Fiorella Palmas Candía, member of the managing committee of the Nutrition area of the Spanish Society of Endocrinology and Nutrition (SEEN).
The new United States Dietary Guide once again places the scientific evidence at the center of dietary recommendationswith a more practical, flexible approach adapted to the different stages of life. In this interview, Fiorella Palmas Candiamember of the managing committee of the Nutrition area of the Spanish Society of Endocrinology and Nutrition (SEEN), analyzes the main changes to the document, its successes and limitsand what messages should be conveyed to the consultation to improve adherence and combat misinformation. In addition, it reviews what lessons can be learned for public health policies and what challenges remain to convert the guidelines into real habits in the population.
The new US guide recommends full-fat dairy products with no added sugar instead of skimmed or low-fat products. In Spain, where the consumption of milk and yogurt coexists with a wide range of sugary dairy products and desserts, how does the Spanish Society of Endocrinology and Nutrition assess this change and what message would it convey to the general population and patients with obesity, diabetes or dyslipidemia?
At SEEN we positively value the focus on a key aspect: distinguishing “real” dairy from sugary or ultra-processed dairy products. In Spain, regular consumption of milk and yogurt coexists with a wide range of dairy desserts, sugary or “dessert-type” yogurts, which are often perceived as healthy when in reality they provide added sugars and low-quality calories. In that sense, the message “no added sugars” is very useful and should be the focus.
That said, recommending full-fat dairy across the board requires nuance. In a healthy general population, full-fat dairy products can fit within a balanced Mediterranean pattern, as long as the portions are moderate and do not displace protective foods. But in patients with obesity, diabetes or dyslipidemia, the advice must be individualized: in many cases it may be preferable to opt for natural and non-sugar versions, but adjusting the fat content according to the lipid profile, caloric control and cardiovascular risk.
The practical message that I would convey would be: Prioritize natural yogurt and milk without added sugar (avoid “desserts” and sugary dairy products). Monitor the ration and overall dietary context. In obesity/diabetes/dyslipidemia, choose the option (whole or semi-skimmed/skimmed) according to objectives: weight control, lipid profile and tolerance, avoiding dogmas.
The United States introduces a quantitative protein target in grams per kilo of body weight and reinforces its role in the pyramid. In the Spanish context, where the Mediterranean pattern already includes legumes, fish, eggs and meats, does it make sense to “numerize” the recommendation for the general population? In what clinical profiles would it be useful and in which could it be counterproductive?
Setting a quantitative protein goal in grams per kilogram of body weight is very useful in clinical settings or when more concrete guidance is needed. However, in the general population it can have an ambivalent effect: on the one hand it provides information and structure, but on the other it can lead to simplistic interpretations, such as thinking that “the more protein, the better.”
It is important to remember that protein is not consumed in isolation, but within whole foods. Although 30 grams of chicken protein and 30 grams of fish protein are equivalent in quantity, the food that accompanies that protein is not. Fish, for example, has a clearly more favorable profile than other types of meat due to its healthy fat content and its positive impact on cardiovascular health.
Something similar happens with legumes. Although they have an excellent nutritional profile, today we cannot affirm that 30 grams of vegetable protein are equivalent, in metabolic terms, to 30 grams of animal protein. In addition, it is important to understand the practical differences: to achieve about 25 grams of protein we can consume approximately 100 grams of chicken, while with legumes we will need around 200–250 grams.
For all these reasons, quantifying protein can be useful in certain profiles, such as: Older people or people at risk of sarcopenia or frailty. Patients in weight loss processes, to preserve muscle mass. Athletes or people with high functional demand. Situations of convalescence or illness with risk of malnutrition.
However, this strategy can be counterproductive in other cases, such as: People with a tendency toward poorly balanced high-protein diets, which displace foods rich in fiber such as legumes and vegetables. Patients with chronic kidney disease or compromised kidney function, in whom protein intake must be individualized. People with high consumption of processed meats, if the message of “more protein” is misinterpreted as “more meat.”
The new pyramid explicitly includes red meat as an option within the recommended pattern. In Spain, with a significant consumption of processed meat and a cultural weight of charcuterie, what implications would such a message have? What limits and nuances does the SEEN consider essential (frequency, portions, fresh versus processed meat) to avoid worsening cardiometabolic and oncological risk?
In Spain, where there is a significant consumption of processed meat and delicatessen with a strong cultural component, introducing a message that normalizes red meat without nuances can have an undesirable effect: it can be interpreted as a validation of products that, by evidence, should be limited.
From the SEEN, the nuance is essential: Clearly differentiate fresh meat vs. processed meat (sausages, bacon, sausages, cold cuts): the latter should be occasional or exceptional, due to its association with greater cardiometabolic and oncological risk. In fresh red meat, insist on moderation and low frequency. Focus on substitution: prioritize legumes, fish, eggs and poultry, and reserve red meat for specific occasions.
In summary, always adhere to the recommendations of the Mediterranean diet as much as possible.
In added sugars, the guide goes from a daily percentage limit to stating that no amount is recommended and even proposes a limit per meal. With Spanish habits such as pastries, sugary drinks in adolescents and “healthy” products with hidden sugar, does SEEN believe that this approach is more effective for health education? How would you translate it into practical advice in consultation without falling into unacceptable messages?
As an ideal goal, trying to achieve it is correct; in practice, if it is not translated into achievable recommendations, it can be perceived as unrealistic or blaming, especially at a social level, and sometimes provoke reactions such as “if I am not going to reach the goal, why am I trying?” As an educational approach, saying “no amount is recommended” can be powerful because it avoids the false message that “there is a safe margin that can be spent daily.”
In Spain, with consumption of pastries, sugary drinks among teenagers and “healthy products” with hidden sugar, a double message may be more effective: Ideal objective: the less, the better. Practical objective: reduce main sources and frequency.
Applicable advice in consultation: Prioritize water as a regular drink; soft drinks and sugary drinks, only occasionally. Change “flavored yogurt/dessert” for natural yogurt and, if necessary, add fruit. Identify sugars in “fitness” or “healthy” foods by reading the label. Simple rule: if a “everyday” food has added sugar, look for an alternative.
The US document intensifies the focus on ultra-processed foods and cites specific ingredients such as colorings, artificial flavors, preservatives and non-caloric sweeteners. In the Spanish market, with very heterogeneous labeling and a large presence of “fitness products” and “sugar-free”, does this type of message help or confuse? What criteria would the SEEN prioritize to guide the patient: degree of processing, nutritional profile or both?
It is positively valued that the focus returns to ultra-processed foods, because it is a real determinant of public health. But listing specific ingredients can generate confusion if the population interprets that “the bad thing is the additives”, when the problem is usually the whole: high palatability, low satiety, caloric density, excess salt/sugar/fats and displacement of fresh foods.
In the Spanish market, with heterogeneous labeling and an abundance of “sugar-free” or “fitness” products, the most useful criterion is to combine: Degree of processing (as an initial filter: the less processed, the better). Nutritional profile (to decide what is processed: added sugars, fiber, salt, saturated fats, serving size).
The Nutri-Score is a front labeling tool used in Spain that makes it easy to compare the nutritional quality of foods visually and quickly. Although there are some points to improve in this labeling, it does not directly measure the degree of processing, it can help consumers identify products with a worse nutritional profile (which often coincide with ultra-processed products).
To guide the patient, the SEEN would prioritize a combination of criteria: degree of processing (avoid ultra-processed foods), general nutritional profile (favor of foods with the best Nutri-Score = green color or letter A), and global dietary context (how that food fits into the diet pattern).
The new guide toughens the recommendation against refined carbohydrates with concrete examples and reinforces whole grains. In Spain, where bread, rice, pasta and potatoes are part of the usual diet, how can this message be applied without breaking adherence to the Mediterranean pattern? What realistic changes would the SEEN propose (for example, type of bread, portions, frequency, combinations with legumes and vegetables) to improve glycemic control and cardiometabolic health?
We must understand that nutritional pyramids are made in the context of a population and the resources available to that area. These recommended changes in the US population seek an urgent change in the habits of its inhabitants due to the high incidence of obesity and metabolic diseases and cardiovascular risk. However, that does not mean that these are the recommendations that we should follow in Spain. It is important that we are aware that there is no better dietary pattern than the Mediterranean. But when we move away from this pattern, this message is compatible with the Mediterranean diet if focused well. The goal is not to demonize bread, rice, pasta or potatoes, but to: Improve quality (whole grains when possible). Adjust portion and frequency according to expenditure, weight and glycemic control. Serve with fiber, protein and quality fat to cushion the glycemic response.
Realistic changes I would propose: Bread: prioritize real whole wheat or sourdough bread, and reduce white bread for automatic consumption. Pasta/rice: switch to whole grains several times a week; If white is used, reduce portion and increase vegetables/legumes. Potato: you can continue, but in a moderate portion, better cooked/baked and accompanied by vegetables and protein. This improves glycemic control and cardiometabolic health without breaking adherence or turning the diet into something restrictive and unaffordable.
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