Welcome to the NDEP Webinar Series, "The Dietary Guidelines
for Americans 2015-2020: What Are They?
How Have They Changed?
And How Can You Use Them In Practice?"
My name is Betsy Rodríguez, Deputy Director of the
National Diabetes Education Program at the Centers for
Disease Control and Prevention.
And today, I will serve as your moderator.
Today two nutrition experts will discuss recommendations for
developing healthier eating patterns; suggestions for small,
manageable dietary changes; and resources for putting
the guidelines into practice.
Before I introduce our presenters, I would like to go
over the purpose of today's webinar, which includes the
following learning objectives: explain the purpose of the
dietary guidelines and how they have changed, and how they
should be used in diabetes education; describe the impact
that changes to the dietary guidelines can have from the
broader public health nutrition work; name the tools to apply
the recommendations in public health; and finally, identify
aspects of culture that can facilitate the
use of the dietary guidelines.
This is the first of our four questions that we will
be asking during our webinar.
We call them 'Knowledge Check.'
If you are in front of a computer, feel free to answer
it directly in your screen.
And the question reads, 'The main theme of the Dietary
Guidelines 2015-2020 is...?'
I will give you a couple of seconds to answer.
Eating patterns, food and drinks?
Compare diets to recommendations?
Guidelines in shifts and food choices?
Or all of the above?
So our poll has been closed.
And as you can see here, 85 percent of the participants
answered all of the above, which is the correct answer.
Good.
As a brief background to food guidance and nutrition
education, as early as 1917 the USDA and FDA worked together to
devise recommendations called, 'Choose Your Food Wisely.'
In the 1940s, the Guide to Food Eating provided the foundation
diets for nutrition adequacy, and included daily number of
servings needed for each of seven food groups.
In 1956, 'Food for Fitness, A Daily Guide Basic Four' was
published and included four groups-milk, meat, vegetable and
fruit, and bread and cereal groups.
Other guides follow, up to the current MyPlate system,
introduced along by the 2010 Dietary
Guidelines for Americans.
The initial approach of the early government document was to
prevent nutrient deficiencies.
All of the guidelines that have been published
since 1980 are shown here.
They evolved over time to make better use of nutrition
science and to better communicate the science.
The 1980s-1985 version of the dietary guidelines were small
brochures aimed at consumers.
The information came mainly from the experts appointed to the
Dietary Guidelines Advisory Committee.
The committee members drew from their collective
knowledge of nutrition research.
Then the 2000 version was a 39-page document that was both
for consumer-oriented and for policy documents.
This reflects the move by the government toward helping
nutrition educators, dietitians, and other nutrition
professionals to better understand the science
behind the consumer material.
In 2005, we got a 70-page booklet that served as a policy
document and represented a departure by acknowledging that
in nutrition education, nutritionists and policymakers
all need the science in plain language that will serve as
the foundation for the work.
Research and review of the scientific literatures served
as the basis for these guidelines.
The 2010 document, again, was a policy document intended for
policymakers to design and carry out nutrition-related
programs, and nutrition educators and healthcare
professionals developing nutrition curricula, teaching
tools, and advice for consumers.
In 2010, a robust systemic approach was used to
organize and evaluate the science on
which the guidelines are based.
For the remainder of today's presentation, we will be
providing details, especially about the newly developed
2015-2020 Dietary Guidelines.
That was a short brief history to set the
foundation for today's webinar.
So let's have another knowledge check.
What changed in the Dietary Guidelines 2015-2020?
And again, let me give you another
couple of seconds to answer.
No longer have the quantitative requirements for dietary
cholesterol, that's choice A.
Choice B, added sugar quantitative requirements.
C, emphasis on food patterns rather than individual's
nutrients and specific food.
D, all of the above.
And E, nothing changed.
So most of the people answer all of the above, 68 percent of the
people, and that's the right answer.
Good.
So as you can see there is a lot to cover today.
So as I said before, today we have a superb group of experts
from the nutrition field that I'm sure will enlighten us with
valuable information regarding the Dietary
Guidelines for Americans.
I am very pleased to introduce Dr. Jennifer Seymour, a Senior
Policy Advisor at the Division of Nutrition, Physical
Activity, and Obesity at CDC.
She was CDC Lead for the development of the Dietary
Guidelines for Americans 2015-2020, a member of the
Healthy Weight Commitment Evaluation Advisory
Committee, and the Feeding American
Nutrition Advisory Team.
Then we will have Lorena Drago, Founder of Hispanic Foodways,
who specialized in the multicultural aspect of
diabetes management education.
She has served for the Board of the American Association of
Diabetes Educators, and Latinos and Hispanics
in Dietetics and Nutrition.
Lorena is also an award-winning author of many diabetes
books and chapters among other accomplishments.
Welcome ladies.
Dr. Seymour, from now on known as Jenna, the
microphone is yours.
Thank you Betsy.
It's very nice to be speaking to all of you today.
So I am going to start out with some of the basic overview of
the dietary guidelines-what it is, what it's not.
So the dietary guidelines really provide evidence-based
recommendations about a healthy and nutritionally adequate diet.
It's important to know that they focus on disease prevention,
rather than disease treatment.
So, of course, as diabetes educators, a lot of you may say,
"Well then, how is this relevant?"
It is important to know that, of course, a healthy diet is really
good thing for everyone to be thinking about.
But it shouldn't really-the guidelines that are for disease
prevention, sort of in general-should not override specific
advice for someone who has a specific chronic disease.
Now, the guidelines also-and I should say, let me just step
back and say-and of course Lorena, after me, is going to be
talking much more specifically about ADA recommendations.
So, we'll really let you see both sides.
And then of course, the dietary guidelines, really, it's a
policy of the federal government.
And therefore it informs federal food, nutrition,
health policies, and programs.
So it's important to understand a little bit about the way
that the guidelines are created.
As Betsy pointed out, the guidelines have changed
quite a bit over the years.
And really, in the last 15 years, have particularly gone
much more from a very simple booklet for the consumer, to
much more of a very large policy.
So, in general, we think of the dietary guidelines
from a three-step process.
There's a lot of detail on this slide, and I'm not going to go
into all of it, but I think it gives you a little more detail
for the people who really want to understand
how the guidelines are created.
What I'm going to say is that the first part of the process is
a review of the science that is done
by a federal advisory committee.
And that advisory committee spends two years doing a really
detailed process and ends up producing a report that is
provided to the secretaries of HHS and USDA.
This year that report was over 500 pages long.
So it's a very intense, detailed report about what we
know about nutrition currently.
The second part of the process is the actual development
of the dietary guidelines.
And this part is really where the government takes the
previous edition to the dietary guidelines, the report from the
advisory committee, comments that come in from the public and
from federal agencies, pulls it all together, and really works
for-usually it takes about a year, really, to put all of that
together, into what becomes the policy that is
known as the dietary guidelines.
And it's really important to know that currently this very
large-this document is over a hundred pages long-it's really
designed for policymakers and for professionals.
And isn't really intended for the
public to understand nutrition.
But, so that's where the third part of the process comes in,
which is the implementation of the dietary guidelines, really
figuring out how to use it.
And part of that is about creating materials that will
end up being for the public.
But also part of it is about using this in the programs and
all the different ways that the federal government
might use these guidelines.
And I'll talk about that in more detail
at the end of the presentation.
So what is in the guidelines?
The guideline starts out, it has an executive summary, an
introduction, three main chapters, and appendices.
What I'm going to focus on in this presentation
is the three main chapters.
But there really is a lot of detail there for someone who
wants to know a lot more about what's
going on in the guidelines.
So what are the actual guidelines?
There are five overarching guidelines that
are part of the DGA 2015-2020.
The first guideline is to follow a healthy eating
pattern across the lifespan.
And this really is a very big change from previous guidelines
that really focused much more on-think earlier-there was much
more focused on specific nutrients.
Then as things started to change over time, there was a bit
more of a focus on food groups.
But the real very big change with these guidelines is a heavy
focus on eating patterns, and really understanding the whole
way you eat is what matters.
The second guideline: getting at the same idea, it's really
talking about and focusing on variety,
nutrient density, and amount.
Really understanding that you need to eat a variety of foods.
You really want to have foods that are very nutrient-dense.
This is getting at the idea that you want foods that have a lot
of the nutrients that we need in our diets without a lot of the
nutrients that we shouldn't be eating very much of, and
certainly without too many calories.
And that also gets into amount, really thinking about the amount
of food that you consume in terms of the
calories that you are taking in.
And then the third guideline is to limit calories from added
sugars and saturated fats and to reduce sodium intake.
And so this is where we do get back to the nutrients that are
real issues in the diet, but this should be thought of within
the context of that healthy eating pattern.
So the fourth guideline gets at the idea of the need to shift to
healthier food and beverage choices.
And I'll really show you a lot more detail about
the shift as we go forward.
But it's really the idea that right now the way Americans are
eating is really not fitting into
that healthy eating pattern.
And there are ways that you can shift your diet much more
towards a healthy eating pattern.
And then finally, the fifth guideline really is about that
bigger support that is needed for healthy eating patterns to
be possible for people to really getting at the role of all the
different ways that the food environment, and where we
live, and where we work, and all those different ways that we
interact with food clearly plays a role in whether we are going
to have a healthy eating pattern or not.
OK.
So let's focus very much on what's in Chapter 1.
This is where we really talk about
the healthy eating patterns.
So what actually is a healthy eating pattern?
The most important thing is that it really encompasses everything
that you eat and drink.
A healthy eating pattern includes vegetables and really
making sure you get a variety of those vegetables from all the
different food-all the different groups of vegetables-dark green,
red, orange, legumes, starchy, and other vegetables.
It includes fruits, especially whole fruits, really whole
fruits over having a lot of juice
as the way you get fruit intake.
Grains, very important, and to make sure that at least half
your grains are whole grains.
Fat-free and low-fat dairy, including milk, yogurt, cheese,
and, for people who can't or who choose not to consume
milk, fortified soy beverages.
And then of course, a variety of protein foods, including
seafood, lean meat, poultry, eggs, legumes,
nut seeds, and soy products.
And oils as opposed to the unhealthy solid fats.
So of course, a healthy eating patterns also limits saturated
trans-fat, added sugars, and sodium.
And what you might notice here is that dietary cholesterol
is not listed here.
I'll talk about dietary cholesterol in
more detail in a little while.
So, of course within the key recommendations, there are also
a number of quantitative recommendations that really do
get at very specific areas where we know that there needs to be
limits on how much someone is consuming.
The big addition in these guidelines is to consume less
than 10 percent of calories per day from added sugars.
Something that's been more consistent in the
guidelines over a number of years is to consume less than
10 percent of calories from saturated fats.
Also quite consistent over the years has been to consume less
than 2,300 milligrams per day of sodium.
And then finally, also, certainly for the last two
editions of the guidelines, if alcohol is consumed, it should
be consumed in moderation, which is up to one drink per day for
women and up to two drinks per day for men, and of course, only
by adults of legal drinking age.
And then finally, not a quantitative recommendation, but
there is a recommendation to meet the Physical Activity
Guidelines for Americans.
In the past, the dietary guidelines often did also talk
about physical activity, sort of as an aside, and eventually it
became clear that there really should
be physical activity guidelines.
And so in 2008, that's when physical activity guidelines
were created for the first time.
And there's a lot of detail within those guidelines that
maybe another webinar on physical activity guidelines
would be a good thing.
So of course, it's important to really think about the
principles of healthy eating patterns.
Really understanding the idea that a diet as a whole is what
matters, that really understanding that there are
synergistic ways that our diet works together, that what you
eat, what you drink, they have an impact on each other.
And that really just thinking in terms of eating more healthfully
as just having an impact on one aspect of your diet is really
probably not going to get you to a healthy eating pattern.
It's also very important to know that nutritional needs should
really be primarily met with foods as opposed to supplements.
There are certainly needs for supplements, that, for various
people and for various different reasons.
But there is so much more to the food that we
eat than what is in supplements.
And so it's really important to get away from a message, that I
have heard in the past, that someone who says, "Oh, I can
just take a multivitamin and then I'll be OK."
And there really is so much more in our food that you will never
get from a multivitamin and that's an
important thing to keep in mind.
And then, of course, it's really important to know that
healthy eating patterns are adaptable.
They really can be tailored to all kinds of sociocultural and
personal preferences.
And there are many kinds of diets that can fit in to the
overall broad perspective of what
is a healthy eating pattern.
So what is the science behind healthy eating patterns?
So in general, a lot of people may think, when they know about
the dietary guidelines, about using scientific studies to
determine what might be said in the dietary guidelines.
But there actually is a lot more that goes into-certainly those
systematic reviews and scientific research
play a very important role.
But there's also really a need to think through, sort of food
pattern modelling, really trying to understand how can you really
go through and figure out all the ways that the person can get
the nutrients that they need, while staying within calorie
limits, while also not getting too much of the nutrients that
we are eating too much of currently, and really trying to
think through all of those aspects, and come up with
patterns that-from out of that model.
And then of course it's also important to realize that there
is a need to analyze current intakes, really understanding
what's already going on, what needs to be improved within
diet, and how does that play into what is going to
be suggested as a healthy diet.
So let's look in a little more detail about a couple of things.
I already mentioned a variety of vegetables.
But it's important to know that within vegetables, all different
forms of vegetables can be a part
of a healthy eating pattern.
You can have fresh, frozen, canned, dried options, and
including vegetable juices.
But of course, you should keep in mind, again,
the idea of nutrient density.
Vegetables should be consumed in a nutrient-dense form with
limited additions of salt, and butter, and cream sauces.
Also, with dairy, you should really be thinking about
including fat-free and low-fat, 1 percent dairy, including milk,
yogurt, cheese, or fortified soy beverages.
I did, sort of in the corner of my eye, see that someone asked
the question about rice milk, and things like that.
This was addressed by the Dietary Guidelines Committee.
And what they looked into and really decided was that a big
role that was being played by the dairy products in our
diet was as a protein source.
And that soy milk has a pretty consistent amount of protein as
compared to dairy products, whereas things like rice
milk and almond milk and other forms do not.
And so that is why they chose not to include other forms of
beverages besides dairy in this recommendation.
So fat-free or low-fat milk and yogurt in comparison to cheese
contains less saturated fat and sodium, and more potassium,
Vitamin A, and Vitamin D.
So it's important to also think in terms of when you're thinking
about the dairy products you consume that there really are
different choices that can be made that will be better
for a healthy eating pattern.
So of course, there are all those other components within a
healthy eating pattern that really need to be thought
about and considered when figuring out what to eat.
And they include the added sugars, saturated fat, trans
fat, dietary cholesterol, sodium, alcohol, and caffeine.
I'm going to focus on two specifically next, that have
been talked about a fair amount since these dietary
guidelines were released.
The first is cholesterol.
So the quantitative recommendation was removed.
But there is a statement in the guidelines that says individuals
should eat as little dietary cholesterol as possible while
consuming a healthy eating pattern.
Now, I saw a question before the webinar
began that asked about this.
And so I want to specifically point out that if the sentence
stopped after the word possible, it would
have a very different meaning.
So this is not suggesting that people need to drastically
limit their dietary cholesterol intake.
What it is saying is that people should eat as little cholesterol
as possible while consuming a healthy eating pattern.
And that's an important addition, because, really, when
you look at the dietary guidelines, look at a Healthy
US-Style Eating Pattern, and really took general US-style
habits but came up with a healthy eating pattern that met
all the criteria, and really found that within that, the diet
was getting between 100 milligrams and
300 milligrams of cholesterol.
And so it's really-it's not actually saying, as little as
possible, because, of course, you could get to zero by eating
absolutely no animal products.
But that is not what the dietary guidelines are suggesting.
So I think that's an important point to keep in mind.
So for caffeine, there was discussion-it's not a key
recommendation-but there was discussion about the fact that
the people can consume caffeinated beverages.
What's important to know here is that most caffeine
evidence focuses on coffee.
So there really hasn't been the kind of studies on all kinds
of other caffeinated beverages.
And so this recommendation should not be taken as a
recommendation to consume a whole bunch
of other caffeinated beverages.
But it really does say that three to five eight-ounce cups
per day can be included in the healthy eating pattern.
It's important to note though that there's nothing that
suggests that a person who isn't consuming caffeine
really should start in any way.
And it really is also important to think about, what else you
get when you are having caffeine in your diet.
Thinking about all the different creams and whole and 2 percent
milk or added sugars that are put in a lot of caffeinated
beverages, really need to be thought of in terms of the
calories that that adds to your diet.
And so I won't go into much detail here.
But I just want to say there are a lot of callout boxes in the
dietary guidelines that go into any number of details about a
whole bunch of issues that may be of interest to people.
And I think one thing that's important to note, and again, I
saw some questions from when people registered
about different kinds of diets.
There are all kinds of diets that can fit the healthy eating
patterns described in the dietary guidelines.
There are three specific ones that are described and pointed
out in the dietary guidelines.
That's the Healthy US-Style Dietary Eating Pattern, the
Healthy Mediterranean-Style Eating Pattern, and the Healthy
Vegetarian Eating Pattern.
And so yes, vegetarianism definitely can fit within the
guidelines and it does show that pattern in the guidelines.
But there are other healthy eating patterns that are outside
of these three that clearly would fit
within the dietary guidelines.
So there are a lot of different ways to meet the guidelines.
Now let's shift to shifting eating patterns.
This is the content of Chapter 2.
So what's important to see here, and I'll try to make this
picture as clear as possible pretty quickly.
Think of the orange bars as sort of more the negative and
the blue bars as the positive.
What this graphic is really showing here is that there are
areas that need a lot of work for Americans.
You can see that Americans are just not eating the vegetables
that they should, that over 80 percent of people are
not getting enough vegetables.
It's really 75 percent not getting enough fruit.
Total grains, looks a little bit better.
But I'll show you why that might not
be so good on the next slide.
Dairy products, really over 80 percent,
again, not getting enough.
Protein foods, again, looks a little bit better.
But there might be something more behind that.
Oils, as opposed to solid fats, really there's still
more need to shift that as well.
And then you can see going in the other direction, people
are consuming way too much added sugar, saturated fat, and
sodium, really got close-we're getting up there-close to 100
percent of people consuming more sodium than they should.
So like I said, I want to make sure, for the two areas where it
looks like we're in pretty good shape for Americans, it's
important to look at this in a little more detail.
So for whole and refined grains, if you look at the blue bars,
that represents the recommendations, and then the
orange is refined grain intake, and
the green is whole grain intake.
And so what you can see is that overall for most men, and then
the second column is women, you can see that our refined grain
intake is well over the recommendations, except for some
older men who are getting very close there.
But the intake of whole grains is well below recommendation.
So overall, grain consumption is in fairly good shape among
Americans, but we need to change the types
of grains that are consumed.
And the same thing for protein.
I'll just specifically show this chart on seafood intake.
So if you look at, again, the blue bars being
recommendations, and the orange being where intake is, you'll
see we're all well below the recommendations
for seafood consumption.
So just let's think a little bit about the way you might shift
toward healthy eating patterns.
So its things like increasing vegetables and mixed dishes
while decreasing the amount of refined grains, meats high in
saturated fat, and/or sodium, in those mixed dishes.
You could think of it as the pizza that you really might want
to start moving towards a whole grain crust that's got quite a
bit more vegetables on it, and removing the pepperoni, and
really thinking from those perspectives, that perspective.
Really trying to make sure you're adding seafood into meals
twice per week, and replacing the meat, poultry, and eggs.
Using vegetable oils in place of solid fats and things using
oil-based dressings and spreads on food instead of those made
with solid fats like butter.
Choosing beverages with no added sugar, like water.
And using the nutrition facts label to compare
sodium content in various foods.
These are just a couple of ideas of things-the kinds of shifts
you can do towards healthier eating patterns.
So I think to save a little time, I'm going to skip past
that overview slide and just go to....
Let's look at a little bit at the food sources of some of
these nutrients that we really need to reduce in our diets.
What you can see is, certainly for added sugar, the plurality
coming close to the majority of added
sugar is coming from beverages.
And so this is a really big component
of the added sugar intake.
If you add in snacks and sweets, that makes up 78 percent of the
added sugar that people consumed.
And so right there, those really are the big areas to be thinking
of in terms of how to reduce added sugar intake.
If you look at saturated fat, the bulk of saturated fat is
coming from these mixed dishes.
That's things like the pizzas, the burgers, the meat, poultry,
seafood dishes, you can think of these as the stews, the soups,
the rice and grain dishes.
These are all the different things
that make up mixed dishes.
And then you can see there's also a big component
made up of snacks and sweets.
So...
And then if you look at sodium, again, it's the mixed
dishes, and there's a fairly big component
also from snacks and sweets.
I wouldn't put that in the...
as one of the higher ones for sodium, but it really should be
thought about the mixed dishes, the snacks and sweets, and then
the beverages kind of together as a bulk area, really are where
the sodium, saturated fat, and added sugar are coming from.
And so those are real areas to focus on in terms of trying to
move people towards the fruits, vegetables, grains, low-fat
dairy, and good protein sources, and moving away from these areas
where people are getting really heavy nutrients
that we want to stay away from.
OK.
So then the third chapter is really focusing on supporting
healthy eating patterns.
So I certainly hope that a lot of you have
seen the socio-ecologic model.
This is one particular version of it.
What I would say is that if you start over to the right, in the
yellow section of this, you can see that this is really where
a lot of people talk about nutrition and really changing
things within nutrition, talk about it from those individual
factors from the perspective of the food and beverage intake and
the physical activity for an individual.
But there really are so many different ways that the settings
that people are in-the early care for children, the
schools-for adults, their work sites-and for everyone, the
recreational facilities-the food service and
retail establishments.
These are all areas where you can constantly be barraged with
all the wrong foods to eat, or you could really have an
environment that allows and makes it so much easier for
people to consume the foods that would be healthy for them.
And of course, there are also the sectors, the government, how
transportation affects people, all the different agricultural
food and beverage industry, retail, and how all
of that affects people's intake.
And then, of course, there are all the social and cultural
norms and values that go into how and why people eat.
And it really is important to be thinking about and taking into
account all of these different aspects in order to really be
thinking about how to help people get to
those healthy eating patterns.
And then, just quickly, I want to talk a little bit about-so
this is getting at some of the tools on the more
environmental or policy end.
There are so many different ways that
the dietary guidelines are used.
For instance in schools.
I think, probably a lot of people have heard because it's
got a lot of attention-the changes to the school breakfast
program-the changes to the school lunch program-the changes
to competitive foods in schools, that was known as Smart
Snacks-all kinds of wellness policies-the changes to food
in the child and adult care food program, as well
as things, like in work sites.
We currently, at CDC, have food service guidelines that we
put together based on the 2010 dietary guidelines.
They are currently right now being updated and being expanded
to include the entire federal government to create guidelines
for the foods served throughout the federal government that will
be based on the 2015-2020 Dietary Guidelines.
And these trickle down.
States end up using them to come up with state guidelines for the
food that will be served in any state facilities.
Local facilities can do this also, and then, also just
private work sites can take this on as well.
And we've seen a lot of private work sites that set standards
about the kind of food.
And all of this, the food service guidelines that I'm
talking about are based on the dietary guidelines.
To look at it from a more direct to consumer perspective, I know
that Betsy at the beginning talked about MyPlate briefly.
So, MyPlate is created by the Department of Agriculture.
And it really is a simple graphic that represents
the dietary guidelines.
It really shows the idea of a plate and the portion of foods
on that plate in terms of trying to get at the idea of what a
healthy eating pattern would look like.
And there's a lot more detail, and they go into any number
of examples, and really thinking through the idea that maybe
not everyone eats on a plate.
And so there are other ways of thinking about those foods and
there's a lot of information.
And it really is a very good source for people to really be
able to track their own diet, to track some progress, to really
get some understanding about the details for a more general
audience than the dietary guidelines themselves.
And then finally, I want to give one example,
there are many out there.
But one example of the way the dietary guidelines are being
used to really make a big difference
to the labelling of food.
So there was a whole process to change the labelling of food
that started long before these dietary guidelines.
But the process was very much influenced by what was
being changed in the 2015 through 2020 guidelines and
when the guidelines came out.
Some issues were tweaked here.
So what you can see on the left is-that is the
current nutrition facts label.
That is what a lot of people have probably seen if they look
at packaged food to see what is in it.
The label on the right is how it is going to change.
And some foods have already made this change.
The new label was announced just quite recently, just a
couple of months ago, from FDA.
Manufacturers have-big manufacturers have until 2018
for this change to happen; small manufacturers until 2019.
But you will start seeing this as companies get it ready and
are ready to make the change.
And some things that I would point out are a much bigger
serving size, so people really understand what this information
on this label-it's about how much of the
food that is in that product.
The calories are much bigger to really make sure
that people are seeing this.
And calories from fat have been removed since there really has
been much more of a move towards saying people should consume
healthy fats not unhealthy fats, as opposed to telling people
that fats in general are bad.
You can see that, if you go farther down in the list that
added sugars have been added to this.
And the percent daily value is based on that 10 percent of
calories as a maximum recommendation that
is in the dietary guidelines.
There are a number of other changes.
I could only show really these two on here.
But I would advise anyone who really is much more interested
to go and see, because they really are going to be for
packages of food, like say, a 20-ounce soda that people really
might drink at one sitting.
That really-that is now going to have a label that describes what
is in that full 20-ounce soda because it really is likely
to be consumed all at once.
And it was very confusing for people to see an eight-ounce
soda and they might assume that what they were seeing on that
label represented what was in that 20-ounce soda.
And there will be any number of other changes that I think would
take a little too long to go into here.
So now I just want to point out that, as I've said, there are so
many things to see, so much more detail here.
So dietaryguidelines.gov is the place to go to get all the
information, to see the dietary guidelines.
This is where you can download a copy or PDF of the guidelines.
This is where you can order a hard copy of the guidelines.
There are additional resources at health.gov and at
choosemyplate.gov which is where all the MyPlate information is.
There's a lot more to see here.
So now, before we turn over to Lorena, we just have
one knowledge check question.
So this one is, Do you know how the Dietary Guidelines
for Americans are used?
So A, is to learn how to control diseases like diabetes?
B, to inform policymakers and health professionals,
not the general public?
C, to teach to help providers how to educate their patients?
D, all of the above?
Or E, none?
So, 70 percent of the people said all of the above.
The answer is actually to inform policymakers and
health professionals.
So I do think that it is important to make clear that,
like I said, the dietary guidelines are designed to be
for disease prevention but not really
to control specific diseases.
And we did think, when we're talking about this, that that
third one, teach providers to educate patients could
be a little bit confusing.
I certainly think that the guideline is a resource for
professionals to read and understand.
But I wouldn't say that there's anything in it that directly
teaches providers how to educate patients.
So really, the inform policymakers and health
professionals is the correct answer there.
OK.
So now I am going to turn the presentation over to Lorena.
Thank you very much Jenna.
That was great.
I was taking my notes as well.
Good afternoon everyone.
So let me just move quickly into the second part of the
presentation, and that is the American Diabetes Association's
Nutrition Recommendations and pretty
much the practical application.
So, how do we take this information for patients with
diabetes and how do we put it all together when we are
teaching patients and their families about food.
So I will be pointing out what are the similarities, as well
as some of the differences in both the nutrition guidelines,
as well as in the dietary guidelines.
So one thing that Jenna had talked about at the beginning of
her presentation was, how this was-the emphasis
was really on dietary patterns.
So, not just specific "diet" or not something that is extremely
prescriptive, but we are learning that not one size
fits all of eating approach.
So that means that we have an array of different dietary
patterns that fit and also that can work very well to
accommodate the patient's socioeconomic status,
cultural, and eating habits.
So at the end, the eating patterns should emphasize
glucose, blood pressure, and lipids.
And we want to emphasize that the eating patterns, the
recommendation should fit the individual and fit for her
needs, and that is ideally provided
by a registered dietitian.
So I am going to focus on just a few nutrients and
look at the recommendations.
The first one is carbohydrates.
When I first started teaching diabetes education, there was a
lot of prescriptive amount of what
the recommendation should be.
It was either 50 percent, 40 percent of the calories,
30 percent if you were recommended in a
low-carbohydrate diet.
So as the recommendations have changed over the years,
those numbers have changed.
Now ultimately, the evidence is inconclusive for
an ideal amount of carbohydrate.
So this has to be done collaboratively with the
patients looking at their blood glucose levels and other
parameters, as well as keeping that
enjoyment of eating and food.
So the amount of carbohydrates and the available insulin will
be the most important factor that influences
that glycemic response.
And that is what should be considered when we are
recommending an amino pattern.
So the patient that has type 2 diabetes, if there is enough
endogenous insulin, the best approach is to look at their
blood glucose levels, pre-prandial, post-prandial, and
then based on those recommendations, as well as
other markers, that should be the carbohydrate, the amount of
carbohydrate that should be recommended.
And that is usually how I approach the recommendation
of the carbohydrate.
So it could range between 30 percent of the total daily
calories, to 40 to 50 percent.
Again, taking into account that not one size fits all and that
I want to look, in general, at the patient's profile and their
blood results in order to make a recommendation about
the amount of carbohydrates.
And I usually use diagrams which I will share with you later on
in practice, as to how does this look?
So I do show, well, we need the carbohydrates that you're
consuming, but we also want to take into the account your
endogenous insulin or the insulin that you are using.
And then that will determine whether your blood glucose
levels are elevated or they are not.
And there are other multiple factors to change those numbers.
So after giving that prescription, what would be the
best way for the patient to monitor the amount of
carbohydrates that they are consuming?
It depends on the patient and also the level of literacy of
that patient and prior education.
So, I already know that patients that only want to use their
hands as a guide, then I indicate the hands to use to
provide them with an average of the amount of
foods that they are consuming.
There are other individuals that like to know the exact amount of
carbohydrates that they are eating.
And they are using apps, or they're just simply
counting their carbohydrates.
And that also works for them.
For other patients, I choose the plate method, because I find
that by using the plate method and kind of estimating
the amount of carbohydrates.
It's perhaps easy for some individuals that may have
literacy problems and they are not as
adept at multiplying and adding.
So whatever method you use, there are many different ways.
And the evidence is Level B.
And this is the level of evidence.
So that means that this is supported by
well-conducted cohort studies.
And I think that that gives the educator a great way and
latitude to making a selection that suits the patient.
So where do these carbohydrates should come from?
Vegetables, fruits, whole grains, legumes, and other
sources that are nutrient-dense.
So here it aligns with the message of the dietary
guidelines: the sources, the nutrient-density that Jenna had
mentioned at the beginning, the variety of the
different fruits and vegetables.
So we are pretty much preaching exactly the same message.
And of course, we are talking about the amount.
I always like to use the Ps and Qs.
And when I talk to patients, I always say, remember
the Ps, to mind your Ps and Qs.
P for portion and Q for quality of the food.
And most of the time, if you're minding your portions and the
quality of the food, you are probably
doing everything the right way.
So here we have again, how to translate the message of the
nutrient-density that will be the quality, and the amount,
that will be P for portion-minding the Ps and Qs.
What about sugar?
And I wanted to include this for two reasons.
Because the recommendations for ADA do allow for some amount of
sugar consumption, as long as you're substituting for the same
amount of calories of other carbohydrate foods.
Now what happens is that the recommendation has to be
very clear to the patient that while it might be OK to
substitute for another food that has equal amounts of
carbohydrates, we have to go back to the original
message of a nutrient density.
And that is what should prevail.
The other issue is where does the added sugars are coming from
and the excess consumption of added sugars.
And in certain communities, it is extremely important to always
address what beverages, if the patient or the community that
you're teaching, what are they drinking?
And that should be part of every single
assessment, in my opinion.
Another recommendation is the emphasis of consuming fruits in
its natural state when possible, because
of the fiber and the nutrients.
And juice, even when there's no added sugar to the juice, even
when the patient says, "I drink juice because it's natural, and
I do not drink sweetened beverages."
It is still very important to relay the message that most of
us do not drink two to three ounces of juice.
Most of us, in our home, do not have glasses that only hold
three to four ounces of juice.
So most likely, the average person might be drinking between
eight to 12 ounces of juice per day.
And that has an impact on blood glucose levels.
Remember, what affects blood glucose levels is the amount of
carbohydrates and the amount insulin available.
So if the amount of carbohydrates increased by the
increasing consumption of sugars, even when they are
coming from fruit juice, that will have a negative
impact on blood glucose levels.
So again, the key message is, consume fruits in
its natural state when possible.
And let's be mindful of the juices, because that will be one
item that the patient or the client is not going to consider
to have a problem later on.
So here it is, something that, again, perfectly aligns with the
recommendations, and that is sugar-sweetened beverages.
And I have added a picture of ginger.
The reason that I have ginger is because most people, at least
the communities that I served, do not consider ginger ale or
other sweetened beverages to have the same impact
as colas or sodas that are not.
So pay attention, especially when you're communicating with
patients that have low health literacy, it's very difficult
for them to sometimes translate the message.
So if you say, "Do not drink sodas or sweetened sodas," they
might not translate that message to ginger ales or any other
sodas that you have not mentioned.
So that is just one tip that I have found
out to be true most of the time.
I'm moving on to fats because the other recommendation with
the dietary guidelines was about fats.
And once again we used to have a very prescriptive message in the
past that 30 percent, and perhaps the nutritionists, the
dietitians in the group would probably remember, no more than
30 percent of the calories should come from fats.
Well, here, again, it appears that it's also inconclusive and
the goal has to be individualized.
We went through the fat-free years in
which everything was fat-free.
And then what happened was, once the fat is removed from the
product, in order to have more palatability,
more carbohydrate was added.
So the consumption of carbohydrates
increased to replace the fat.
And then that had a more detrimental effect
on the cardio-metabolic profile.
So be aware of sharing that message
that we have shared for so long.
It is also a little difficult to say not all fats are bad-and
that's part of the message-but also that the quality is
important and remember the Ps and Qs.
Even when you're sharing the types of fats that are
healthier, it has to be conveyed into the right amount.
And it has to be part of that eating
pattern, not isolated nutrients.
And then I just want to focus on the saturated fats,
the cholesterol, and trans fat.
That the recommendations are the same as that recommended
for the general population.
Therefore, the recommendation of saturated fats will be less
than 10 percent of the calories.
The sodium recommendation, it will be exactly the same-of less
than 2,300 milligrams-again, very much aligned
with the dietary guidelines.
One thing that is very important, and that's why I have
that folder here that says top-secret salt mission, is that
most people believe that most of the sodium that they consume
comes from the salt shaker.
And that's why I love Jenna's slide that shows that almost
50 percent of the sodium that we consume are the mixed dishes,
the snacks, and even the sweets.
So this is the key message.
Ask the educator that you need to translate that message and
work on the implementation, where it comes from.
So now I just want to just give you a few minutes of respite
before the end of the presentation and allow you to
see the beautiful view and the beautiful sea because
this will be a great segue-- -- to talk about
the different eating patterns.
And the first one that I have here is the Mediterranean style.
So I just wanted you to just help
you travel to the Mediterranean.
And these are-and since you're going to receive copies of the
slides later on they will be available, I am not going
to read through all of them.
But I just want to highlight that the key of the different
eating patterns, the Mediterranean, which is the stew
of different countries, but it focuses on whole grains-once
again, we are repeating the same thing-using healthy fats such as
olive oil; consume moderate amounts of certain foods that
are high in saturated fats; and also focusing on locally growing
fruits and vegetables and a variety-and, of course,
a glass of wine at times.
So I love that piece.
Then there's the vegetarian or vegan.
That will also be an option for patients that want to
do or try something different.
And then the low-fat diet is one that is a little bit more
focusing on the amount of fat reduction to the right amount.
And again, the emphasis is on the right kind of fat.
And then we have two more recommendations of the different
ones that have been proven to have yield optimal results, and
that it is the low-carbohydrate diet, as well as the DASH diet
or the Dietary Approaches to Stop Hypertension.
So the key message that I want to leave you with is,
there are different patterns.
So whether someone chooses a little bit lower carbohydrate,
a little bit higher carbohydrate, a different
variety, there is a choice for someone
that should be individualized.
And I think that it speaks beautifully how it dovetails
that it is individualized.
And I also wanted to add something else, which is, if
you're looking at patients from different countries and
cultures, there is a way to find out what is it that they're
eating, and then adapting things if its needed to the
recommendation based on their favorite foods.
So the last few minutes that I have left, I just want to tell
you something that I find to be very helpful in practice.
The first is using risk communication.
And I just want to go briefly through what it is to use risk
communication when you're talking
to the patient or the client.
When you tell someone that he or she is at risk of-and I'm using
this example of cardiovascular risk-it is important to talk
about, what is someone's risk?
Am I in danger?
If my blood pressure is high, or if my cholesterol level is high,
or if I smoke, what is my risk based on those markers compared
with someone that doesn't have those conditions?
And that's why I always like to use graphs.
So in this example, based on the risk factors, you can see the
cardiovascular mortality once there are more risk factors.
So it is important to communicate that to the patient.
Instead of just providing them with a blanket statement about
hypertension leads to...define it.
Where is the patient?
And what are the risk factors?
The other thing that is important when it comes to risk
communication is not just to throw the numbers.
Not to say, "Your goal should be less than seven
when it comes to A1C levels."
But, tell the patient what is your level, and
this is what the goal should be.
Make it very specific so that the patient can understand what
is the goal, and where is he or she compared to that goal?
Show them the risk factors.
The other thing that is important is explain
numbers that need explanation.
And the A1C, this is the chart that I really love because it
has side by side the A1C and the blood glucose levels that the
patient is more familiar with.
So I numbered it from nine to seven for someone who doesn't
understand what A1C means, might not be taking seriously
because it's only two points.
So if I have an A1C of 9, and the goal is of 7, in my head,
I'm thinking, "It's not so bad.
I'm only two points away from the goal."
However, if it's explained that a 9 means an average of 212, and
the goal is 154, immediately, I can see that there is almost
60 points between where I am and where I am supposed to be.
Also provide treatment strategies, and ask what are you
doing and then make a suggestion.
It's very important to show and to show and ask the patient if
this is something that he or she will be amenable to changing.
I focus on three things.
What am I going to say?
What am I going to show?
And what is the patient going to do?
So let me just give you a few examples of what I mean.
If my key message is - I want the patient to choose whole
grains, reduce the saturated fats and replace it with
poly-unsaturated fats, not carbohydrates - I want to focus
on the patient's reduce in sodium and added sugars.
So these are some of the examples
that I choose from my real life.
So what am I going to say?
And I'm using the example of whole grains.
Well, going back to risk communication,
I want to be very specific.
I want to tell them, "Well, if, some studies have shown, that if
you eat more whole grains, you're going
to reduce type 2 diabetes."
And what does that mean?
I want to quantify it, if possible.
So I can use examples of two servings, or I can say,
"Well, three servings of whole grains have shown
to reduce this percentage."
I'd like to be as exact as possible so that it
is tangible, what I am saying.
Then what am I going to show?
And that is the show and tell.
That is the props session.
What are you going to show so that-most
of us are visual learners.
So I always think, how can I convey this message and
translate that into application?
Well, I like to use analogy.
In order for me to explain what is a whole grain that I am
telling the patient to consume, I compare
that to the yolk, to an egg.
And I say, "Well, just like an egg has
three parts, so does the grain.
And we want to make sure that all those three parts are there
when you eat them because each one brings you that nutrient
density that you need in order to have the
effects that you would want."
I also want to focus on what is the patient going to do?
And usually a patient has already given you what he or she
is eating, and then you talk about swapping.
And it has to be based on what the patient wants to change.
And in this example, I am talking about saturated fats.
Again, I talk about what are saturated fats?
And again, specific, I say, "Well, in terms of reduction of
the food that you're consuming that has saturated fat, you
might see, based on the studies that there, your LDL or bad
cholesterol, or your healthy cholesterol, can drop from
150 to 135 milligrams per deciliter."
I also want to ask them about the food so that then I can
provide suggestions, and then we will share decision-making
because the patient can decide what goals to choose.
And because my population is Hispanic, I usually have
everything in English and Spanish.
I have mentioned how much I enjoy having-creating my own
teaching materials and I like to use graphs.
In this example, on the left is what I call their saturated
fat-based budget, which is about-based on a 1,200 to 1,500
calorie-less than 10 percent of the calories from saturated fat.
So I used the concept of budgeting.
Budgeting saturated fat, budgeting
carbohydrates, et cetera.
And then, I give them an example of different foods, and based
on their serving size, the amount of
saturated fat that each one has.
This is a slide that can be used not just for patients that have
restricted health literacy but everyone can appreciate
the message at that point.
So right there I can see the difference between
whole milk and 1-percent.
You can see the difference between one cut
of meat and another cut of meat.
And this creates awareness to show, where is their diet?
That will suggest choosing what are the items that they
should be looking at and then thinking about recreating so
that overall their eating patterns becomes better.
So again, I do a lot of swapping with the patients.
And you can see here, this is a just an example of
what the patient just gives me.
And last but not least, I-this is a project that we created for
patients that, instead of going to restaurants, they'll be using
small mom-and-pop stores, and they were consuming a lot of
different sandwiches, especially at lunch time.
And we were concerned about the amount of sodium.
So we wanted to help them to select the cold cuts that
had the least amount of sodium.
So we created this handout.
And as you can see here, going back again to my love of graphs,
we indicated what were the different types of cheeses and
cold cuts, which one had more or less amount of sodium.
So that when there's not the best choices, I want to offer
the better choices, the more realistic choices.
But everything is guided.
And even there are some recommendations here that says,
"If you consume the high-sodium lunch, then this is what you can
do at night and have these others choices
that are lower in sodium."
Because I am not focused on just one meal.
I am focused on what is done day-in and day-out.
So circling back again to the healthy eating patterns, not
just demonizing one meal versus another.
And to make sure that your patients know, always use
what we call the 'Teach-Back.'
Have the patient tell you, what did I learn today.
Ask the patients to demonstrate or
explain what you have just said.
When you go home, how would you share this with
your husband or your children?
And how would you reconstruct this meal to make it healthier?
Then you know whether your explanation actually
was clear to the patient.
So this one of my favorite slides, and one boy tells the
other one, "I taught my dog how to sing."
And then the young man says, "I don't hear anything."
And he responds, "I said I taught him how
to sing, not that he learned."
So remember, information is not education.
So to conclude, I just want to show you some of the
questions that you can pose to use the teach-back method.
You can say things like, "Using your own words, you tell me..."
Or many times, I say, "I have given you so much information.
Can you tell you me in your own words..."
Or, "How could you describe this to someone else?"
So we have to come to the end of this presentation.
And this is the knowledge check question.
The amount of saturated fat for someone with diabetes should be?
Individualized?
Less than 10 percent of the calories?
Less than 30 percent of calories?
Depends on the triglycerides level?
OK.
So let's me show you.
Fifty-five percent of you says less
than 10 percent of the calories.
So that is the correct answer, because the recommendations are
that the amount of fat that is recommended is the same as the
general population and the recommendations from the dietary
guidelines do specify that the consumption of saturated fats
should be less than 10 percent.
So I am going to pass this over to my friend, Betsy, who will
give you a summary of the presentation.
Thank you very much.
Thank you Jenna and thank you Lorena.
We have been blessed of having these great
two speakers with us today.
As we conclude our overview this webinar today, we are reminded
of the important potential for the guidelines to implement
policy as well as practice.
Given the significant nutrition-related health issues
facing the US population, such as cardiovascular diseases,
type 2 diabetes, and certain cancers, the importance of the
best possible science to inform the public regarding dietary
recommendations is a paramount.
Managing the chronic disease like diabetes requires multiple
decisions each day on a range of complex process.
There are no vacations, no time-outs.
At best, conditions like poverty and food insecurity, only
complicates diabetes self-management.
At worst, they make effective self-management impossible.
This simple fact is true for the millions of Americans who live
with diabetes while facing food insecurity.
We're hoping that with today's webinar, healthcare
professionals remind ourselves that we all have a critical role
in implementing dietary guidelines recommendations to
people with diabetes and at risk.
Now, we're moving into the Q&A section.
We have been getting a lot of great questions and
Jenna answered some of those.
We will try to get to as many questions as possible.
So let me see what questions we have here.
Betsy?
Yes.
So there's a question that I just
saw that I'd be happy to answer.
It was a question around the WHO and the American Heart
Association are recommending an amount of added sugar that would
be significantly less than what's
in the dietary guidelines.
So what I would say in response to that is it's very important
to understand that the dietary guidelines is saying, a maximum
of less than 10 percent of calories.
That is not to suggest that 10 percent of calories is good or
right, but that it really is a maximum.
And actually when the advisory committee did an analysis and
looked at how much added sugar could be included in people's
diets, what they really found, in order to then also get all
the healthy nutrients you need, what they found is really it's
between 4 percent and 9 percent of calories, depending on the
number of calories you should be consuming.
And so really that recommendation of less than
10 percent is setting it at a high goal from the understanding
that right now Americans' consumption is above that.
And so there's no question that we want to be moving people,
that no one would be satisfied with getting everyone to
10 percent, that this is pushing for and really trying to.
But this is the first time that the dietary guidelines have had
a quantitative recommendation for added sugar.
And I think that's important to realize that the dietary
guidelines are not always about the optimal diet but about
moving people in the right direction.
And right now our added sugar consumption
is well above the 10 percent.
And so, and that is just a recommendation
to less than 10 percent.
Thank you, Jenna.
Thank you, Jenna.
I have a question here for Lorena.
Yes.
Lorena, how do we explain to patients why their total carbs
do not equal to fiber and total sugars?
Yes.
The way that I explain it is, I use a nutrition facts label.
And then I say that there are different
types of carbohydrates.
And that the total already includes the
others, the sugars, et cetera.
So that's the way that I explain that.
And there were recommendations in the past that the dietary
fiber was subtracted from the total amount of carbohydrates,
which later on changed to only half of the
total fiber would be reduced.
And now it's pretty much whatever the amount of
carbohydrate is there, that's the amount of it that we count.
So I just want to just say that I usually say everything is
already included in the total amount.
So that's the message that I say.
And then I use the example, if it's 20 grams of
carbohydrates, and when they look at sugars, it says 10, I
say, you don't have to count this twice but the 10 is already
part of the 20 grams of carbohydrate.
Thank you Lorena.
And now, Jenna, I have a question here that says, what
about recommendations for eggs?
I'm telling my patients one or two egg yolks per day.
Then, egg white for patients with no cardiovascular diseases.
Yes.
So, of course, it's important to know and I would not want to say
anything if the patients that you are treating
specifically have diabetes.
So I'm going to say, if that's true, there probably will be a
different answer to this question.
But if I would say that that's a very reasonable recommendation
in general, and it really is kind of moving away from the,
sort of, very rigid anti-egg view that may have come in the
past when there were more strict limits on dietary cholesterol.
And it really did hurt the egg industry in a major way that
people were really avoiding eating eggs that really are a
very healthy protein source when kept in moderation.
I just wanted to add a little bit to what
Jenna just said about the eggs.
And the emphasis that I try to do is to show that saturated
fats and trans fat usually have much more of an impact on
dietary cholesterol in general.
So I do what Jenna says is just very safe recommendations when
it comes to dietary cholesterol.
But to understand that about 3 percent of the dietary
cholesterol is what impacts blood cholesterol levels, and
then to focus more on the saturated
fats and trans fat in the diet.
Good.
I have a question here for you Lorena.
It says, are there are substitution
list for ethnic foods?
Are there substitutions?
Well, yes.
Yes, there are.
There are certain sources that have looked at different
foods of different ethnicities and religious groups, and what
are their healthier alternatives.
So there is a source of that.
So I was the co-editor and co-writer
of this particular book.
So it sounds like a shameless plug, but there
are sources that provide this.
Will high fructose be eliminated?
So at this point, I assume high-fructose corn syrup, so of
course, high-fructose corn syrup is considered an added
sugar, and certainly will be taken into account.
Will it be eliminated?
There is no, at this point, no regulation that is
going to eliminate it from food.
I think there is pressure.
There are a lot of people, just in the general public,
who are pushing against it.
And so products are taking it out and replacing it.
But I think it is important to note that if they just replace
it with other sugar, that's really not addressing the
problem of added sugar in people's diet.
And so I do think it is important to note that there are
a lot of people who maybe feel like, "Well, if I drink the soda
that's made with sucrose that somehow that's OK because it's
no longer high-fructose corn syrup."
And I think it is important to note that it's still sugar and
a lot of sugar certainly in a soda.
And it's all added sugar and no other beneficial ingredients.
And so I think that we need to get away from the notion that if
we just get rid of high-fructose corn syrup that we'd be-that
people would be OK consuming other kinds of sugar.
Thank you Jenna.
I would like to have more time for more questions
but we're running out of time.
Also, we are in the process of updating one of the most
popular resources for the National Diabetes Education
Program, which is the bilingual recipe book, Tasty Recipes for
People with Diabetes and Their Families.
So stay tuned in the next few months to see our updated
booklet reflecting some of the changes that
have been discussed here today.
I'd like to also mention to you that the NDEP
webinar series is offering continuing education credits.
You will have to complete an online evaluation
in order to claim your credits.
Just go to the CDC TCEO at the link that is showing at the top
of your screen and follow the instructions.
You will receive a certificate of completion too.
I'd like to thank everybody that joined us today.
It has been an amazing participation.
You have seen my contact information
during the Q&A session.
So please feel free to contact me.
Thank you Jenna, and thank you Lorena for sharing your
expertise and words of wisdom.
Everyone else, see you next time for another
great NDEP webinar series.
Thank you again and goodbye.
For more infomation >> Jeremy Bash: It's clear that Nunes blocked Sally Yates hearing for the White House - Duration: 1:23. 
For more infomation >> PAPA SERPIENTE. Bullet For You. Todo Rock Murcia. 4K - Duration: 5:13. 
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