Many medical organizations have lined up to criticize the updated Dietary Guidelines for Americans, 2020-2025, released by the US Department of Agriculture (USDA) and the Department of Health and Human Services (HHS) during the previous administration.1 The guidelines did not lower sugar and alcohol intake as recommended by an advisory committee, with some organizations suggested that industry bias may have trickled into the guidelines.2

The USDA-HHS cited a lack of sufficient evidence to substantiate changes to the quantitative limits for sugar or alcohol as the reason for deviating from the advisory committee’s recommendations on sugar and alcohol limits.2,3 Thus, the updated guidelines retain the 2015-2020 recommendations to limit added sugar to less than 10% of calories per day and alcohol beverages to 2 drinks per day for men and 1 drink per day for women. This decision was made despite the 2020 Dietary Guidelines Advisory Committee’s recommendations to lower sugar intake to less than 6% of caloric intake and limit alcoholic beverages to 1 drink per day for both men and women.

The updated guidelines were based in part on findings from systematic evidence-based reviews of the literature by the advisory committee as well as consultation with experts at federal agencies and comments from both these agencies and the public, according to the USDA-HHS.3

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The Sugar and Alcohol Debate

According to the American Institute for Cancer Research (ACIR), the guidelines “ignore critical evidence” on the link between alcohol use and cancer and that the USDA-HHS “bowed to industry pressure” in not lowering the alcohol intake recommendation for men.4 A single drink is defined in the guidelines as 12 fluid ounces of regular beer (5% alcohol), 5 fluid ounces of wine (12% alcohol), or 1.5 fluid ounces of 80 proof distilled spirits (40% alcohol).

Retaining the 2015-2020 guidelines implies that 2 alcoholic drinks per day are safe for men. However, “that advice is contrary to the convincing evidence that intake of even less than 1 drink per day elevates the risk for several cancer types, including head and neck, esophageal, and breast cancers,” the ACIR said.

Literature reviews and meta-analyses conducted as part of the World Cancer Research Fund and AICR’s Continuous Update Project “have found strong evidence that consumption of alcoholic drinks increases the risk for 6 types of cancer, with convincing evidence showing elevated risk with consumption of less than even 1 serving of alcohol per day, for some cancers,” said Nigel Brockton, PhD, Vice President of Research at ACIR. 

Although the new guidelines recommend limiting added sugars and choosing unprocessed forms of meats, they “do not fully reflect the research on the health benefits of reducing intake of processed meats and further reducing intake of added sugars,” noted ACIR. The ACIR’s evidence review concluded that added sugars provide excess calories and increase the risk for overweight and obesity, which is a risk factor for 12 types of cancer.

The American Heart Association (AHA) also expressed disappointment that the advisory committee’s recommendations were not included in the guidelines.5 “Many adults and children have little room in their diet for empty calories and need to go lower than 10% [of sugar] to have a healthy dietary pattern and meet their essential nutrient needs,” said AHA President Mitchell S. V. Elkind, MD, MS, FAHA, FAAN.

NPs and PAs Weigh In on Sugar and Alcohol Guidelines


“Obesity and detrimental effects of alcohol have tremendous negative consequences on health,” said incoming President of the American Association of Nurse Practitioners (AANP) April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FAAN, in an interview with Clinical Advisor. “I would encourage the USDA-HHS to continue study into the effects of sugar and alcohol consumption and evidence-based parameters,” said Dr. Kapu, who is an acute care nurse practitioner and associate chief nursing officer at Vanderbilt University Medical Center and Professor of Clinical Nursing at Vanderbilt University School of Nursing in Nashville, Tenn.

 “As NPs, we follow the evidence when counseling patients on diet and nutrition,” she added. “We use multiple sources and emerging evidence.  Based on that evidence, many of us have been counseling patients to consume lower levels than in the guidelines, especially for patients whose family history, risk profile, and other factors increase their likelihood of dietary-related disease.”

If patients were able to adhere to lower intakes of sugar and alcohol “I do believe we would see both improved rates of overweight and obesity and reduced complications from alcohol intake,” agreed Allyson Hamacher, PA-C, RD, who is a physician assistant (PA) in the department of neurology at Mayo Clinic in Phoenix, Arizona, and a faculty member of the PA Foundation Nutrition Outreach Fellowship. The challenge, she said, is that many people were already not meeting the 2015-2020 guidelines for sugar and alcohol intake.

How Can Clinicians Boost Adherence to Dietary Guidelines?

The Healthy Eating Index (HEI) scores measure how closely a population’s diet aligns with the Dietary Guidelines, a USDA spokesperson told Clinical Advisor. Although the HEI score for the US population has made incrementally small advances over the years, it remains low at a score of 59 out of 100 in 2015-2016 (Figure).1 As noted in the Dietary Guidelines, children aged 2 to 4 years and adults aged 60 years and older are doing the best, with scores of 61 and 63 respectively. HEI scores were lowest among children aged 9 to 13 years (52) and adolescents aged 14 to 18 years (51).

Figure. Adherence to the USDA-HHS Dietary Guidelines in the US population. Reprinted with permission from the US Department of Agriculture.1

“The clinician’s role in helping patients eat healthier and move closer to aligning with the Dietary Guidelines for Americans cannot be underestimated,” the USDA spokesperson said. “While HEI scores have remained low, rates for diet-related conditions have continued to rise to concerning levels. With each step closer to a diet that aligns with the core elements of a healthy dietary pattern … HEI scores will increase and risk for chronic disease will decrease.”

Nurse practitioners work closely with patients to counsel them on the benefits of a healthy diet, Dr. Kapu said. “Consequently, the diet should be one that is attainable, affordable, and suitable to one’s stage of life, personal preferences, and cultural traditions. NPs listen, discuss, and guide individuals to make healthy lifestyle choices and select optimal, nutrient-dense food and beverages each day, from sources that are attainable. NPs support the continued quest for a healthy lifestyle and a diet low in added sugar, saturated fat, sodium, and with a limitation on alcohol consumption.” 

“First and foremost, PAs should know their patients so they can customize recommendations,” Ms. Hamacher said. “Understanding a patient’s dietary habits and motivations illuminates areas for improvement as well as reasons to adhere to healthier eating guidelines.”

“One patient may struggle with drinking too many sugar-sweetened beverages and would benefit from talking through alternative drink options,” Ms. Hamacher said. “Another patient may be binge eating high-calorie foods due to depression; helping to address their underlying mental health problem is one way to help address overeating. Some patients are not ready for changes, but PAs shouldn’t stop having discussions that show our recommendations are driven to improve the health of patients, not shame their choices.”

In addition to helping make changes on the individual patient level, PAs are advocates for public health policies that help improve health on the community level, Ms. Hamacher said. These policies include sugar-sweetened beverages taxes, reducing advertising or impulse purchase displays of high-calorie low nutrient-dense foods, and supporting policies that improve walkability and safe neighborhoods to improve outdoor physical activity, she said.

“One key consideration for clinicians is the importance of meeting their patients where they are and helping them make small, simple choices that can add up over time to a healthy pattern that yields benefits,” the USDA spokesperson said. “The Dietary Guidelines serve as a framework — they are intentionally not prescriptive — in order for people to be able to make specific choices that they will enjoy and, therefore, be able to build into healthy habits over time.”

The updated USDA-HHS Dietary Guidelines were also the first to include nutrition recommendations for infants, toddlers, and women who are pregnant or breastfeeding. For a summary of these new recommendations, click here.


1. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2020-2025. 9th Edition. December 2020.

2. Dietary Guidelines Advisory Committee. 2020.Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and the Secretary of Health and Human ServicesU.S. Department of Agriculture, Agricultural Research Service, Washington, DC.

3. USDA-HHS response to the National Academies of Sciences, Engineering, and Medicine: using the Dietary Guidelines Advisory Committee’s report to develop the Dietary Guidelines for Americans, 2020-2025. Accessed February 18, 2021.

4. New dietary guidelines for Americans ignore critical evidence on Alcohol and Cancer. News Release. American Institute for Cancer Research. December 29, 2021. Accessed February 18, 2021.

5. Federal dietary guidelines emphasize healthy eating habits but fall short on added sugars. News Release. American Heart Association. December 29, 2020. Accessed February 18, 2021.