Evidence 67
References 67
1.4 Include milks, yoghurts, cheeses and/or alternatives 75
Terminology 75
Background 76
Scientific basis 79
Practical aspects of this guideline 86
Relationship to other guidelines 87
Conclusion 88
Evidence 88
References 89
1.5 Drink plenty of water 95
Background 95
Scientific basis 96
Practical aspects of this guideline 99
Relationship to other guidelines 101
Conclusion 102
Evidence 102
References 102
1.6 Limit saturated fat and moderate total fat intake 107
Terminology 107
Background 109
Scientific basis 110
Practical aspects of this guideline 122
Relationship to other guidelines 123
Conclusions 123
Evidence 124
References 124

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Dietary Guidelines for Australian Adults
1.7 Choose foods low in salt 133
Terminology 133
Background 134
Scientific basis 136
Practical aspects of this guideline 140
Relationship to other guidelines 144
Conclusion 144
Evidence 145
References 146
1.8 Limit your alcohol intake if you choose to drink 151
Terminology 151
Background 151
Scientific basis 156
Practical aspects of this guideline 165
Relationship to other guidelines 166
Conclusion 166
Evidence 166
References 167
1.9 Consume only moderate amounts of sugars and foods
containing added sugars 171
Terminology 171
Background 172
Scientific basis 178
Practical aspects of this guideline 186
Relationship to other guidelines 186
Conclusion 187
Evidence 187
References 187
2 Prevent weight gain: be physically active and eat according
to your energy needs 193
Terminology 193
Background 194
Scientific basis 197
Practical aspects of this guideline 202
Relationship to other guidelines 204
Conclusion 204
Evidence 205
References 206

vi Dietary Guidelines for Australian Adults
CONTENTS
3 Care for your food: prepare and store it safely 211
Background 211
Scientific basis 212
Practical aspects of this guideline 216
Relationship to other guidelines 223
Conclusion 224
Evidence 224
References 225
4 Encourage and support breastfeeding 227
Terminology 227
Background 227
Scientific basis 230
Relationship to other guidelines 240
Conclusion 240
Evidence 240
References 241
SPECIAL CONSIDERATIONS
A The nutrition of Aboriginal and Torres Strait Islander peoples 249
Current health and nutritional status 249
Social determinants of Indigenous Australians’ health 250
Health aspects of traditional diets and lifestyles 252
Traditional Aboriginal diet and food preferences 253
Contemporary diet 253
Contemporary use of traditional foods 256
The National Aboriginal and Torres Strait Islander Nutrition
Strategy and Action Plan 257
Dietary guidelines for Australia’s Indigenous peoples 258
References 259
B Social status, nutrition and the cost of healthy eating 265
Social status and nutrition 265
The cost of healthy eating 268
References 270
C Dietary guidelines and the sustainability of food systems 271
References 273

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CONTENTS
Dietary Guidelines for Australian Adults
PREFACE
The Australian government has been providing nutrition advice for more than 75
years. In the past two decades the National Health and Medical Research Council
has developed and disseminated guidelines providing dietary advice for
Australians. This document is the third edition of the Dietary Guidelines for
Australian Adults. The second edition was published in 1992. A new edition of
the Dietary Guidelines for Children and Adolescents in Australia, incorporating
the Infant Feeding Guidelines for Health Workers has also been produced, and
the Dietary Guidelines for Older Australians was published in 1999. All these
guidelines seek to promote the potential benefits of healthy eating, not only to
reduce the risk of diet-related disease but also to improve the community’s health
and wellbeing.
The Australian Food and Nutrition Policy, endorsed in 1992, aims to improve the
health of Australians and reduce the burden of preventable diet-related death,
illness and disability through strategies that support the dietary guidelines. It is
estimated that the current economic cost to the nation of the principal diet-
related conditions—coronary heart disease, stroke and cancer—is about $6 billion
a year, so the potential economic benefit of an effective nutrition-based
preventive strategy is enormous.
The Australian Food and Nutrition Policy is based on the principles of good
nutrition, ecological sustainability and equity. This third edition of the Dietary
Guidelines for Australian Adults is consistent with these principles. The food
system must be economically viable and the quality and integrity of the
environment must be maintained. In this context, among the important
considerations are conservation of scarce resources such as topsoil, water and
fossil fuel energy and problems such as salinity. Other important considerations
have been noted in Food for Health, the Nutrition Taskforce’s report to the New
Zealand Ministry of Health. They include the change in consumer demand
towards foods that are fresher and lower in fat and the recent restructuring of the
food industry from a protected market to an open, competitive one. Although this
has led to greater concentration of ownership, pricing strategy and policy
development in the food sector, it has also given health policy makers greater
access to the industry. In addition, globalisation is playing an increasing role in
framing the management of the food supply.
The Dietary Guidelines for Australian Adults are aimed at healthy, independent
adults. This document describes the scientific rationale for the guidelines and is
intended for health professionals. Other documents will be produced in a format
that is more suitable for consumers. The guidelines may also be useful for health
professionals wanting to develop suitable diets for adults in other health

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Dietary Guidelines for Australian Adults
circumstances: it must always be remembered, however, that these guidelines are
for healthy people and may not satisfy the specific nutritional requirements of
people with particular diseases or conditions.
The Dietary Guidelines are an essential tool to support broader strategies to
improve nutrition outcomes in Australia as outlined in Eat Well Australia: An
Agenda for Action in Public Health Nutrition which was endorsed in 2001 by the
Australian Health Ministers.
Compared with the two previous editions, this edition of the guidelines focuses
more on food groups and lifestyle patterns, moving away from specific nutrients.
In particular, the references to the Australian Guide to Healthy Eating will make
it easier for consumers and nutrition educators to implement the guidelines. The
Australian Guide to Healthy Eating is not the only food guide in use in Australia,
and the Working Party recognises the potential for using other suitable guides to
promote diets consistent with these guidelines.
The guidelines apply to the total diet: they should not be used to assess the
‘healthiness’ of individual food items, nor should individual guidelines be
considered in isolation. The guidelines are not ranked in order of importance;
they form a consistent and complete package when taken together. Each one
deals with an issue that is key to optimal health.
Two of the guidelines relate to the quantity and quality of the food we eat—
getting the right types of foods in the right amounts to meet the body’s nutrient
needs and to reduce the risk of chronic disease risk. The ‘variety’ guideline
creates a positive setting for nutrition and reflects the fact that nutritious food can
be one of the great pleasures of life. Sections 1.1 to 1.9 within this guideline
detail the relationships between different food groups as part of the total diet.
Given the epidemic of obesity we are currently experiencing in Australia, the
other of these two guidelines specifically relates to the need to be active and to
avoid overeating. Another guideline stresses the need to be vigilant about food
safety and, in view of the increasing awareness of the importance of early
nutrition, there is a further guideline that encourages everyone to support and
promote breastfeeding.
Detailed information about requirements for specific nutrients in the Australian
diet is provided in the NHMRC’s Recommended Dietary Intakes for Use in
Australia. The recommended dietary intakes and the dietary guidelines
complement each other in providing comprehensive nutrition advice for the
Australian community. Implementation of the dietary guidelines will result in
significant health gains.
The revision process for this edition involved extensive consultation with the
Australian community, the food industry and experts. The guidelines are based
on the best evidence available, although the Working Party notes that in some
cases the evidence for each guideline statement is not complete. In these
instances the guidance is provided with the community’s safety and health as the
primary concern. The guidelines are a distillation of current knowledge about the
relationship between diet and disease, the nutrients available in the Australian

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Dietary Guidelines for Australian Adults
food supply, and the contribution diet can make to optimising quality of life and
reducing the levels of morbidity and mortality among Australians.
Each guideline is supported by background information prepared by members of
the Working Party, with some additional assistance, as detailed in the next
section.
Dr Katrine Baghurst, from CSIRO Health Sciences and Nutrition, and Professor
Colin Binns, from the School of Public Health at Curtin University of Technology,
chaired the Working Party.
Katrine Baghurst
Colin Binns
September 2002

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PREFACE
Dietary Guidelines for Australian Adults
THE WORKING PARTY
The Working Party developed the guidelines in accordance with National Health
and Medical Research Council procedures and in keeping with the following
terms of reference established by the NHMRC.
TERMS OF REFERENCE
• Undertake a review of the Dietary Guidelines for Australians … and the
Dietary Guidelines for Children and Adolescents … and other related
NHMRC dietary guidelines as identified.
• Undertake broad consultation to develop a suite of resources for both sets
of guidelines, including:
– comprehensive scientific background papers explaining the rationale
for each guideline
– appropriate consumer resources.
• Produce a dissemination and evaluation plan for both sets of guidelines.
• Report to the Health Advisory Committee.
MEMBERS OF THE W ORKING PARTY
Dr Katrine Baghurst (Co-chair)
CSIRO Health Sciences and Nutrition
Prof. Colin Binns (Co-chair)
School of Public Health, Curtin University of Technology
Prof. A Stewart Truswell
Human Nutrition Unit, University of Sydney
Dr Amanda Lee
Public Health Services, Queensland Department of Health
Dr Peter Williams
School of Nutrition and Dietetics, University of Wollongong
Dr Ivor Dreosti
CSIRO Health Sciences and Nutrition
Assoc. Prof. Malcolm Riley
Nutrition & Dietetics Unit, Monash University

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Dietary Guidelines for Australian Adults
Ms Isobel Brown
Government Relations Australia Ltd
Dr Merelie Hall
Royal Australian College of General Practitioners
Dr Geoff Davidson
Gastroenterology Unit, Women’s and Children’s Hospital, Adelaide
Ms Pat Crotty
Consumer representative
Ms Sue Jeffreson
Food Standards Australia New Zealand
Secretariat
Ms Karina Desarmia, Ms Lorraine O’Connor, Ms Tess Hill and
Ms Linda Robertson
National Health and Medical Research Council
Ms Jacinta Dugbaza, Ms Leticia White and Ms Michelle Coad
Commonwealth Department of Health and Ageing
OTHER CONTRIBUTORS
A number of the background papers were co-authored by experts, and the
Working Party thanks them for their contribution:
Dr Trevor Beard
Menzies Centre for Population Health Research, University of Tasmania
Dr Tim Gill
International Taskforce on Obesity, Human Nutrition Unit, Sydney University
Ms Kirsti McVay, Ms Rochelle Finlay and Ms Patricia Blenman
Food Standards Australia New Zealand
Dr Mi Kyung Lee
School of Public Health, Curtin University of Technology
The Working Party expresses particular thanks to Ms Dympna Leonard (Tropical
Public Health Unit, Queensland Health, Cairns) for assistance in preparing the
paper on Aboriginal and Torres Strait Islander peoples.
Ms Leanne Lester (School of Public Health, Curtin University of Technology) and
Ms Sally Record (CSIRO Health Sciences and Nutrition) helped with statistical
analysis of the results of the 1995 National Nutrition Survey.

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WORKING PARTY
Dietary Guidelines for Australian Adults
ASSESSING THE EVIDENCE
The National Health and Medical Research Council has released a guide called
How to Use the Evidence: assessment and application of scientific evidence (2000).
This guide relates, however, to evidence assessment in connection with clinical
practice. In many cases evidence-based guidelines for clinical practice deal with
evidence associated with a specific disease and a specific therapeutic agent.
Similar criteria are not easily used for evidence assessment related to food and
the maintenance of general community health and wellbeing, which is the
primary focus of dietary guidelines.
A number of initiatives are under way around the world to try to develop an
evidence-based approach to nutrition and public health, but this has generally
been in response to the need for ‘proof’ in relation to health claims for food
components. Food Standards Australia New Zealand (formerly the Australia New
Zealand Food Authority) developed a set of proposed levels of evidence for food
or health claims that is similar to, but somewhat broader in scope than, the
NHMRC approach for clinical guidelines. Nevertheless, the FSANZ set is still
primarily intended for assessing evidence of the efficacy of individual nutrients or
food components in relation to a specific health outcome.
The Working Party considered, however, that it would still be useful to consider
the NHMRC designation of levels of evidence for clinical practice in relation to
the scientific data discussed in this document. These levels of evidence are
outlined in the box.
NHMRC levels of evidence
I Evidence obtained from a systematic review of all relevant randomised controlled
trials.
II Evidence obtained from at least one properly designed randomised controlled
trial.
III-1 Evidence obtained from well-designed pseudo-randomised controlled trials
(alternate allocation or some other method).
III-2 Evidence obtained from comparative studies (including systematic reviews of such
studies) with concurrent controls and allocation not randomised, cohort studies,
case-control studies, or interrupted time series with a control group.
III-3 Evidence obtained from comparative studies with historical control, two or more
single-arm studies, or interrupted time series without a parallel control group.
IV Evidence obtained from case series, either post-test or pre-test/post-test.
Source: National Health and Medical Research Council. A guide to the development,
implementation and evaluation of clinical practice guidelines. Canberra: NHMRC, 1999.

xiv
ASSESSING THE EVIDENCE
Dietary Guidelines for Australian Adults
Six levels of evidence are designated by the NHMRC. Level I is based on a
systematic review of all relevant randomised controlled trials and Level II is
based on evidence obtained from at least one properly designed randomised
controlled trial. There are very few Level I or Level II food-based nutrition trials,
although some nutrient-supplement trials fall into these categories. Most food–
health studies fall into Level III, the level of evidence that includes study designs
such as cohort studies, case-control studies, and comparative ecological studies
with historical controls.
Because of the nature of the dietary guidelines, the background papers were
developed as a result of a process of comprehensive, rather than systematic,
review of the literature. At the conclusion of each guideline, there is a summary
of the NHMRC levels of evidence for the literature cited.
The NHMRC notes, ‘A decision should be made about what is feasible and
appropriate in a given situation and the extent to which reasonable standards
have been met by the available body of evidence’.
The evidence base for the background papers was developed using a variety of
data bases and search terms. The literature was assessed using data bases and
abstracting systems including the Cochrane Data Base for Randomised Control
Trials; Medline, HealthStar, CINAHL using ‘systematic review’ filter, PubMed,
Embase, Food & Technology Abstracts, Emerald, BioSis, Australasian Medical
Index, Science Direct, Current Contents and searches of citations found in
identified papers. Terms used in searches included food groupings such as fruits,
vegetables, nuts and seeds, legumes, cereals, meat, poultry, fish, dairy, milk,
yoghurt, cheeses, soy, water, alcohol, breastmilk (and breastfeeding) and dietary/
food intake patterns as well as nutrients such as fats (total and types),
carbohydrates sugars, starches, protein, iron, zinc, B12, calcium and salt as well
as physical activity. These were investigated where relevant in relation to health
outcomes such as overweight, obesity, growth, heart disease, cancers of various
sorts, diabetes, bone density and osteoporosis, cognition and ageing. Whilst
searches concentrated on human studies and those available in the English
language, findings from some animal studies were included to provide evidence
on possible mechanisms. The reviews were completed in January 2002 but some
key papers published since then have been included.

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ASSESSING THE EVIDENCE
Dietary Guidelines for Australian Adults
THE CONSULTATION PROCESS
Development of the Dietary Guidelines for Australian Adults has involved
consultation with the community and with experts working in the fields of public
health and nutrition.
Preliminary work took place from December 2000 until May 2001 and involved
the following:
• analysis of 104 completed and returned questionnaires dealing with the
content and use of the second edition of the dietary guidelines
• establishment of an interactive website providing information about the
review of the guidelines
• several meetings with stakeholders.
The public consultation process took place between July and August 2001,
allowing about six weeks for consideration of the draft Dietary Guidelines for
Australian Adults and preparation and lodgment of submissions. Notification was
published in the Commonwealth of Australia Gazette and on the NHMRC
website. Copies of draft documents and supporting information were available
free of charge from the Office of the NHMRC and on the website. In addition,
notices were placed in other publications and with media such as newspapers
and radio and circulated to bodies expected to be interested.
The Dietary Guidelines for Australian Adults were submitted for consultation
along with the Dietary Guidelines for Children and Adolescents in Australia,
incorporating the Infant Feeding Guidelines for Health Workers. Ninety-three
submissions were received. The Working Party met in September 2001 to
consider the submissions; initial revisions were made by the end of December
2001 and were then reconsidered by the Working Party and revisions finalised by
February 2002. Some additional key references were added during the technical
editing and review period.
Additional specialist comment was obtained from Dr Peter Hartman (University of
Western Australia), Dr Jane Scott (University of Glasgow), Dr Karen Cashell
(University of Canberra), Ms Anne Croker (Australian Breastfeeding Association,
formerly the Nursing Mothers Association of Australia), Ms Judy Seal (Strategic
Inter-governmental Nutrition Alliance and Tasmania Health), Dr Wendy Oddy
(NHMRC fellow, Curtin University of Technology) and Dr Gulnara Semonova
(Director, Australian Breastfeeding Association Lactation Resource Centre).
The document was technically edited by Chris Pirie.

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Dietary Guidelines for Australian Adults

xvii
ASSESSING THE EVIDENCE
Dietary Guidelines for Australian Adults
THE DIETARY GUIDELINES FOR AUSTRALIAN
ADULTS
Enjoy a wide variety of nutritious foods
• Eat plenty of vegetables, legumes and fruits
• Eat plenty of cereals (including breads, rice, pasta and noodles), preferably
wholegrain
• Include lean meat, fish, poultry and/or alternatives
• Include milks, yoghurts, cheeses and/or alternatives. Reduced-fat varieties
should be chosen, where possible
• Drink plenty of water.
and take care to
• Limit saturated fat and moderate total fat intake
• Choose foods low in salt
• Limit your alcohol intake if you choose to drink
• Consume only moderate amounts of sugars and foods containing added
sugars.
Prevent weight gain: be physically active and eat according to your
energy needs
Care for your food: prepare and store it safely
Encourage and support breastfeeding
These guidelines are not in order of importance.
Each one deals with an issue that is key to optimal health.
Two relate to the quantity and quality of the food we eat—getting the right types of
foods in the right amounts to meet the body’s nutrient needs and to reduce the risk of
chronic disease. Given the epidemic of obesity we are currently experiencing in Australia,
one of these guidelines specifically relates to the need to be active and to avoid
overeating.
Another guideline stresses the need to be vigilant about food safety, and, in view of the
increasing awareness of the importance of early nutrition, there is a further guideline
that encourages everyone to support and promote breastfeeding.

xix
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Dietary Guidelines for Australian Adults
Background information

1
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
Dietary Guidelines for Australian Adults
1 ENJOY A WIDE VARIETY OF
NUTRITIOUS FOODS
Colin Binns and Mi Kyung Lee
TERMINOLOGY
Food variety
Food variety can be defined on the basis of foods that are biologically diverse or
nutritionally distinct from each other. Eating a variety of nutritious foods means
consuming different food types in appropriate amounts, as illustrated by the
Australian Guide to Healthy Eating (shown in Figure 1.1), to attain all the
required nutrients without excess energy intake.1Variety further refers to
choosing a range of items from within each food group, particularly within the
plant-based groups (vegetables, fruits and cereals). While variety is an important
nutritional principle—and given the evolution of modern sedentary society—if it
is to be maintained, a reduction in serving size needs to be considered,
particularly for more energy dense foods with limited nutrient content (see the
‘Practical aspects of this guideline’ section).
Nutritious foods
The term nutritious foods is used to describe foods that make a substantial
contribution towards providing a range of nutrients, have an appropriate nutrient
density, and are compatible with the overall aims of the Dietary Guidelines for
Australians.2The nutrients that are essential for human life are found in varying
amounts in many different foods, and a varied diet is essential for obtaining
sufficient quantities of all required nutrients (known and not yet known), for
increasing the consumption of protective factors (phytochemicals), and for
minimising exposure to toxicants.
Phytochemicals
Substances found in plant materials which may confer some health benefits and
which include a number of chemical categories such as carotenoids, flavonoids
and isoflavonoids, polyphenols, isothiocyanates, indoles, sulphoraphane,
monoterpenes, xanthin, and non-digestible oligosaccharides.
BACKGROUND
Australians today enjoy a wide variety of foods, relatively independent of season
and location, and can choose from a number of cuisines. The available food
supply is adequate to meet the nutritional needs of Australians, but appropriate

2Dietary Guidelines for Australian Adults
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
choices must be made so that all nutrient requirements are met.3There are also
disadvantaged groups in Australia, for whom, because of factors such as poverty,
particular food beliefs, distance or disability, special efforts are needed to ensure
an adequate diet. Australia is also fortunate in having a food supply that is
relatively free of contaminants and pollutants, as shown by the Australian Total
Diet Survey.4
Figure 1.1 The Australian Guide to Healthy Eating1

3
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
Dietary Guidelines for Australian Adults
Sample serves suggested for adults
Cereals
(including Lean meat,
breads, rice Milk fish, poultry,
pasta and Vegetables yoghurt, nuts and Extra
Food group noodles) and legumes Fruit cheese legumes foods
Women
19–60 yrs 4–9 5 2 2 1 0–2˚
4–6 4–7 2–3 2–3 1–1˚ 0–2˚
60+ yrs 4–7 5 2 2 1 0–2
3–5 4–6 2–3 2–3 1 – 1 ˚ 0–2
Pregnant 4–6 5–6 4 2 1 ˚ 0–2˚
Breastfeeding 5–7 7 5 2 2 0–2˚
Men
19–60 yrs 6–12 5 2 2 1 0–3
5–7 6–8 3–4 2–4 1 ˚ – 2 0–3
60+ yrs 4–9 5 2 2 1 0–2˚
4–6 4–7 2–3 2–3 1–1˚ 0–2˚
Notes: The sample serves allow for two different eating patterns: the top row in each category
includes a lot of cereals, bread, rice, pasta and noodles; the bottom row includes less of these
products and more of the other groups.
Examples of sample sizes are:
• 2 slices (60g) bread, 1 medium bread roll, 1 cup cooked rice, pasta or noodles
• ˚ cup (75g) cooked vegetables or legumes, 1 cup salad vegetables, 1 small potato
• 1 medium piece (150g) of fruit, 1 cup diced pieces or canned fruit, ˚ cup fruit juice
• 1 cup (250ml) fresh milk, 2 slices (40g) cheese, 1 small carton (200g) yoghurt
• 65–100g cooked meat or chicken, 80–120g cooked fish fillet, 2 small eggs, ˚ cup cooked
legumes, 1/3 cup nuts, ˘ cup sesame seeds.
With the exception of breastmilk in the first six months of life, no single food
can provide a complete and healthy diet. A diet containing a wide range of foods
from the different food groups is most likely to offer protection against non-
communicable chronic diseases such as vascular disease, obesity, diabetes, and
possibly even cancer (see Sections 1.1 and 1.2). The benefits are gained by
reducing the intake of foods that supply excessive amounts of fat, salt and
alcohol and by maximising the intake of protective factors such as vegetables,
fruits and cereals although recent work suggests that the situation with obesity is
not straightforward.5A varied diet also increases the possibility of receiving
essential nutrients in adequate amounts.6
Variety in the diet is becoming increasingly important as the emphasis on non-
nutrients increases. Foods have traditionally been classified according to their
macro-nutrient and micro-nutrient value, but now their non-nutrient value is
gaining recognition in terms of food’s role in non-communicable chronic diseases
and in ageing (see Section 1.1 and 1.2). Most non-nutrient factors are
phytochemicals that are not directly associated with deficiency syndromes but do

4Dietary Guidelines for Australian Adults
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
have some relationship to optimal health. Phytochemicals can be multi-
functional; alternatively, more than one class of phytochemicals can provide a
particular function. Interactions between compounds are likely to be complex
and deep, causing a masking or synergy of effects.7
Phytochemicals can fall into one of a number of chemical categories including
carotenoids, flavonoids and isoflavonoids, polyphenols, isothiocyanates, indoles,
sulphoraphane, monoterpenes, xanthin, and non-digestible oligosaccharides.
Variety in the diet is recommended so that the protective benefits of nutrients
and non-nutrients can be obtained: it is not known exactly which food
constituents are responsible for the protective effect against chronic diseases.
Another benefit of variety may come from dilution of potentially toxic
components in foods. Plants contain various toxic substances that, although often
useful for discouraging insects and other predators, have the potential to harm
humans. Minimising the risk posed by naturally occurring toxicants is a useful
goal of public health policy.8Historically, until fire was first used, only raw foods
could have been eaten. Cooking must have immensely increased the safety and
availability of these foods by destroying the thermolabile poisons in otherwise
edible plants as well as the parasites and toxins common in flesh and carrion.9
Now a large number of processing and storage methods are used to reduce any
toxicity problems foods might pose.
Consuming a wide variety of nutritious foods in appropriate amounts will thus
increase dietary quality, improve chronic disease status and minimise the intake
of toxic components.
Current Australian dietary practices
The National Nutrition Survey was conducted between February 1995 and March
1996, as an adjunct to the 1995 National Health Survey.10 The dietary intakes of
approximately 13 800 people aged 2 years or more from urban and rural areas in
all states and territories were recorded for one day by 24-hour recall. Additional
information on physical measurements and eating habits and patterns was also
collected. The resultant data showed that, during the 12 years since the previous
survey, food variety in Australia had increased significantly, with a much greater
number of foods being recorded in 1995 than in 1983. The increase in the variety
of foods available reflects the wide range of fresh, processed, mixed and
prepared food forms that are now conveniently obtainable in Australia on a daily
basis.
This expansion in the number of foods available is largely a result of the cultural
diversity that now characterises our population. The influx of European
immigrants after World War 2 and the migration of Asian people in more recent
decades have led to the development of an Australian population consuming a
wide variety of cuisines, in place of the ‘traditional’ Anglo-Celtic foods.

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Dietary Guidelines for Australian Adults
Few countries have such ready access to such a variety of cuisines. On 30 June
1999 there were approximately 4.5 million overseas-born people living in
Australia—about 24 per cent of the population. Twenty-seven per cent of
overseas-born people were originally from the United Kingdom and Ireland; 5
per cent were from Italy; 3 per cent were from Greece; and 3 per cent were
from Germany. The number of immigrants from Asia is increasing: the
Vietnamese community is now second in number after the English.11 The ready
availability of different cuisines allows most Australians—at least those in urban
areas and larger regional centres—to experiment with foods not common in the
everyday diet, thus increasing the opportunity for expanding their food variety.
Some Australians choose diets that are mainly or exclusively vegetarian but the
numbers are relatively small. In the National Nutrition Survey 4 per cent of
subjects described themselves as vegetarian; the food-frequency questionnaire
data recorded only 2 per cent as consuming no animal products, and a further 2
per cent restricting themselves to fish or white meat only. Ninety-six per cent of
respondents reported consuming some red meat, with 79 per cent having red
meat at least three times a week. However, in some selected groups, such as
female university students in Perth, larger numbers reported eating only minimal
amounts of meat. In the Perth study, 13 per cent classified themselves as
vegetarian and 17 per cent as semi-vegetarian.12
The 1995 National Nutrition Survey data show that, generally, the diet of older
Australians is more varied than that of younger groups. In the survey, the foods
eaten were classified into 14 different groups. Figure 1.2 shows the cumulative
percentage of people consuming various numbers of food groups on the day of
the survey. This analysis showed that, in virtually all age groups, males who live
alone eat significantly fewer food groups each day. For example, just over 40 per
cent of males living alone ate five or fewer food groups on the day of the
survey; this compares with only 10–12 per cent of the other three groups eating
five or fewer food groups. No other demographic group showed such a
divergence from the mean.
A comparison of the National Nutrition Surveys of 1983 and 1995 shows that
there have been changes in the intakes of many nutrients, generally in the
direction encouraged by the Dietary Guidelines for Australians (see Table 1.1).
The most noteworthy change contrary to the dietary guidelines is the increasing
prevalence of obesity; this is discussed in relation to Chapter 2.
Table 1.2 shows the average intakes recorded in the 1995 National Nutrition
Survey for selected nutrients. Despite the variety of foods and cuisines in
Australia, comparison with recommended dietary intakes shows that some
nutrients are still at risk, among them iron in pre-menopausal women and
calcium in women.

6Dietary Guidelines for Australian Adults
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
Table 1.1 Nutrient intakes in Australia, 1980s and 1995
Adults (25–64 yrs) Adolescents (10–15 yrs)
Nutrient Direction Extent of change Direction Extent of change
Energy Increased Males 3%; females 4% Increased Boys 15%; girls 11%
Protein Unchanged Increased Boys 14%; girls 13%
Carbohydrate Increased Males 17%; females 16% Increased Boys 22%; girls 18%
Fat Decreased Males 6%; females 4% Unchanged
Cholesterol Decreased Males 14%; females 22% Unchanged
Fibre Increased Males 13%; females 10% Increased Boys 13%; girls 8%
Calcium Increased Males 18%; females 14% Unchanged
Iron Increased Males 11%; females 15% Increased Boys 16%; girls 11%
Vitamin C Decreased Males 8% Decreased Girls 10%
Notes: Estimates based on 24-hour intake; capital cities only. Where there is a trend in mean
intake direction, it is significant to the 1 per cent level.
Source: Unpublished results of the Australian Food and Nutrition Monitoring Unit (2001), based
on analysis of comparable samples from the 1983 National Dietary Survey of Adults, the 1985
National Dietary Survey of School Children and the 1995 National Nutrition Survey.
Figure 1.2 Food groups eaten on the day of the 1995 National Nutrition Survey

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Dietary Guidelines for Australian Adults
Table 1.2 Mean nutrient intakes on the day of the 1995 National
Nutrition Survey13
Age group
Nutrient (RDIa) 19–24 25–44 45–64 65+ 19+
Males
Energy (Mj) 13.3 11.7 10.3 8.5 11.1
Protein (g) (55) 128 115 105 84 109
Fat (g) 119 106 91 74 99
Carbohydrate (g) 376 317 274 235 301
Fibre (g) 26.2 26.1 26.3 24.0 25.9
Alcohol (g) b15.2 19.7 20.2 14.7 18.5
Vitamin A (µg) c(750) 1233 1306 1360 1301 1311
Thiamin (mg) (1.1) 2.3 2.1 1.8 1.6 1.9
Niacin (equiv. mg) (19) 57.6 53.9 48.8 38.8 50.7
Folate (µg) (200) 322 311 310 277 307
Vitamin C (mg) (40) 150 133 138 127 136
Calcium (mg) (800) 1101 989 885 796 946
Phosphorus (mg) (1000) 2052 1867 1692 1419 1776
Magnesium (mg) (320) 390 393 383 334 381
Iron (mg) (7) 17.9 16.7 16.2 14.4 16.4
Zinc (mg) (12) 17.3 14.9 14.0 11.4 14.4
Potassium (mg) (1950–5460) 3943 3818 3733 3232 3725
Females
Energy (Mj) 8.4 7.9 7.2 64. 7.5
Protein (g) (45) 78 76 75 64.3 74
Fat (g) 75 72 64 57 68
Carbohydrate (g) 243 220 200 182 211
Fibre (g) 19.2 20.0 21.5 20.2 20.3
Alcohol (g) b6.6 8.2 8.0 4.6 7.3
Vitamin A (µg) c(750) 889 1024 1145 1059 1047
Thiamin (mg) (0.8) 1.5 1.4 1.3 1.2 1.4
Niacin (equiv. mg) (13) 36.1 35.3 34.5 29.4 34.1
Folate (µg) (200) 233 227 247 225 233
Vitamin C (mg) (30) 120 109 118 112 113
Calcium (mg) (800) 750 762 769 686 749
Phosphorus (mg) (1000) 1332 1300 1295 1132 1272
Magnesium (mg) (270) 273 284 297 268 283
Iron (mg) (12–16) 11.9 12.0 12.3 11.3 11.9
Zinc (mg) (12) 10.2 9.9 9.8 9.0 9.7
Potassium (mg) (1950–5460) 2752 2816 2930 2626 2805
a. The recommended dietary intakes are for males aged 19–64 years and females aged 19–54
years. The RDIs are soon to be reviewed.
b. Represents pure alcohol.
c. Retinol equivalents.

8Dietary Guidelines for Australian Adults
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
SCIENTIFIC BASIS
Dietary variety and chronic disease
There is evidence about the relationship between dietary variety and chronic
disease from two prospective cohort studies and two ecological studies. Research
that illustrates the health benefits of increasing food variety in the diet comes
from the US National Health and Nutrition Examination Survey Epidemiologic
Follow-up Study, which studied 4 160 men and 6 264 women. A dietary diversity
score of 0 to 5 was used, with 5 being the maximum possible score and
indicating high food variety. An increased risk of mortality was associated with a
low dietary diversity score at nearly every level of age, income, education, race,
smoking status and fibre intake. There was also an increased risk of mortality
from all causes for both men and women where a food group was omitted from
the diet. Fewer than 5 per cent of study participants reported omitting foods
from the meat or grain groups on the survey day, whereas 46 per cent reported
no fruit, 25 per cent reported no dairy products, and 17 per cent reported no
vegetables. Reporting no consumption of fruits and vegetables was associated
with low serum vitamin C, whereas reporting fruit and vegetable consumption
was associated with a high vitamin C concentration.14
In a prospective US study, Kant et al.15 evaluated the association between dietary
quality (based on dietary guidelines) and mortality in women. A food-frequency
questionnaire was completed by 42 254 women (mean age 61.1 years) who were
followed up for an average of 5.6 years. The results showed that women who
reported dietary patterns that included fruits, vegetables, whole grains, low-fat
dairy products and lean meats, as recommended by the dietary guidelines, had a
lower risk of mortality. The data suggested that a dietary pattern characterised by
consumption of foods recommended in current dietary guidelines is associated
with decreased risk of mortality in women.
Ecological comparisons of cuisines and health outcomes have suggested that
‘Mediterranean’ diets and the Japanese diet (in particular the Okinawan diet) and
may show benefits in terms of decreased mortality from chronic diseases and
increased life expectancy in countries where these diets predominate.16 A study
of Greek populations in Melbourne and Greece concluded that food variety was
an important determinant of morbidity and mortality.17 Traditional Mediterranean
diets are based on plant foods, contain small amounts of animal products, use
olive oil as the principal fat, contain moderate amounts of alcohol, and balance
energy intake with energy expenditure. They are low in saturated fat and high in
the protective compounds found throughout a variety of plant foods.18,19 The
Okinawan diet is varied, with a substantial amount of fish, and is associated with
the longest reported life spans of any population.20
Dietary variety and nutrient intake
Apart from consideration of specific chronic disease health outcomes, one
Melbourne study of Chinese migrants5has shown that variety in food choice is
more likely to result in diets with an acceptable nutrient profile. In this study,

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Dietary Guidelines for Australian Adults
when the diet failed to provide more than 40 per cent of the maximum
achievable variety (over 12 months), participants were far more likely to have at
least one nutrient level fall below two-thirds of the Australian recommended
dietary intakes. It is unclear how this would relate to the general Australian
population. Interestingly, food variety in the diet of these migrants increased
with length of stay in Australia, independent of age, which suggests that food
variety can be increased if there is continued exposure to new foods.5
Nutrient interactions
Maximising nutrient bioavailability is another potential benefit of variety. There
are many complex relationships between foods and nutrients, and they can
mutually influence the absorption, metabolism and retention of other nutrients.
When a diet is well balanced and nutrients are in adequate supply, such
interactions pose few problems; when the intake of some nutrients is habitually
low, excesses of others can have detrimental effects.21 The following are
examples.
•Interactions between sodium, protein and calcium. Sodium and calcium
compete for the same transport mechanism in the kidney, and an excess of
one will cause excretion of the other. Protein has a similar effect on urine
calcium levels. This interaction is important in the older population
because factors that affect urinary calcium loss are likely to affect bone
health: recognition of the interaction allows for the prevention of calcium
losses related to high protein intakes. When diets are high in protein, a
reduction in sodium intake can reduce the physiological need for calcium22
and so improve calcium nutrition (see Section 1.7). Other inhibitors of
calcium absorption are phosphates, phytic acid from the husks of cereals,
and oxalic acid in spinach and rhubarb, which form insoluble complexes
with calcium.23
•The effects of various nutrients on iron absorption. Vitamin C-containing
foods (such as citrus fruit) and meats have a positive effect on the
absorption of iron from plant foods when eaten at the same meal.24
Consuming iron from animal sources (such as meat, which is also high in
protein) will also promote iron absorption.25 In contrast, non-haem iron
absorption is inhibited by phytates, polyphenols (for example, tannins)
and calcium.26 This is discussed further in Section 1.3.
•Zinc bioavailability. Zinc found in animal products, crustaceans and
molluscs is more readily absorbed than zinc found in plant foods. In
contrast, legumes and unrefined cereals contain phytates that reduce zinc
absorption. The zinc content of refined cereals is lower than that of
unrefined cereals but, because a large part of the phytic acid present in
cereals is removed during the refining process, zinc bioavailability is
increased. Phytate in the presence of calcium may also reduce zinc
bioavailability.27 By including adequate amounts of wholegrain products
and legumes in a varied diet, lacto-ovo-vegetarians can meet their zinc
requirements and maintain zinc balance.28 Eating a varied diet usually
protects against these interaction effects.

10 Dietary Guidelines for Australian Adults
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
It must also be remembered that, in storing, preparing, cooking and processing
foods, losses of some nutrients occur, while in other cases absorption or
availability is improved by processing. For example, riboflavin is destroyed by
exposure to ultraviolet light; ascorbic acid is destroyed by exposure to oxygen
(air); beta-carotene, thiamin and ascorbic acid are destroyed by heating; and
minerals are leached out of foods soaked in water.
In some cases the chemical form of a nutrient used for fortification may be less
available than the natural product (for example, iron added to breakfast cereal
compared with haem iron); in other cases it may be more bioavailable (for
example, folic acid compared with naturally occurring folates).
The balance between different nutrients also needs to be considered. There is
emerging evidence that the balance between n-3 and n-6 fatty acids might be
important (see Section 1.6).29,30
Special groups
People following a strict vegetarian diet need to be careful to include a variety
of protein sources to get the right mix of amino acids. Iron, zinc, and vitamin
B12
31–33 may also pose some problems. Plant foods can provide some iron and
zinc but these sources have lower bioavailability. Vitamin B12 is found only in
animal products and, in strict vegetarians, may need to be sourced from enriched
foods or supplements. Suitable diets would normally include a higher proportion
of legumes and nuts to provide additional nutrients, including iron and protein.
PRACTICAL ASPECTS OF THIS GUIDELINE
The balance between variety and over-consumption
Energy
As variety in a diet increases, it is important to reduce serving sizes and the
amounts of each food eaten to avoid over-consumption of energy (and thus
avoid obesity). There have been a number of short term studies in humans
showing links between overconsumption and variety34–39 and McCrory et al.40
have reported on a long-term human study to determine whether dietary variety
within food groups is associated with energy intake and body fatness. Dietary
energy from the individual food groups examined was positively related to
variety within that group. However, whilst high variety of more energy-dense
food groups such as sweets, snacks, condiments, entrees and carbohydrate-based
foods was associated with body fatness, variety in vegetable consumption was
inversely associated. The authors suggested that the wide range of energy dense
foods available might be partly responsible for increasing body fatness in the
community. Thus high variety in vegetable consumption does not appear to have
detrimental effects on body weight but portion size must be taken into account
when the variety principle is applied to more energy dense food groups.

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Dietary Guidelines for Australian Adults
Other nutrients
While eating a wide variety of foods will maximise the potential benefits of the
biological diversity of foods (particularly plant foods), nutrition is complex and
over-consumption has the potential to be as big a problem as deficiency.
Excessive intakes of individual essential nutrients usually cause only minor
problems, but in some rare cases can be fatal. Major problems are nearly always
associated with excessive intakes in the form of supplements, although it is
certainly possible to develop symptoms of toxicity with very unbalanced diets.
This applies even to different chemical forms of the ‘same’ nutrient. Table 1.3
provides some examples.
A diet limited in the range of foods consumed and with excessive, long-term
consumption of a particular food can cause problems however this is rare unless
accompanied by supplementation. Examples are high and prolonged
consumption of carrot juice, which will result in excess beta-carotene intake, or
eating very large portions of liver, which may cause vitamin A poisoning. It is
impossible to consume nutrients to the excessive levels necessary for these
effects if a person’s diet is varied, nutritious and healthy, consistent with the
Australian Guide to Healthy Eating.
Table 1.3 Potential outcomes of excessive vitamin intake41–47
Nutrient excess Potential outcome
Provitamin A Yellow or orange skin colour
Preformed vitamin A Headache, vomiting, extensive skin peeling, bone
abnormalities and liver damage41
Vitamin A supplements in pregnancy Serious birth defects
Niacin as nicotinic acid Flushing, hyperglycaemia and abnormalities of
liver function42
Vitamin C Nausea, vomiting and diarrhoea (cited in reference 43)
Vitamin C in pregnancy Rebound scurvy, due to vitamin C deficiency, in the
newborn infant (cited in reference 43)
Pyridoxine (vitamin B6) Peripheral neuropathy44,45
Vitamin D Hypercalcaemia, dehydration and calcification of soft
tissue, including kidney failure46
Iron Acute excessive intake can result in vomiting and
gastrointestinal bleeding47;chronic excessive
consumption can lead to haemosiderosis with
liver damage
Food contaminants
Eating a variety of foods dilutes the naturally occurring toxicants and any added
contaminants. The Australian food supply is one of the safest and cleanest in the
world, ensuring that a minimum of toxicants are ingested. The 19th Australian

12 Dietary Guidelines for Australian Adults
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
Total Diet Survey found that levels of pesticide residues and heavy metal
contaminants in the Australian food supply remain very low and well within
safety standards set by Australian and international health authorities.4
RELATIONSHIP TO OTHER GUIDELINES
Eat plenty of vegetables, legumes and fruits
Including a variety of vegetables, legumes and fruits in the diet will ensure the
intake of a wide range of vitamins, minerals, dietary fibres and beneficial, non-
nutrient phytochemicals found in plant foods. These occur in the various
vegetables, legumes and fruits to varying degrees. The only way to ensure that
all the beneficial components are eaten is to include a wide variety of
vegetables, legumes and fruits. Vegetables should include green leafy varieties,
red and yellow and starchy vegetables. Fruits should include those high in
vitamin C and those high in vitamin A (and its analogues).
Eat plenty of cereals (including breads, rice, pasta and noodles),
preferably wholegrain
As with vegetables, legumes and fruits, different cereal grains can contribute a
variety of nutrient and non-nutrient benefits. A wide range of cereal-based
products is advisable and could include those from different cuisines; such as
wholegrain or wholemeal bagels, pita bread and pumpernickel. Low-fat, low-salt
and low-sugar products are preferable where possible.
Prevent weight gain: be physically active and eat according to your
energy needs
The work of McCrory and Coulston48 indicates that a varied diet can result in
higher energy intake if care is not taken with portion size. While variety is an
important nutritional principle—particularly given the evolution of modern
sedentary society—if variety is to be maintained, activity must be encouraged
and food serving sizes, especially of the energy-dense foods, may need to be
reduced. Consumer and food service education 49 that focuses on reduced portion
sizes may help reduce opportunities for overeating, especially of high–energy
density foods.
CONCLUSION
Australians are in a position to include in their diet a range of cuisines that add
variety to the ‘traditional’ Australian diet and have been associated with health
gains. Recommending to Australians that they ‘enjoy a wide variety of nutritious
foods’ will not only help ensure appropriate intakes of major dietary components
such as protein, carbohydrates and fats but also help ensure adequate and

13
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
Dietary Guidelines for Australian Adults
appropriate intakes of vitamins and minerals, individual fatty acids and amino
acids. Mennell et al.50 refer to the varying cuisines of the world as ‘culinary
culture’ and define this as ‘the ensemble of attitudes and tastes people bring to
cooking and eating’. Enjoying a variety of nutritious foods remains an important
message for all age groups. Experimenting with other cuisines, and incorporating
new and traditional foods will encourage variety in the diet, help meet nutrient
requirements, and provide some protection against non-communicable chronic
diseases. Serving sizes of more energy dense foods may need to be reduced to
accommodate variety.
EVIDENCE
Evidence of the importance of variety to gain sufficient nutrients is available at
Level III (references 14, 15, 18 and 40) and at Level IV (references 5 and 6).
Evidence also comes from cross-cultural observational studies of diet, health and
longevity.
REFERENCES
1. Department of Health and Family Services. The Australian guide to healthy
eating: background information for nutrition educators. Canberra: DHFS,
1998.
2. National Health and Medical Research Council. Dietary guidelines for
Australians. Canberra: Australian Government Publishing Service, 1992.
3. Australian Bureau of Statistics. Apparent consumption of foodstuffs and
nutrients, Australia, 1998. Canberra: ABS, 2000.
4. Australia New Zealand Food Authority. 19th Australian Total Diet Survey.
Canberra: ANZFA, 2001.
5. Hsu-Hage B, Wahlqvist M. Food variety of adult Melbourne Chinese: a case
study of population in transition. World Rev Nutr Diet 1996;79:53–69.
6. Hodgson J, Hsu-Hage B, Wahlqvist M. Food variety as a quantitative
descriptor of food intake. Ecol Food Nutr 1994;32:137–48.
7. Wahlqvist M, Wattanapenpaiboon N, Kannar D, Dalais F, Kouris-Blazos A.
Phytochemical deficiency disorders. Curr Ther 1998;July:53–60.
8. Park D. Surveillance programmes for managing risks from naturally
occurring toxicants. Food Addit Contam 1998;12(3):361–71.
9. Cuthbertson WFJ. Evolution of infant nutrition. Brit J Nutr 1999;81:359–71.
10. Australian Bureau of Statistics. National Nutrition Survey: users’ guide. Cat.
no. 4801.0. Canberra: ABS, 1998.
11. Australian Bureau of Statistics. Migration. Canberra: ABS, 2000.

14 Dietary Guidelines for Australian Adults
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
12. Rangan A, Aitkin I, Blight G, Binns C. Factors affecting iron status in 15–30
year old female students. Asia Pacific J Clin Nutr 1997;6:291–5.
13. Australian Bureau of Statistics. National Nutrition Survey: nutrient intakes
and physical measurements. Cat. no. 4805.0. Canberra: ABS, 1995.
14. Kant A, Schatzkin A, Harris T, Ziegler R, Block G. Dietary diversity and
subsequent mortality in the first National Health and Nutrition Examination
Survey Epidemiologic Follow-up Study. Am J Clin Nutr 1993;57:434–40.
15. Kant AK, Schatzin A, Graubard BI, Schairer C. A prospective study of diet
quality and mortality in women. JAMA 2000;283(6):2109–15.
16. Yamori Y, Miura A, Taira K. Implications from and for food cultures for
cardiovascular diseases: Japanese food, particularly Okinawan diets. Asia
Pacific J Clin Nutr 2001;10(2):144–5.
17. Wahlqvist ML, Kouris-Blazos A, Hsa-Hage BH. Aging, food, culture and
health. Southeast Asian J Trop Med Pub Hlth 1997;28(suppl. 2):100–12.
18. de Groot LC, van Staveren WA, Burema J. Survival beyond age 70 in
relation to diet. Nutr Rev 1996;54:211–12.
19. Trichopoulou A, Kouris-Blazos A, Vassilakou T, Gnardellis C,
Polychronopoulos E, Venizelos M et al. Diet and overall survival of elderly
Greeks: a link to the past. Am J Clin Nutr 1995;61:1346S–1350S.
20. Wahlqvist ML. Nutrition and diabetes in the Asia–Pacific region with
reference to cardiovascular disease. Asia Pacific J Clin Nutr 2001;10:90–6.
21. Heaney R. Nutrient interactions and the calcium requirement. J Lab Clin
Med 1994;124:15–16.
22. Heaney R. Protein intake and the calcium economy. J Am Diet Assoc
1993;93:1259–60.
23. Wahlqvist M ed. Food and nutrition: Australasia, Asia and the Pacific.
Sydney: Allen & Unwin, 1997.
24. Gerster H. High-dose vitamin C: a risk for persons with high iron stores?
Internat J Vit Nutr Res 1999;69(2):67–82.
25. Cobiac L, Baghurst K. Iron status and dietary iron intakes of Australians.
Food Aust 1993;April:S1–S24.
26. Mendoza C, Viteri FE, Lonnerdal B, Raboy V, Young KA, Brown KH.
Absorption of iron from unmodified maize and genetically altered low-
phytate fortified with ferrous sulfate or sodium iron EDTA. Am J Clin Nutr
2001;73:80–5.
27. Horwath C. Dietary intake studies in elderly people. World Rev Nutr Diet
1989;59:1–70.

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Dietary Guidelines for Australian Adults
28. Hunt JR, Matthys LA, Johnson LK. Zinc absorption, mineral balance, and
blood lipids in women consuming controlled lactoovovegetarian and
omnivorous diets for 8 weeks. Am J Clin Nutr 1998;67:421–30.
29. National Health and Medical Research Council. The role of polyunsaturated
fats in the Australian diet. Canberra: National Health and Medical Research
Council, 1992.
30. James M, Gibson R, Cleland L. Dietary polyunsaturated acids and
inflammatory mediator production. Am J Clin Nutr 2000;71:343S–348S.
31. Haddad E, Sabate J, Whitten C. Vegetarian food guide pyramid: a
conceptual framework. Am J Clin Nutr 1999;70:615S–619S.
32. Ball M, Bartlett M. Dietary inake and iron status of Australian vegetarian
women. Am J Clin Nutr 1999;70:353–8.
33. Messina V, Burke K. Vegetarian diets—position of the American Dietetics
Association. J Am Diet Assoc 1997;97:1317–21.
34. Pliner P, Polivy J, Herman CP, Zakalusn I. Short term intake of overweight
individuals and normal weight dieters and non-dieters with and without
choice among a variety of foods. Appetite 1980; 1: 203-13.
35. Bellisle F, Le Magnen J. The structure of meals in humans:eating and
drinking patterns in lean and obese subjects Physiol Behav 1981; 27:649-
58.
36. Rolls BJ, Rowe EA,Rolls ET, Kingston B,Megson , Gunary R. Variety in a
meal enhances food intake in man Physiol Behav 1981; 26: 215-21.
37. Rolls, BJ, Rolls ET, Rowe EA, Sweeney K. Sensory specific satiety in man.
Physiol Behav 1981; 27 :137-42.
38. Rolls BJ, Rowe EA, Rolls ET. How sensory propoerties of foods affect
human feeding behaviour Physiol Behav 1982; 29: 409-17.
39. Spiegel TA, Stellar E. Effects of variety on food intake of underweight,
normal weight and overweight women. Appetite 1990; 15: 47-61.
40. McCrory MA, Fuss PJ, McCallum JE, Yao M, Vinken AG, Hays NP et al.
Dietary variety within food groups: association with energy intake and
body fatness in men and women. Am J Clin Nutr 1999;69:440–7.
41. Russell RM. The vitamin A spectrum: from deficiency to toxicity. Am J Clin
Nutr 2000;71:878–84.
42. Dreosti IE. Niacin. J Food Nutr 1984;41:126–34.
43. Ausman LM, Mayer J. Criteria and recommendations for vitamin C intake.
Nutr Rev 1999;57(7):222–9.
44. Rutishauser IHE. Vitamin B-6. J Food Nutr 1982;39:158–67.

16 Dietary Guidelines for Australian Adults
1. ENJOY A WIDE VARIETY OF NUTRITIOUS FOODS
45. Rutishauser IHE. Vitamin B-6—update. In: Truswell A, ed. Recommended
nutrient intakes—Australian papers. Sydney: Australian Professional
Publications, 1990.
46. Fraser DR. Vitamin D. J Food Nutr 1987;44:3–8.
47. Roeser HP. Iron. J Food Nutr 1985;42:82–92.
48. McCrory MA, Coulston AM. Limitations on the adage ‘eat a variety of
foods’? Am J Clin Nutr 1999;69(3):350–1.
49. Hill JO, Peters JC. Environmental contributions to the obesity epidemic.
Science 1998;280:1371-4.
50. Mennell S, Murcott A, van Otterloo A. The sociology of food: eating, diet
and culture. London: Sage, 1992.

Dietary Guidelines for Australian Adults 17
1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
1.1 EAT PLENTY OF VEGETABLES,
LEGUMES AND FRUITS
Ivor Dreosti
TERMINOLOGY
Vegetables
Vegetables includes all leafy green vegetables (for example, spinach, lettuce,
silver beet and bok choi), members of the crucifer family (for example, broccoli,
cabbages and brussels sprouts), all root and tuber vegetables (for example,
carrots, yams and potatoes), edible plant stems (for example, celery and
asparagus), gourd vegetables (for example, pumpkin and cucumber), allium
vegetables (for example onion, garlic and shallot) and corn, although this last
food is usually regarded as a cereal. Some vegetables are eaten raw; others are
best cooked because this makes them more palatable and digestible.
Fruits
The term fruit generally applies to the sweet, fleshy edible portion of a plant
that arises from the base of the flower and surrounds the seeds; apples, oranges,
plums, berries, tomatoes and avocados are examples. Most fruit is eaten raw,
although in some cases cooking can offer a tasty alternative.
Legumes
Legumes refers also to pulses and includes all forms of prepared beans and
peas—dried, canned and cooked legumes, bean curd, tofu, and legume-flour
products such as pappadams. Among the well-known edible legumes are butter
beans, haricot (navy) beans, red kidney beans, soybeans, mung beans, lentils,
chick peas, snow peas and various other fresh green peas and beans. Legumes
are generally cooked: this improves their nutritional value and reduces the risk
of toxicity that occurs with some legumes because of the presence of heat-labile
toxins. Occasionally, however, they can be eaten raw; snow peas are an
example. Strictly speaking, legumes are specialised forms of fruit since the pod
surrounds the seeds and arises from the base of the flower, as occurs with fruit.
But, because the main food material in legumes is the seeds, they are generally
placed in a separate category.

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Dietary Guidelines for Australian Adults
BACKGROUND
Each year in Australia about 40 per cent of all deaths can be attributed to
diseases of the circulatory system and 27 per cent to cancer, accounting for
annual health care costs of around $4 billion and $2 billion respectively.1
Scientific surveys of populations around the world have consistently provided
good epidemiological evidence that people who regularly eat diets high in fruits
and vegetables and legumes have substantially lower risks of coronary heart
disease2–4, stroke2,5, several major cancers6,7 and possibly hypertension8,9, type 2
diabetes mellitus10,11, cataracts12,13, and macular degeneration of the eye.14,15 A
large number of experimental studies with model systems have afforded further
evidence of a protective effect of fruits and vegetables against these non-
communicable chronic diseases and offer some clues about the actual substances
in these foods that may be protective as well as the mechanisms by which they
may act. Accordingly, a new term, phytochemicals, has been added to the
vocabulary of nutritionists; it refers to the many different substances occurring in
plant foods in small amounts (in addition to the well-established nutrients) and
which appear to contribute significantly to reducing the risk of non-
communicable chronic diseases.
The Australian Guide to Healthy Eating recognises the importance of fruits and
vegetables in a healthy diet and recommends consumption of two to four
servings of fruit and four to eight servings of vegetables each day for adults16,
which is generally in line with the minimum five servings of vegetables and two
of fruit established by the core food group analysis endorsed by the National
Health and Medical Research Council.17 It should, however, be noted that
average current vegetable and fruit consumption in Australia falls significantly
short of this recommendation, as Table 1.1.1 shows.
Table 1.1.1 Mean intakes of fruits and vegetables in Australian adults in
relation to the NHMRC core food group recommendations18
Fruit Vegetables
Mean intake Mean intake
(% recommended) (% recommended)
Including Without
Age Including Excluding potato/ potato/
group juice juice Recommended legumes legumes Recommended
M F M F (g/day) M F M F (g/day)
16–18 49 65 26 29 300–450 98 66 42 29 300
19–24 65 62 31 31 300 86 68 46 42 300–375
25–44 67 67 42 44 300 87 69 52 45 300–375
45–64 76 74 53 57 300 95 79 60 52 300–375
65+ 74 75 60 59 300 88 75 54 49 300–375
Notes: Mean intake data are from the 1995 National Nutrition Survey. One serve of fruit equals
150g; one serve of vegetables equals 75g; where recommendations are a range, the mid-point
has been used for calculations. The World Cancer Research Fund recommends 400–800g per
day of fruits and vegetables combined, but excluding potatoes and legumes, for adults.

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SCIENTIFIC BASIS
Original and recent studies
Cardiovascular disease
In 1997, 28 studies in humans of fruit and vegetable consumption and the risk of
cardiovascular disease were reviewed, and good evidence was found of a
protective effect associated with higher intakes of plant foods.2Some years
earlier, in 1993, the US Food and Drug Administration allowed a health claim to
the effect that diets low in saturated fat and cholesterol and rich in fruits,
vegetables and grain products containing fibre, particularly soluble fibre, may
reduce the risk of coronary heart disease19, although a similar claim was not
allowed by the Canadian food authority. A subsequent large study in females
also reported a significant inverse association between fruit and vegetable intake
and cardiovascular disease.3
Recent experimental studies suggest that protection against heart disease may
arise in several ways, including through the presence of antioxidant
phytochemicals (for example, bioflavonoids and carotenoids) and antioxidant
vitamins (for example, vitamins E and C) at significant levels in fruits and
vegetables, which may reduce the risk of cholesterol becoming oxidised in
coronary blood vessels and deposited to form atheromatous plaques.20
Importantly, a review of the effect of beta-carotene on coronary heart disease in
several observational and intervention studies suggests protection only in the
observational studies, highlighting the possibility that the benefit reported in
some studies may be related to foods rich in beta-carotene and other
antioxidants and micro-nutrients—or indeed other confounding factors—rather
than to the beta-carotene alone.21 Also important is the apparent capacity of
vegetable protein to reduce blood cholesterol levels in people habitually
consuming an omnivorous diet.22
Particular emphasis is being focused at present on the importance of the vitamin
folate in reducing blood levels of the compound homocysteine, which is a
possible risk factor for coronary heart disease.4,23 Especially noteworthy is the
fact that a major source of dietary folate is green, leafy vegetables, and studies
suggest that many adults have folate intakes well below the level needed to
minimise the risk associated with raised levels of homocysteine.24
Stroke
A systematic review of 14 studies including ecological, case-control and cohort
studies dealing with stroke and fruit and vegetables found strong evidence of a
protective effect associated with higher intakes of plant foods.2The mechanism
for this apparent protection is not clear, but it appears to exist for strokes of both
haemorrhagic and ischaemic origin.5In one large study extending over eight
years, protection was associated with vegetable intake rather than fruit25,
although generally both types of plant food are considered to be likely
protective agents.26

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1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
Dietary Guidelines for Australian Adults
Hypertension
Because plant foods contribute significantly to the intake of potassium and
magnesium—both of which have been proposed to be associated with a lower
blood pressure—diets high in fruits and vegetables will increase the daily intake
of both minerals and may help prevent or control hypertension.6,27 In a study
with women in the United States, lowered blood pressure was found to be
associated with higher intakes of fruits and vegetables, fibre and magnesium8;
more recently, data from the Dietary Approaches to Stop Hypertension (DASH)
randomised clinical trial have indicated that diets rich in fruits and vegetables,
with or without low-fat dairy products, significantly reduced ambulatory blood
pressure after an eight-week intervention period28, especially in African
Americans and people with hypertension.29 Similar results were found with US
adolescents who had elevated blood pressures: blood pressure was lower in
those subjects with higher intakes of a combination of nutrients including
potassium, calcium, magnesium and vitamins, as provided by diets rich in fruits
and vegetables and low-fat dairy products.30
Cancer
Health researchers have estimated that at least 30 per cent of many major
cancers have a strong dietary link and that the link may be even stronger for
some cancers.6Among the dietary factors underlying this association are
substances that may aggravate the development of cancer and, very importantly,
substances that reduce cancer risk. Dietary components in the latter group
include fibre, fruits and especially vegetables. In fact, the association between
fruits and vegetables is sufficiently widely recognised that the US Food and Drug
Administration has allowed a health claim to the effect that diets low in fat and
rich in fruit and vegetables may reduce the risk of some cancers.19
Not surprisingly, the protective effect of fruit and vegetables has been noted
especially in relation to the oral cavity, oesophagus, stomach and large bowel,
where local contact may be a factor. Significant risk reduction has also been
observed for cancers of the lung and possibly the breast, endometrium and
pancreas.6,7 Many factors in fruit and vegetables have been proposed to account
for the foods’ protective effect and many potential mechanisms suggested. Much
emphasis is currently placed on the many novel phytochemicals found in plant
foods (for example, carotenoids, bioflavonoids, isothiocyanates and indole
carbinols) and on several established vitamins and minerals (for example,
vitamins C and E, folate, selenium and calcium). Proposed mechanisms range
from reduced formation of cancer-promoting substances in the gastrointestinal
tract (through antioxidant activity), to the part played by phytochemicals and
micro-nutrients in detoxification of carcinogenic substances, and to functions
relating to the containment and destruction of existing cancer cells by means of a
variety of physiological processes and improved immunological activity against
cancer cells.6,7,31
In the 1997 World Cancer Research Fund and American Institute for Cancer
Research (WCRF–AICR) global review of nutrition and cancer prevention7,

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1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
Dietary Guidelines for Australian Adults
prevention by fruit and vegetables was rated to be ‘convincing’ for cancers of the
mouth, pharynx, oesophagus, stomach, colon, rectum and lung; ‘probable’ for
the larynx, pancreas, breast and bladder; and ‘possible’ for the ovaries, cervix,
endometrium, thyroid, liver, prostate and kidney. Since that report, data
generally confirming these findings have become available from a number of
further case-control and cohort studies. In particular, lower risks of cancer have
again been found for the oral cavity32,33, stomach34 and colon and rectum35 in
relation to higher vegetable and fruit intake, although a recent study found no
evidence that one extra serving of fruit and vegetables provides any measurable
additional protection.36
Two recent studies on lung cancer also consistently indicate that a high intake of
fruit and vegetables is protective, particularly with respect to brassicae
vegetables, tomatoes, lettuce and cabbage.37,38 Further suggestive evidence of
protection by fruits and vegetables has been noted for cancer of the bladder39,40,
breast41,42 and, to a lesser extent, prostate, notably in relation to the carotenoid
lycopene.43,44
It should be noted, however, that although considerable emphasis has been
placed on the WCRF–AICR review, attention should be paid to the study by the
UK Department of Health Committee on the Medical Aspects of the Food Supply
(COMA), which also reviewed the evidence concerning the potential protection
against cancer afforded by fruit and vegetables.45 The COMA study ranked the
evidence into four categories, the top two being ‘strong’ and ‘moderate’. No
‘strong’ association was found between fruit and vegetable consumption and
cancer at any site, while a ‘moderate’ association was noted for cancers of the
stomach, colon and rectum. In contrast, the WCRF–AICR rated as ‘convincing’ the
evidence for an association for the mouth/pharynx, stomach, colon, rectum and
lung.7Convincing was defined to mean that the evidence of causal relationships
was conclusive and sufficient for making dietary recommendations. Clearly,
COMA’s interpretation of the data is more cautious than the WCRF–AICR
interpretation, but both committees recognise the importance of these foods in
reducing cancer risk. The WCRF–AICR is currently updating its analysis to
incorporate studies published since 1997.
Type 2 diabetes mellitus
Several recent reports have noted an association between increased consumption
of plant foods and lower incidence of obesity (which is a risk factor for diabetes)
and type 2 diabetes itself, although it is not clear at this stage whether this
apparent protection arises principally from a lower body weight. In the dietary
control of type 2 diabetes, vegetables are likely to be of particular value because
of their content of fibre and low–energy density carbohydrates and their possible
hypoglycaemic activity.6,10 Recently, a cross-sectional study in the United
Kingdom revealed an inverse association between the risk of type 2 diabetes and
frequent consumption of vegetables throughout the year, although the effect did
not appear to be significant during the summer months.46

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1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
Dietary Guidelines for Australian Adults
Cataract and macular degeneration of the eye
Several studies in humans have reported that the risk of developing ocular
cataracts is significantly higher in people with low dietary intakes of fruit and
vegetables, vitamins C and E, and beta-carotene.12,47 A similar increased risk was
observed in people with low levels of vitamins C and E in their blood.
Experimental studies with model systems have added further support to the
notion that above-average intakes of antioxidant nutrients may delay the onset of
senile cataract.12 More recently, a modest protective effect against the
development of cataracts has been observed for higher intakes of the carotenoids
lutein and zeaxanthin.48
Age-related degeneration of the macula—the colour-sensitive yellow spot on the
retina of the eye—is another serious cause of acute blindness in the elderly and
is not reversible. Findings from a number of human studies suggest that people
with low levels of carotenoids and the antioxidant vitamins C and E in their
blood, and who smoke, are at increased risk of developing macular
degeneration. Experimental studies indicate that two carotenoids in particular—
lutein and zeaxanthin—appear to be accumulated by the macula, and in a human
study when the dietary intake of carotenoids was analysed the sum of the intake
of lutein and zeaxanthin had the strongest protective effect against macular
degeneration. Taken together, these findings suggest that in many cases macular
degeneration may be prevented by eliminating smoking and ensuring an
adequate intake of fruit and vegetables.14 Of particular interest are several recent
reports that highlight the presence of lutein and zeaxanthin in precise but
different orientations in the membranes of the macula, which suggests that these
two carotenoids may serve a special role in reducing the risk of age-related
macular degeneration.49,50
Special groups
Pregnancy
The Australian Guide to Health Eating advises an additional daily intake of
around one serving of fruit and one of vegetables during pregnancy.16 This
increase is especially important to provide the extra folate, vitamin C and other
micro-nutrients recommended in the Recommended Dietary Intakes for Use in
Australia.51
Lactation
The Australian Guide to Health Eating advises an additional daily intake of
around three servings of fruit and two of vegetables during lactation.16 This is
needed to meet the substantially increased requirement for vitamin A, folate,
vitamins C and E, and other micro-nutrients at that time.51

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Dietary Guidelines for Australian Adults
Vegetarians
This guideline applies equally to vegetarians and to people eating other diets.
Vegetarians should, however, give particular emphasis to eating legumes and
nuts in order to increase their iron and complementary protein intake from plant
sources. In addition, fruit juices or fruit should be consumed in the same meal in
order to provide vitamin C, which will increase iron absorption.
PRACTICAL ASPECTS OF THIS GUIDELINE
Relationship to the Australian Guide to Healthy Eating
A wide variety of fruits is recommended, including apples and pears, citrus
fruits, melons, tomatoes, berries, grapes, bananas, and stone fruits such as
apricots and peaches. The Australian Guide to Health Eating’ contains
recommendations for fruit include raw, stewed or canned varieties, with rather
less emphasis on fruit juices and dried fruit since they tend to be lower in fibre
and more energy dense respectively, although a modest intake of both (say, one
serving a day) is acceptable.
A variety of vegetables is also recommended, including dark green vegetables
such as spinach and broccoli; orange or yellow vegetables such as pumpkin and
carrots; crucifers such as broccoli, cauliflower and cabbage; starchy vegetables
such as potatoes, yams and the cereal food corn; and salad vegetables and fruits
such as lettuce, tomato, cucumber and capsicum. Many of these foods can be
eaten raw or slightly cooked, and some, for example salad items, should be
served that way to maximise their nutrient content.
The dominance of potatoes as a source of vegetables in Australia is of some
concern: they are not as rich in phytochemicals as many other vegetables and
some of the more popular forms—French fries, for example—can also be
relatively high in fat.
How do nuts and seeds fit in?
Many nuts and seeds are similar to fruits except that the seed is the main edible
component and the whole structure becomes dry on maturing. Most nuts and
seeds provide a wide range of nutrients and are generally pleasantly flavoured,
so they can usefully be included with fruits and vegetables in plant-based dishes
or other dishes such as stir-fries and in desserts. These foods are of particular
value in providing significant levels of protein and essential fatty acids, both the
n-6 fatty acids and, in some cases (such as walnuts, canola and flaxseed), the n-3
fatty acids.

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1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
Dietary Guidelines for Australian Adults
Preparation of fruit and vegetables
Certain nutrients and phytochemicals in plant foods are damaged by cooking;
others are not. In fact, in some cases the availability of a nutrient may be
increased by the cooking process; for example, carotenoids are absorbed better
from cooked tomatoes than raw ones. As a general rule, fruit and vegetables may
be eaten in the manner most palatable to the consumer, although a good
proportion should always be eaten raw.
When vegetables are cooked they should not be overcooked since this will cause
loss of nutrients. Stir-frying is an effective method of cooking vegetables: it tends
to minimise nutrient loss and provides a tasty product with good texture. Light
microwaving and steaming are also better than deep-frying or prolonged boiling.
Generally, when cooking vegetables it is useful to use a small amount of oil
because this enhances absorption of the fat-soluble vitamins (for example,
vitamins A and E) as well as other fat-soluble dietary components such as the
carotenoids.
It should be noted that eating the variety of fruits and vegetables recommended
in the Australian Guide to Health Eating will ensure an adequate intake of some
of the less widely distributed dietary components—for example, green leafy
vegetables for folate; yellow and orange fruits and vegetables for carotenoids;
cruciferous vegetables for dithiolthiones and isothiocyanates, which improve the
body’s detoxification capacity; the allium vegetable family for allyl sulfides,
which also improve detoxification processes; fruit for bioflavonoids, which
appear to serve many beneficial functions in the body, including acting as
antioxidants; and citrus fruit and capsicum for vitamin C. Where necessary,
frozen and canned fruits and vegetables are acceptable since good levels of
nutrients are retained by both processes, especially freezing.
Dietary change
The objective of the fruit and vegetable guideline is not to encourage people to
eat only vegetarian meals; rather, it is to highlight the important health benefits
to be derived from regular consumption of plant-based dishes together with
individual fresh and cooked fruits and vegetables.
RELATIONSHIP TO OTHER GUIDELINES
The present guideline differs from the previous guideline in that two separate
guidelines have been established, one for breads and cereals and one for
vegetables, legumes and fruits. This change reflects the approach taken in the
recent Dietary Guidelines for Older Australians52: it is felt that the health benefits
conferred by these two categories of plant foods often occur through largely
different mechanisms and the dietary components involved are distributed
differently between cereal grains and vegetables, legumes and fruits.

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1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
Dietary Guidelines for Australian Adults
Enjoy a wide variety of nutritious foods
In order to obtain optimal health benefits from vegetables, legumes and fruit, a
wide variety should be consumed.
Eat plenty of cereals (including breads, rice, pasta and noodles),
preferably wholegrain
Apart from providing a good source of energy, cereal-based foods contribute a
number of protective factors to the diet, complementing and extending many of
the benefits derived from vegetables, legumes and fruits.
Limit saturated fat and moderate total fat intake
Vegetables, legumes and fruits are low in saturated fat.
Choose foods low in salt
Vegetables, legumes and fruits are low in salt (sodium) but are good suppliers of
potassium.
Care for your food: prepare and store it safely
The nutritional value and palatability of fruit and vegetables will decline if these
foods are not adequately stored. In addition, there is a risk that moist vegetables,
legumes and fruits that are not peeled may develop bacteria on their surface and
cause sickness if they are not well washed in clean water. Sprouts and salads are
prone to contamination with bacteria and viruses and need thorough washing
and sanitation.
CONCLUSION
There is strong evidence of a protective effect of certain vegetables, legumes and
fruit against the development of a number of non-communicable chronic
diseases, among them cancer, cardiovascular disease, type 2 diabetes,
hypertension, and cataract and macular degeneration of the eye. This may, in
part, be mediated through phytochemicals. Adults are encouraged to consume on
average at least two helpings of fruit and five of vegetables each day, selected
from a wide variety of types and colours and served cooked or raw, as
appropriate.

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1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
Dietary Guidelines for Australian Adults
EVIDENCE
There is Level II evidence (reference 9) and Level III evidence (references 3, 4,
8 and 30) in relation to the benefits of fruit and vegetable consumption and
coronary heart disease, hypertension and stroke. There is Level III evidence
(references 32 to 44) in relation to fruit and vegetable consumption and cancer
of various kinds.
Although current evidence concerning the benefit of vegetables and fruit in
protecting against several degenerative diseases is strongly persuasive, it is
largely based on retrospective observational studies. Further prospective
intervention studies are needed, although it is recognised that these are difficult,
and costly, to carry out. Nevertheless, a considerable number are already under
way and they will provide invaluable information in the coming decade. In
addition, more needs to be established concerning the roles of the various
phytochemicals in disease prevention, as well as their interaction with the range
of genotypes found in the human population.
REFERENCES
1. Australian Parliament. National Health Priority Areas initiative. Current
Issues Brief 18, 1999–2000. <www.aph.gov.au/library/pubs/cib/1999-
2000cib18.htm>, viewed February 2002.
2. Ness AR, Powles JW. Fruit and vegetables, and cardiovascular disease: a
review. Int J Epidemiol 1997;26:1–13.
3. Liu S, Manson JE, Lee IM, Cole SR, Hennekens CH, Willett WC et al. Fruit
and vegetable intake and risk of cardiovascular disease: the Women’s
Health Study. Am J Clin Nutr 2000;72:922–8.
4. Law MR, Morris JK. By how much does fruit and vegetable consumption
reduce the risk of ischaemic heart disease? Eur J Clin Nutr 1998;52:549–56.
5. Gillman MW, Cupples LA, Gagnon D, Posner BM, Ellison RC, Castelli WP,
Wolf PA. Protective effects of fruits and vegetables on development of
stroke in men. JAMA 1995;273:113–17.
6. Steinmetz KA, Potter JD. Vegetables, fruit and cancer prevention: a review.
J Am Diet Assoc 1996;96:1027–39.
7. World Cancer Research Fund & American Institute for Cancer Research.
Vegetables and fruits. In: Food, nutrition and the prevention of cancer: a
global perspective. Washington, US: American Institute for Cancer Research
1997;436–46.
8. Ascherio A, Hennekens C, Willett WC, Sacks F, Rosner B, Manson J et al.
Prospective study of nutritional factors, blood pressure and hypertension
among US women. Hypertension 1996;27:1065–72.
9. Moore TJ, Vollmer WM, Appel LJ, Sacks FM, Svetkey LP, Vogt TM et al.
Effects of dietary patterns on ambulatory blood pressure: results from the

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1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
Dietary Guidelines for Australian Adults
Dietary Approaches to Stop Hypertension (DASH) trial. Hypertension
1999;34:472–7.
10. Platel K, Srinivasan K. Plant foods in the management of diabetes mellitus:
vegetables as potential hypoglycaemic agents. Nahrung 1997;41:68–74.
11. Williams DE, Wareham DJ, Cox BD, Byrne CD, Hales CN, Day NE.
Frequent salad vegetable consumption is associated with a reduction in the
risk of diabetes mellitus. J Clin Epidemiol 1999;52:329–37.
12. Taylor A. Cataract: relationship between nutrition and oxidation. J Am Coll
Nutr 1993;12:138–46.
13. Brown L, Rimm EB, Seddon JM, Giovannucci EL, Chasan-Taber L,
Spiegelman D et al. A prospective study of carotenoid intake and risk of
cataract extraction in US men. Am J Clin Nutr 1999;70:517–24.
14. Snodderly DM. Evidence for protection against age-related macular
degeneration by carotenoids and antioxidant vitamins. Am J Clin Nutr
1995;62:1448S–1461S.
15. Goldberg J, Flowerdew G, Smith E, Brody JA, Tso MO. Factors associated
with age-related macular degeneration: an analysis of data from the first
National Health and Nutrition Examination Survey. Am J Epidemiol
1998;128:700–10.
16. Department of Health and Family Services. The Australian guide to healthy
eating. Canberra: DHFS, 1998.
17. Cashel K, Jeffreson S. The core food groups. Endorsed by the National
Health and Medical Research Council. Canberra: Australian Government
Publishing Service, 1995;83.
18. Baghurst P, Beaumont-Smith N, Baghurst KI, Cox D. The relationship
between the consumption of fruits and vegetables and health status. Report
to Department of Health and Aged Care. Adelaide: CSIRO, 1999:75.
19. Kurtzweil P. Staking a claim to good health. FDA Consumer Magazine
1998;Nov/Dec:1–7.
20. Hamilton CA. Low-density lipoprotein and oxidised low-density
lipoprotein: their role in the development of atherosclerosis. Pharmacol
Therapeut 1997;74:55–72.
21. Tavani A, LaVerchia C. Beta-carotene and risk of coronary heart disease: a
review of observational and intervention studies. Biomed Pharmacother
1999;53:409–16.
22. Jenkins DJ, Popovich DG, Kendall CW, Vidgen E, Tariq N, Ranson TP et al.
Effect of a diet high in vegetables, fruit and nuts on serum lipids.
Metabolism 1997;46:530–7.
23. Verhoef P, Stampfer MJ, Rimm EB. Folate and coronary heart disease.
Current Opinion in Lipidology 1998;9:17–22.

28
1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
Dietary Guidelines for Australian Adults
24. Brussaard JH, Lowik MR, van der Berg H, Brants HA, Goldbohm RA. Folate
intake and status among adults in the Netherlands. Europ J Clin Nutr
1997;51(suppl. 3):S46–S50.
25. Manson JE, Willett WC, Stampfer MJ, Colditz GA, Speizer FE, Hennekens
CH. Vegetable and fruit consumption and incidence of stroke in women.
Circulation 1994;89:932.
26. Van Duyn MA, Pivonka E. Overview of the health benefits of fruit and
vegetable consumption for the dietetics professional: selected literature. J
Am Diet Assoc 2000;100:1511–21.
27. Kawano Y, Matsuoka H, Takashita S, Omae T. Effects of magnesium
supplementation in hypertensive patients: assessment by office, home and
ambulatory blood pressures. Hypertension 1998;32:260–5.
28. Moore TJ, Vollmer WM, Appel JL, Sacks FM, Svetkey LP, Vogt TM et al.
Effect of dietary patterns on ambulatory blood pressure: results from the
Dietary Approaches to Stop Hypertension (DASH) Trial Collaborative
Research Group. Hypertension 1999;34:472–7.
29. Svetkey LP, Simons-Morton D, Vollmer WM, Appel LJ, Conlin PR, Ryan DH
et al. Effects of dietary patterns on blood pressure: subgroup analysis of
the Dietary Approaches to Stop Hypertension (DASH) randomised clinical
trials. Arch Intern Med 1999;159:285–93.
30. Falkner B, Sherif K, Michel S, Kushner H. Dietary nutrients and blood
pressure in urban minority adolescents at risk for hypertension. Arch
Pediat Adolesc Med 2000;154:918–22.
31. Dreosti IE. What do our guidelines do for cancer prevention? Cereals,
vegetables including legumes and fruit guideline. Aust J Nutr Diet
2000;57:221–2.
32. Franceschi S, Favero A, Conti E, Talamini R, Volpe R, Negri E et al. Food
groups and oils and butter, and cancer of the oral cavity and pharynx. Brit
J Cancer 1999;80:614–20.
33. Bosetti C, Negri E, Franceschi S, Conti E, Levi F, Tomei F et al. Risk factors
for oral and pharyngeal cancer in women: a study from Italy and
Switzerland. Brit J Cancer 2000;82:204–7.
34. Ekstrom AM, Serafini M, Nyren O, Hansson LE, Ye W, Wolk A. Dietary
antioxidant intake and the risk of cardia cancer and non-cardia cancer in
Sweden. Int J Cancer 2000;87:133–40.
35. Franceschi S. Nutrients and food groups and large bowel cancer in Europe.
Europ J Cancer Prev 1999;9:549–52.
36. Michels KB, Giovannucci E, Joshipura KJ, Rosner BA, Stampfer MJ, Fuchs
CS et al. Prospective study of fruit and vegetable consumption and
incidence of colon and rectal cancer. J Nat Cancer Inst 2000;92:1740–52.
37. Voorrips LE, Goldbohm RA, Verhoeven DT, van Popper GA, Sturmans F,
Herman RJ et al. Vegetable and fruit consumption and lung cancer risk in

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1.1 EAT PLENTY OF VEGETABLES,LEGUMES AND FRUITS
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the Netherlands Cohort Study on diet and cancer. Cancer Causes and
Control 2000;11:101–15.
38. Michaud DS, Feskanich D, Rimm EB, Colditz GA, Speizer FG, Willett WC et
al. Intake of specific carotenoids and risk of lung cancer in two
prospective US cohorts. Am J Clin Nutr 2000;72:990–7.
39. Steinmaus CM, Nunez S, Smith AH. Diet and bladder cancer: a meta-
analysis of six dietary variables. Am J Epdiemiol 2000;151:693–703.
40. Nagano J, Kano S, Preston DL, Moriwaki H, Sharp GB, Koyama K et al.
Bladder cancer incidence in relation to vegetable and fruit consumption: a
prospective study of atomic bomb survivors. Int J Cancer 2000;86:132–8.
41. Ronco A, De Stefani E, Boffetta P, Deneo-Pellegrini H, Mendilaharsu M,
Leborgne F. Vegetables fruits and related nutrients and risk of breast
cancer: a case control study in Uruguay. Nutr & Cancer 1999;35:111–19.
42. Gandini S, Merzenich H, Robertson L, Boyle P. Meta-analysis of breast
cancer risk and diet: the role of fruit and vegetable consumption and the
intake of associated micronutrients. Europ J Cancer 2000;36:636–46.
43. Jain MG, Hislop GT, Howe GR, Ghadirian P. Plant foods, antioxidants and
prostate cancer risk. Nutr and Cancer 1999;34:173–84.
44. Cohen JH, Kristal AR, Stanford JL. Fruit and vegetable intake and prostate
cancer risk. J Nat Cancer Inst 2000;92:61–8.
45. UK Department of Health: Nutritional aspects of the development of cancer:
report of the working group on diet and cancer of the Committee on
Medical Aspects of Food and Nutrition Policy. Norwich, UK: The Stationery
Office, 1998.
46. Williams DE, Wareham NJ, Cox BD, Byrne CD, Hales CN, Day NE.
Frequent salad vegetable consumption is associated with a reduction in the
risk of diabetes mellitus. J Clin Epidemiol 1999;52:329–35.
47. Tavani A, Negri E, LaVecchia C. Food and nutrient intake and cataract. Ann
Epidemiol 1996;6:41–6.
48. Brown L, Rimm EB, Seddon JM, Giovannucci EL, Chasan-Taber L,
Spiegelman D et al. A prospective study of carotenoid intake and risk of
cataract extraction in US men. Am J Clin Nutr 1999;70:517–24.
49. Bone RA, Landrum JT, Friedes LM. Distribution of lutein and zeaxanthin
stereoisomers in the human retina. Expl Eye Res 1997;64:211–18.
50. Sommerburg EG, Siems WG, Hurst JS, Lewis JW, Kliger DS, van Kuijktu.
Lutein and zeaxanthin are associated with photoreceptors in the human
retina. Curr Eye Res 1999;19:491–5.
51. National Health and Medical Research Council. Recommended dietary
intakes for use in Australia. Canberra: Australian Government Publishing
Service, 1991.
52. National Health and Medical Research Council. Dietary guidelines for older
Australians. Canberra: NHMRC, 1999.

Dietary Guidelines for Australian Adults 31
1.2 EAT PLENTY OF CEREALS (INCLUDING BREADS,RICE,PASTA AND NOODLES), PREFERABLY WHOLEGRAIN
1.2 EAT PLENTY OF CEREALS
(INCLUDING BREADS, RICE, PASTA
AND NOODLES), PREFERABLY
WHOLEGRAIN
Peter Williams
TERMINOLOGY
Cereals
Cereals refers to the entire class of cereal foods, including whole or partially
processed cereal grains (for example, rice, oats, corn and barley), breads,
breakfast cereals, pasta, noodles, and other plain cereal products such as flour,
polenta, semolina, burghul, bran and wheatgerm. It excludes cereal-based
products with a significant amount of added fat and sugar—cakes, pastries,
biscuits, and so on.
Breads
Breads refers to leavened and unleavened wholemeal, white, mixed-grain, rye
and fruit breads, as well as rolls, bagels, English muffins, crispbreads, crumpets
and low-fat crackers.
Pasta and noodles
Pasta and noodles includes a wide range of Italian and Asian products based on
sheets of dough made from flours—usually wheat or rice flour—and water,
sometimes with egg added. Examples are plain spaghetti, lasagne, fettuccine,
udon and Hokkien noodles, rice paper and wonton wrappers. The term excludes
some instant noodles and flavoured pasta mixes with significant amounts of
added fat and salt.
Wholegrain
Wholegrain refers to cereal foods that incorporate all the components of the
natural grain, including the bran and germ. Foods that contain at least 51 per
cent by weight of any combination of whole grains can be termed wholegrain.1
This definition includes such foods as wholemeal breads and crispbreads, many
high-fibre breakfast cereals, oatmeal, wholemeal pasta, brown rice and popcorn.

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BACKGROUND
From an evolutionary perspective, consumption of cereal grain is relatively
recent, dating from only 5000 to 10 000 years ago, yet, today, eight cereals—
wheat, maize, rice, barley, sorghum, oats, rye and millet—provide more than
56 per cent of the energy and 50 per cent of the protein consumed on earth.2
Many traditional hunter-gatherer societies had diets with a relatively low
proportion of energy from carbohydrate (22–40 per cent) and only small amounts
of grain3, although Indigenous Australians may have consumed large quantities of
grain in some areas. However, it is difficult to base conclusions about desirable
dietary patterns for modern societies simply from an assessment of traditional
eating patterns of hunter-gatherers. Many things such as activity patterns,
availability of various foods and genetic background can influence food
consumption patterns or dietary needs. Recommendations made in a recent UN
report state that carbohydrate should provide more than 55 per cent of energy
for optimal health.4
Cereal grains form the basis of diets in many different cultures and cuisines.
They are generally an excellent source of carbohydrate and dietary fibre and are
also an important source of protein (ranging from 8 to 16 grams per 100 grams).
They are mostly low in fat and are good sources of B-group vitamins, vitamin E
and many minerals, notably iron, zinc, magnesium and phosphorus. Eating
enough cereal foods helps ensure an adequate nutritional intake. They can also
be stored safely for long periods and are relatively inexpensive: in 1998–99
purchases of cereal products accounted for only 7 per cent of household food
expenditure.5Ecologically, a high-carbohydrate diet based on cereals makes
good use of the world’s resources, since grain crops require relatively few input
resources per unit of food energy produced.6For these reasons all current dietary
guides have cereal foods as the largest component of the recommended daily
food intake.
Current intakes in Australia
Apparent consumption of cereal foods in Australia (an estimate of intake based
on national food-disappearance data), has remained relatively constant since the
1930s. In 1998–99 apparent consumption was 138.1 kilograms per person.7 There
have, however, been changes in the mix of products since the 1930s.
Consumption of rice and breakfast cereals has increased significantly and
consumption of flour has fallen. Bread consumption has varied over time: from
69.1 kilograms per head a year in 1958–59 it fell to a low of 44.4 kilograms in
1988–89 then rose to 53.4 kilograms in 1998–99.
The 1995 National Nutrition Survey, using 24-hour diet recall, found that 94.5 per
cent of Australians aged 19 years and over had eaten cereal foods on the day of
the survey, with the most commonly consumed foods being bread (80.5 per
cent) and breakfast cereals (50.9 per cent).8 The mean adult daily intakes were
250 grams for men and 181 grams for women. Intakes were somewhat lower
among people in rural and remote areas compared with people in metropolitan

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1.2 EAT PLENTY OF CEREALS (INCLUDING BREADS,RICE,PASTA AND NOODLES), PREFERABLY WHOLEGRAIN
areas and significantly higher among people born in Southeast Asia (because of
their much higher consumption of rice).
The National Nutrition Survey also found that for adult Australians, cereals are
important sources of energy, carbohydrate, dietary fibre, thiamin, iron and
magnesium, providing more than 20 per cent of the total daily intake of these
nutrients (see Table 1.2.1). They also provided more than 10 per cent of the
daily intakes of protein, polyunsaturated fat, riboflavin, niacin, folate, calcium,
phosphorus and zinc.
Table 1.2.1 Percentage of mean adult nutrient intake provided by cereal
foods, 19959
Nutrient Men aged 19 years and over Women aged 19 years and over
%%
Energy 20.0 20.8
Carbohydrate 33.2 33.1
Dietary fibre 34.9 33.6
Thiamin 41.3 40.5
Iron 30.1 29.3
Magnesium 24.3 24.8
Note: Biscuits, cakes and other cereal-based items are excluded.
Two Australian studies have shown that socioeconomic status may affect cereal
intake. One study of cereal intakes in various socio-economic groups in Australia
found that cereal foods contribute more to nutrient intakes among upper
occupational groups for both males and females.10 A study of 18-year-olds in
Western Australia also found higher levels of cereal consumption in groups of
higher socio-economic status.11
Most Australians seem to be satisfied with the amount of cereal foods they eat.
In the National Nutrition Survey only 8 per cent of respondents aged 19 years or
more reported they would like to change the amount they ate; this compares
with up to 30 per cent reporting that they wanted to eat more fruit and
vegetables.12 Despite this, the survey data show that even among adults with the
highest intakes (those aged 19–24 years), on the day of the survey only 34 per
cent of men and 21 per cent of women met the recommended core food group
cereal targets of seven servings a day.13
SCIENTIFIC BASIS
There have been many experimental studies dealing with individual nutritional
components provided by cereal foods (such as dietary fibre, starch and vitamin
E), but relatively few prospective studies or controlled experimental trials have

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1.2 EAT PLENTY OF CEREALS (INCLUDING BREADS,RICE,PASTA AND NOODLES), PREFERABLY WHOLEGRAIN
Dietary Guidelines for Australian Adults
used whole foods to find support for this dietary guideline. It is difficult to gain
people’s acceptance of long-term changes to the largest staple components of
their diets—and generally impossible to do so in a double-blind manner. As a
result, most of the available evidence comes from ecological, cross-sectional,
case control and cohort studies. Even in these the dietary methodology is often
inadequate for analysing the consumption of different types of cereals or
quantifying dose-responses.
All recent reviews have supported the beneficial effects of cereal fibre and
whole grains in relation to decreased risk of coronary heart disease and some
cancers1,14–17, and data from several countries suggest that higher intakes of
breads and cereals help people achieve dietary targets for lower fat
consumption.18,19 Cereals are also a major source of resistant starch in the diet,
which is important for colon health.20 In 1999 the US Food and Drug
Administration approved the health claim that ‘diets rich in whole-grain foods
and other plant foods and low in total fat, saturated fat and cholesterol may
reduce the risk of heart disease and certain cancers’.14
Coronary heart disease
The published results of over 200 human trials have led to the general
conclusion that foods rich in soluble fibre can lower plasma cholesterol.21–23 The
National Heart Foundation of Australia has stated, ‘The consumption of dietary
fibre, especially cereal fibre, is associated with a lower risk of CHD’.24 Meta-
analyses of intervention trials with two cereal foods, oats and psyllium, have
shown that these are particularly effective in reducing serum cholesterol.25,26 By
contrast, controlled human trials with supplements of isolated wheat fibre have
consistently shown no effect on plasma cholesterol.21
A large prospective study of male health professionals in the United States found
that dietary fibre intake was strongly associated with reduced rates of myocardial
infarction and that cereal fibre was apparently more protective than fibre from
fruits or vegetables.27 The study reported a 29 per cent reduction in coronary
heart disease for every 10-gram increase in daily intake of cereal fibre. Other
studies have also found a stronger association between cereal fibre and reduced
risk of coronary heart disease than with fibre from fruit or vegetables.28–30
Analysis of a prospective study of 31 284 post-menopausal women in Iowa
found the relative risk of CHD was 0.76 (95%CI: 0.55–1.05) among women in the
highest quintile of dietary fibre intakes compared with the lowest.35
The principal mechanism is probably viscous polysaccharides acting in the
gastrointestinal tract to decrease reabsorption of biliary cholesterol31, but other
components may be involved in the protective effect of wholegrain cereals:
vitamin E, folate, selenium, phytoestrogens and phytic acid may all be
important.32
In the Nurses Health Study, wholegrain consumption was associated with
significant reductions in risk of both CHD33 and ischaemic stroke.34 In older
women there is also evidence from the Iowa Women’s Health Study of a clear

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Dietary Guidelines for Australian Adults
1.2 EAT PLENTY OF CEREALS (INCLUDING BREADS,RICE,PASTA AND NOODLES), PREFERABLY WHOLEGRAIN
inverse association between wholegrain intake and the risk of ischaemic heart
disease35 as well as all-cause mortality.36 The authors calculated that if all women
consumed one serving of wholegrain foods each day total mortality rates might
be reduced by 8 per cent or more.
In that study there was a small positive association (adjusted hazard rate ratio
1.16) between refined grain intake and total mortality, but this was attenuated
and lost significance when wholegrains were added to the model. There was no
association between refined grain intake and risk of CHD.35 In a study of dietary
associates in patients with established coronary disease, a high intake of not only
wholegrain but also total cereal products was associated with lower total
cholesterol.37
Dietary carbohydrates may also exert an influence on cardiovascular disease risk
via their effect on insulin response. High–glycaemic index (or high GI)
carbohydrates are characterised by rapid absorption and high post-prandial
glucose and insulin responses and may result in decreased insulin sensitivity38, a
risk factor for CHD.39 (Appendix I to the Dietary Guidelines for Older Australians
provides a detailed discussion of the glycaemic index.) At least three cross-
sectional studies have also found an inverse relationship between HDL
cholesterol and the dietary glycaemic load.40–42 In the prospective Nurses Health
Study, over 10 years both the glycaemic load and the total diet GI were
predictive of CHD risk.43 One randomised crossover study with type 2 diabetics
found that lowering the GI of a diet (mainly by altering the physical form of the
cereals) resulted in significantly lower LDL and higher HDL cholesterol levels.44 A
study in free-living Australian diabetic subjects also found HDL cholesterol levels
were higher on a low- versus high-GI diet.45
Obesity
Although total energy intake and overall nutrient density appear to be the most
important factors affecting weight regulation, a high-fibre, low-fat diet is
recommended for maintenance of body weight and prevention of obesity.46–48
Obesity is associated with low fibre intake.49 When high-starch, high-sucrose and
high-fat ad libitum diets were compared, energy intake was lowest on the high-
starch, high-fibre diet50, and higher intakes of carbohydrates have been linked to
lower waist–hip ratios and lower body mass index.51 The recent CARMEN study
found there were no significant differences in weight loss when fat was replaced
with either simple or complex carbohydrate, but energy density and energy
intake were lower with diets high in complex carbohydrates.52
There are several ways high-fibre cereals can reduce energy intake and help
maintain weight: they take longer to eat; they decrease the energy density of a meal;
and some fibres may slow gastric emptying and affect gastrointestinal hormones that
influence food intake.53 Compared with low-GI choices, consumption of high-GI
carbohydrates promotes a more rapid return of hunger and increases subsequent
energy intake, and slower digestion of carbohydrate is associated with higher
satiety.54 Thus, consumption of wholegrain and lower GI cereals, instead of highly
refined cereals, may help prevent excess weight gain.55,56

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Dietary Guidelines for Australian Adults
Diabetes
The joint WHO–FAO consultation on carbohydrates concluded that foods rich in
slowly digested, or resistant, starch or high in soluble fibre might be protective
against diabetes.4Recent large prospective studies of men and women have
found cereal fibre intake was inversely associated with the risk of developing
type 2 diabetes and that the protective effect was even greater when combined
with a low total glycaemic load.30,57
A large prospective study of adult women in the United States found that a lower
risk of type 2 diabetes was associated with higher intakes of all cereal grains (RR
0.75; 95%CI: 0.63–0.89) and wholegrains in particular (RR 0.73; 95%CI: 0.63–
0.85), whereas a higher intake of refined grain was related to increased risk (RR
1.26; 95%CI: 1.08–1.46).58 The individual foods associated with the strongest
protective effects were wholegrain breakfast cereal, brown rice and bran.
However, in that study refined grain included a wide range of higher fat cereal-
based foods such as cakes, desserts and pizzas, and wholegrain foods included
some that are relatively refined (such as couscous).
For people with established type 2 diabetes, use of low-GI foods is associated
with improvement in glycaemic control.44,59 In Southern European patients with
type 2 diabetes, HbA1c was 11 per cent lower in patients whose diets were in the
lowest quartile for GI compared with those in the highest and was related to
eating more pasta.41 During pregnancy, women on a low-GI diet (eating bran
breakfast cereal, wholegrain bread and pasta) experienced no change in their
glycaemic response to a 500-calorie test meal with 55 per cent of energy from
carbohydrate, whereas those who switched to a high-GI diet experienced a
190 per cent increase in their response.60
Cancer
Two major reviews of the relationship between cereal consumption and cancer
prevention have been published.61,62 It is difficult to evaluate many studies
because of the paucity of biological markers; the inadequacy of many food-
intake measurements, which often do not distinguish the degree of refinement of
cereal foods; and the low overall intakes of cereal fibre in many of the studies
from the United States. There is, however, emerging agreement on the probable
protective role of cereals in relation to some important cancer types. In
particular, it appears that wholegrain intake confers benefits. In a review of 40
case-control studies of 20 cancers, the pooled odds ratio for high versus low
wholegrain intake was 0.66 (95%CI: 0.60–0.72).63 Among the protective
components in wholegrains may be fermentable carbohydrates, oligosaccharides,
flavonoids, phenolics, phytoestrogens, lignans, protease inhibitors, saponins and
selenium.64–66
Some case-control studies have suggested not only that wholegrains are
protective but also that, conversely, consumption of refined cereals (including
bread, pasta and rice) increases the risk of cancers of the oral cavity,

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oesophagus, larynx, stomach and colon.