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1 Summary D IETARY RECOMMENDATIONS for the U.S. population have been promulgated for almost a century. Early dietary guidance was directed mainly at the avoidance of deficiency diseases, with little attention given to reducing the risk of chronic conditions other than obesity. However, there have been substantial advances in the past 25 years in understanding the relation of diet to health. As a result, consensus has developed about the role of diet in the etiology and prevention of chronic diseases. The National Research Council report, Diet and Health: Implications for Reducing Chronic Disease Risk (NRC, 1989; hereinafter referred to as the Diet and Health report) and The Surgeon General's Report on Nutrition and Health (DHHS, 1988) provide authoritative reviews of the evidence relating dietary factors to health and disease and make clear that there is now broad agree- ment on the overall nature of dietary modifications to reduce the risk of diet-related chronic diseases. The main challenge no longer is to determine what eating patterns to recommend to the public (although, admittedly, there is more to be learned), but also how to inform and encourage an entire popula- tion to eat so as to improve its chance for a healthier life. There has been an increasing recognition that simply issuing and disseminating recommendations is insufficient to produce change in most people's eating behaviors. Many federal and state programs exist to imple- ment the federal government's dietary guidelines. Also, there are persistent efforts by the private sector to produce and publicize food products that help people to meet various recommendations. How 1

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2 IMPROVING AMERICA'S DIET AND HEALTH ever, there remains a clear need for comprehensive and coordinated actions to improve America's diet and health. The Committee on Dietary Guidelines Implementation was con- vened in 1988 under the auspices of the Food and Nutrition Board (FNB) of the Institute of Medicine to address this widely felt need. In this report, the committee promotes the recommendations of the Diet and Health report. These recommendations are well suited for imple- mentation because they are the most comprehensive and authorita- tive currently available and have been established by an eminent group of biomedical scientists based on a comprehensive evaluation of the scientific evidence linking nutrient intake, food intake, and dietary patterns with risks of developing many chronic degenerative diseases. In addition, the Diet and Health recommendations specify quantitative targets (e.g., limit fat intake to 30% or less of calories) and are presented in a priority order that reflects their likely impact on public health; they will be reviewed regularly and revised as needed to incorporate new findings. All of these qualities facilitate their interpretation and translation into specific strategies and actions for implementation. Nevertheless, the committee's goals, strategies, and actions for implementation are qualitative and apply equally well to the recom- mendations in the Diet and Health report, The Surgeon General's Report on Nutrition and Health (DHHS, 1988), and the Dietary Guidelines for Americans report of the U.S. Departments of Agriculture and Health and Human Services (USDA/DHHS, 1990) (see Appendix A for all 3 sets of recommendations). The third serves as the basis for nutrition policies of the federal government. The term dietary recommendations is used throughout this report to refer as a group to these three documents of dietary guidance. This committee's strategies and actions proposed for implementation also apply to most of the dietary guidelines issued by expert groups that focus on specific diseases (e.g., guidelines issued by the American Heart Association and the National Cancer Institute), because they are similar to those of the FNB, Surgeon General, and USDA/DHHS. The committee believes that the United States should move toward adopting a single set of dietary recommendations to communicate and promote. One set of recommendations should reduce confusion and provide implementors with a common focus for their activities. PLACING DIETARY RECOMMENDATIONS IN PERSPECTIVE Although the focus of this report is on improving dietary patterns, the committee emphasizes that diet is only one important determi

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S UMMARY 3 nant of health and well-being. Various personal behaviors (e.g., re- fraining from smoking and abuse of drugs, engaging in regular exer- cise, and taking care to avoid accidents) and other factors (e.g., fam- ily history of disease, access to health-care services, and the state of the environment) are also strongly linked to risks of disease and should not be neglected in health promotion programs by an overemphasis on diet. Healthful dietary behaviors and other ways of life will im- prove the health of many people but will not guarantee good health or long life for any person. The committee hopes that implementation initiatives undertaken in response to the recommendations in this report will be linked with other health-promoting practices whenever possible. A long-term commitment to implementation by promoting incremental changes is more likely to be successful than are drastic, one-shot efforts. Be- cause the food system and public responses to new dietary patterns change slowly, a realistic time frame for implementation will be mea- sured in years rather than months. ISSUES IN IMPLEMENTING DIETARY RECOMMENDATIONS The primary issue facing the committee was to determine how the U.S. population could be mobilized to improve its eating patterns to reduce the prevalence of diet-related chronic diseases. This goal will be met in the following ways: enhancing awareness, understanding, and acceptance of dietary recommendations; creating legislative, regulatory, commercial, and educational en- vironments supportive of the recommendations; and improving the availability of foods and meals that facilitate implementation of the recommendations. The general tactics for increasing the prevalence of healthful eating patterns can be divided into three classes: Altering the food supply by subtraction (e.g., reducing the fat in meat and cheese), addition (e.g., appropriate fortification of foods with nutrients), and substitution (e.g., replacing some of the fat in margarine with water). Altering the food acquisition environment by providing more food choices that help consumers meet dietary recommendations, better in- formation (e.g., more complete and interpretable product labeling), advice at points of purchase (e.g., tags indicating a good nutrition buy in supermarkets or cafeterias), and more options for selecting health

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4 IMPROVING AMERICA 'S DIET AND HEALTH ful diets (e.g. better food choices in vending machines and restau- rants). Altering nutrition education by changing the message mix (e.g., presenting consistent messages in education programs, advertisements for products, and public service announcements) and by broadening exposure to formal and nonformal nutrition education (e.g., mandating education on dietary recommendations from kindergarten through grade 12, in health-care facilities, and in medical schools). Although common sense suggests that desirable dietary changes will most likely occur when all these components are made to be mutually reinforcing, there is insufficient research on their individual effectiveness or how they can best be assembled into a package. As related in Chapter 3, there is evidence that some people have already adopted eating patterns that are consistent with dietary rec- ommendations. Throughout the United States, for example, per-capita consumption of fresh fruits and vegetables, breakfast cereals, and other grains has increased, and consumption of whole milk is declining while that of low-fat milk is increasing. Many consumers report that they use less salt and fat in food preparation. But other changes in consumption patterns, such as increasing intake of high-fat cheeses and frozen desserts, fats and oils, snack foods, candy, and some alco- holic beverages, do not appear to be consistent with good nutrition principles. As is the case with changing dietary patterns, recent changes in consumer attitudes and beliefs about food and nutrition provide cause for both optimism and concern. Overall, there is a general trend toward recognition of the important role that diet plays in disease prevention, but surveys indicate that many people lack both the detailed knowledge and the skills needed to act effectively on this information. Consumers often seem unable to translate the recommendations into food choices or to assess the suitability and composition of their own diets in comparison with the recommendations. This country's increasing attention to promoting healthy eating patterns and providing advice on how to achieve dietary change can be credited to many developments. These include the preparation of dietary recommendations by experts and the efforts of the private sector to reduce the fat and sodium content of many traditional food products and to provide voluntary nutrition information programs. In addition, the media, recognizing that nutrition sells, have been instrumental in calling the public's attention to dietary recommenda- tions. These efforts, although commendable, have been fragmented, not necessarily consistent, and thus far insufficient to promote large- scale dietary modification. Most people in the United States do not

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S UMMARY 5 choose diets that conform to dietary recommendations, and current efforts to communicate these recommendations seem to benefit pri- marily those who are educated and of higher socioeconomic status. How can the barriers to dietary change be overcome and the pub- lic become motivated to adopt healthier diets? Promoters of dietary change need to acknowledge that eating is often social and fun. The committee does not wish to have people focus on health alone in deciding what to eat but, rather, to encourage them to modify their eating behaviors in ways that are both healthful and pleasurable. Promotion of dietary change among currently healthy people may be especially challenging, because the immediate physical and psycho- logical benefits may not be apparent and the appeal is most com- monly made on the grounds of potential future well-being. Although the committee recognizes the difficulty of modifying eating behavior, its extensive review of current theory and practice in Chap- ter 3 suggests that it is possible to modify food preferences and eating patterns in this country. Some of the factors affecting food choices are difficult to modify (e.g., inherent taste preferences and household income), but other factors such as cultural and social norms (which largely determine what, when, where, how much, and how quickly food is to be eaten), knowledge of and beliefs about food, skills at food selection and preparation, and availability of health-promoting foods are more subject to modification. Initiatives to promote di- etary change tend to be most effective when they identify means to help people (1) make the information personally relevant, (2) inte- grate the information into existing belief structures, (3) acquire new skills and self-perceptions, and (4) select situations that will help them translate newly acquired attitudes into behaviors that become habitual. Research in schools, at work sites, and in communities indicates that certain theory-based intervention programs can produce significant reductions in risk factors for diet-related diseases. It seems reasonable to infer that new national programs to promote the adoption of dietary recommendations by individuals, together with policies that increase the availability of health-promoting foods, will lead to improved dietary patterns. THE TASKS AND THE PARTICIPANTS IN IMPLEMENTATION Implementation begins with the conveyance of dietary recommen- dations to the U.S. population in a language and format that is relevant and comprehensible to the majority of people of all backgrounds, cultures, languages, and interests. The information provided must identify the components of a healthful diet. Proper interpretation of

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6 IMPROVING AMERICA'S DIET AND HEALTH dietary recommendations is essential if implementors including food planners, cooks, educators, policymakers, curriculum designers, the private sector, and health-care professionals, as well as individuals- are to use them consistently and successfully in a wide variety of contexts. Chapter 4 interprets the nine dietary recommendations of the Diet and Health report and provides general guidance for their use in selecting and preparing foods and constructing healthful diets. The guidance is also relevant to the implementation of most recent sets of dietary guidelines. Both individual and societal actions are needed to encourage and enable Americans to alter their food consumption practices in more healthful directions. Individuals have the responsibility to seek out and use information to improve their eating habits. Sectors of soci- ety including governments, the private sector, health-care profes- sionals, and educators have responsibilities to facilitate the adop- tion of better diets by increasing the availability and accessibility of health-promoting foods and using their considerable resources to make such foods easily identifiable (e.g., improved nutrition labeling and nutrition education), economical, and appealing. Society also has an obligation to ensure that food choices over which individual consumers rarely have control (e.g., meals served in institutional cafeterias, on airplanes, or at various social events) are, whenever possible, sufficiently varied so that those who wish to eat in accordance with the principles of dietary recommendations are able to do so. The committee began its work by imagining a wide range of strategies for modifying eating behavior. To the extent possible, each of these was examined in terms of such criteria as history of effectiveness, affordability, political feasibility, public acceptability, and legal and ethical considerations. Together, these criteria served as the basis for selecting intervention strategies and actions that in the committee's judgment are likely to be successful. The committee concluded that its recommended strategies and actions could not be put in any order of importance or priority because they are diverse in scope, each requiring different levels of resources and participation from various societal sectors, and they all are important and should be carried out simultaneously. Much of the committee's work was done by four task forces, each focusing on specific societal sectors: public, private, health-care pro- fessions, and public education. These groupings were an effective mechanism for identifying the main interventions that have been at- tempted and for recommending those that might be undertaken. The recommendations of these task forces clearly overlap; they are pre- sented in Chapters 5 through 8 and summarized below.

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SUMMARY Public Sector 7 This sector includes governments at all levels the executive, leg- islative, and judicial branches at the federal, state, and local levels. Governments promote implementation of dietary recommendations through direct efforts of legislation and rule-making; provision of information and education; awarding of research and demonstration grants; intramural research, education, and extension programs; food assistance and farm programs; their own vast meal service functions; and in acting as role models by providing examples of implementa- tion in government facilities, by government officials, and at govern- ment-funded events. The public sector can also encourage this effort indirectly by setting an agenda for the implementation of various strate- gies, opening communication with the private sector and voluntary organizations, and coordinating implementation efforts. The five stra- tegies and associated actions developed for the public sector are de- scribed in Chapter 5 and summarized below. 1. Improve coordination of federal efforts to implement dietary recommendations. Although the federal government has done much to encourage Americans to eat well, there is no governmentwide nu- trition policy that provides a coherent blueprint for fostering health- ful dietary patterns. The committee recommends that the executive branch establish a comprehensive coordinating mechanism to pro- mote the implementation of dietary recommendations by all govern- ment agencies with responsibilities in food and nutrition. The U.S. Congress and state legislative bodies also need to be active in imple- mentation by developing and passing relevant legislation and by overseeing agency activities. 2. Alter federal food assistance, food safety, nutrition, and farm subsidy, tariff, and trade programs (e.g., the Food Stamp Program, School Lunch Program, and Commodity Distribution Program) that directly influence the food consumed by many of the nation's school- children, elderly people, residents on Indian reservations, and most other Americans to encourage the consumption of diets that meet dietary recommendations. 3. Change laws, regulations, and agency practices that have an appreciable but indirect impact on consumer dietary choices or that will make more foods available to support nutritionally desirable diets. Examples include nutrition labeling of foods, food standards of identity, dairy price supports, quality grading of meat, and de- scriptors for ground beef. 4. Enable government feeding facilities to serve as models to pri- vate food services and help people to meet dietary recommendations.

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8 IMPROVING AMERICA'S DIET AND HEALTH These facilities include U.S. Department of Veterans Affairs hospital cafeterias; U.S. Department of Defense dining halls, hospitals, and clinics; eating facilities in jails; government cafeterias; and establish- ments where official meal functions are held. 5. Develop a comprehensive research, monitoring, and evaluation plan to achieve a better understanding of the factors that motivate people to modify their eating habits and to monitor the progress toward implementation of dietary recommendations. The National Nutrition Monitoring System will need to be improved, expanded, and provided with adequate resources. The committee believes that successful implementation of dietary recommendations by the public sector requires adherence to the fol- lowing principles: (1) provide information and education; (2) ensure freedom of choice by providing adequate choice at reasonable prices whenever possible; (3) foster long-term commitment and incremental approaches to dietary change to minimize disruption of food prefer- ences; (4) facilitate access to health-promoting foods; (5) present healthful eating in a context of total health promotion; (6) involve all who have some stake in planning and implementing actions; (7) ensure that healthful diets are appealing and convenient and entail the fewest disruptions to current food preferences and life-styles; and (8) encourage the incorporation of health-promoting foods in food programs. These principles also served the committee in devising many of its recom- mendations for other societal sectors. Private Sector In this report, the private sector is defined broadly to include pro- ducers of several major commodities (fruits and vegetables, grains and legumes, dairy products, meat, poultry, fish and seafood, and eggs); food manufacturers, processors, and retailers; food service es- tablishments (restaurants, fast-service food establishments, and insti- tutional food-service providers); and work sites (cafeterias and vend- ing machines in office buildings and factories). The two strategies and associated actions developed for the private sector are described in Chapter 6 and summarized below. Promote dietary recommendations and motivate consumers to use them in selecting and preparing foods and in developing health- ful dietary patterns. This can be done, for example, by using the methods of public relations and advertising and by providing a vari- ety of user-friendly consumer information programs and materials at retail outlets, food-service establishments, and work sites (e.g., infor

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S UMMARY 9 mation on the nutritional value of specific products at points of pur- chase). The private sector should initiate and participate in collabora- tive efforts with other societal sectors to develop consumer education and information programs and materials. It should also continue to contribute to efforts to improve the nutrition labeling of food. 2. Increase the availability of a wide variety of appealing foods that help consumers meet dietary recommendations. New food prod- ucts are being developed and traditional ones modified, usually by reducing their total fat, saturated fat, sodium, or sugar content or by increasing their fiber content-in response to scientific consensus about diet and health relationships, consumer interest, and the availability of new technologies and ingredients. It is now easier to select health- promoting meals in many food-service establishments. The private sector should also contribute to efforts to revise or develop food quality criteria (such as standards of identity and grading), pricing struc- tures, and food product descriptors to promote the production of more nutritionally desirable food products. In addition, this sector should fund or conduct surveys on consumer attitudes, knowledge, and practices regarding food and nutrition issues to receive more guidance on how to improve their products and campaigns to encourage healthful eating patterns. Although there are obvious barriers, there are also many incen- tives for the private sector to assist consumers in implementing dietary recommendations. The hinderances include the costs of new product research, development, and promotion as well as lack of knowledge or practical guidance on how to make changes in the food supply; the latter is partly due to the fact that many companies do not employ registered dietitians or nutritionists and that chefs and food-service personnel often do not have sufficient background or training in nu- trition or in recipe or menu modification. Yet many incentives for the private sector exist to help implement dietary recommendations. These include the potential for an enhanced image and increased product sales, and new and repeat business by increasing customer satisfaction and loyalty. Health-Care Professionals People are looking more and more to nutritionists, physicians, nurses, health educators, and other health-care professionals to provide clear information on the links between dietary patterns and risks of dis- ease as well as practical guidelines for eating in ways that meet di- etary recommendations. In addition, health-care professionals have renewed interest in preventive over reparative practices. This group

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10 IMPROVING AMERICA'S DIET AND HEALTH performs multiple roles in implementing dietary recommendations beyond their roles as educators and advisers. As organizers, they initiate or contribute to community programs to improve nutrition, and as investigators, they gain new knowledge about diet and dis- ease relationships and the factors that govern behavioral change. The three strategies and associated actions developed for health-care pro- fessionals are described in Chapter 7 and summarized below. 1. Raise the level of knowledge among all health-care profession- als about food, nutrition, and the relationships between diet and health. The committee recommends (1) establishment of an identifiable pro- gram within the faculty of every health-care professional school to plan and develop a research and education agenda in human nutri- tion; (2) establishment of a program within the U.S. Public Health Service to support the training of faculty in nutrition; (3) development of curricular materials emphasizing dietary recommendations; and (4) encouragement of licensing and certification bodies to require a demonstration of knowledge of nutrition for students in health-care professional schools before graduation. 2. Contribute to efforts that will lead to health-promoting dietary changes for health-care professionals, their clients, and the general population. Health-care professionals should integrate nutrition information into their contacts with clients and patients. They and their professional asso- ciations should take advantage of opportunities to disseminate sound nutrition advice through the media; provide guidance to regulatory and legislative bodies concerned with the establishment of policies governing the production, harvesting, processing, preservation, dis- tribution, and marketing of food products; and distribute practical information such as menus, recipes, and ideas for health promotion initiatives to private and public providers of meals. 3. Encourage the public and private sectors to intensify research on the relationships between food, nutrition, and health and on the means to use this knowledge to promote the consumption of health- ful diets. The results of such research will enable health-care profes- sionals to provide up-to-date nutrition advice and counseling in more effective ways. Major barriers to the implementation of dietary recommendations by many health-care professionals include inadequate time and com- pensation to provide the kinds of nutrition guidance that individuals may desire or need, the perception that many people lack interest in eating better and that they do not follow recommended diets, inad- equate knowledge and skills needed to teach people how to improve their diets, and inadequate preparation for their new and expanding

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SUMMARY 11 roles as promoters of good nutrition. Fortunately, programs estab- lished by foundations, voluntary organizations, governments, and other groups are attempting to help health-care professionals prepare for their expanded roles. Education of the Public The committee divided education of the public into three catego- ries based on the settings in which learning is assumed to occur: formal (in schools), nonformal (organized teaching and learning events that occur, for example, in hospitals, community centers, and clinics), and informal (the almost infinite variety of educational experiences that include preparing dinner, watching product advertising on tele- vision, and reading a newspaper article). Educators face difficulties in helping consumers to eat in ways that meet dietary recommenda- tions in an extensive, complicated, and confusing information envi- ronment that includes tens of thousands of food products from which to choose. Success is most likely to be achieved if emphasis is placed on the importance of developing healthful dietary patterns rather than teaching consumers about nutrients whose presence in food products can be individually concentrated or diluted in ways to make these products appear more desirable. The six strategies and associated actions proposed for education of the public are described in Chapter 8 and summarized below. 1. Ensure that consistent educational messages about dietary rec- ommendations reach the public. This can occur if leaders of various national groups concerned with health develop a series of common educational initiatives to implement the recommendations. Materials prepared by these groups should be reviewed prior to publication to ensure consistency and compatibility with dietary recommendations. In addition, broad guidelines should be developed that publishers could use to convey consistent and authoritative information on di- etary recommendations. The educational materials from various food industry sources made available to schoolteachers should also be re- viewed and evaluated. 2. Incorporate principles, concepts, and skills training that sup- port dietary recommendations in all levels of schooling. For example, a model curriculum for teaching food skills, nutrition, and health from kindergarten through grade 12 should be developed and should include teacher-tested lessons. Institutions of higher learning should offer a nutrition course for interested students. Additional actions to achieve this strategy include (i) mandating the inclusion of a food skills, nutrition, and health course in teacher preparation programs

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1~ IMPROVING AMERICA 'S DIET AND HEALTH in each state; (ii) reviving the successful Nutrition Education and Training (NET) Program, administered by the U.S. Department of Agriculture, which linked classroom teaching about nutrition with the lunchroom and trained school food service personnel to prepare meals based on the lessons they had learned; and (iii) offering each student in grades 7 through college a periodic computer analysis of his or her diet and a professional evaluation of how the student's food habits conform to dietary recommendations. 3. Ensure that children in child-care programs receive nutritious meals served in an environment that takes account of the importance of food to children's physical and emotional well-being. An interdis- ciplinary task force of experts could develop national recommenda- tions for legislation, regulations, and standards, as well as education and training guidelines for professionals and the public to ensure achievement of this recommendation. 4. Enhance consumers' knowledge and skills needed to meet di- etary recommendations through appropriate food selection and preparation. This would entail the development of a consumer manual that outlines strategies for influencing local food providers and ap- propriate others to increase the availability of nutritionally-desirable foods. Also, the preparation of an inexpensive, continually updatable foods data bank would provide consumers, food planners, and oth- ers with the nutritional content, composition, and production/pro- cessing histories of the products available to them. 5. Establish systems for designing, implementing, and maintaining community-based interventions to improve dietary patterns. Relevant professional organizations should work to engage community lead- ers in the development of community-based programs that promote dietary recommendations. Schools of higher learning in various re- gions of the United States should be encouraged to develop pro- grams to educate and update individuals in the skills they need to play key roles in community nutrition education projects. 6. Enlist the media to help decrease consumer confusion and in- crease the knowledge and skills that will motivate and equip con- sumers to make health-promoting dietary choices. This can be done in part through social marketing campaigns and by coordinating me- dia activities to promote healthful eating. In addition, committees should be appointed to review whether television food advertising aimed at children should be regulated and to examine the utility of national entertainment television as a community organizing tool that can be used to enhance efforts of local health agencies in encouraging appropriate dietary changes.

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S UMMARY PRINCIPAL IMPLEMENTATION STRATEGIES 13 In addition to developing recommendations for implementation by individual sectors of society, the committee derived three princi- pal strategies to form the basis for furthering the implementation of dietary recommendations across all sectors. In the committee's judgment, these principal implementation strategies collectively offer the best promise of success in bringing about desirable dietary changes on a national level. Although the committee acknowledges that each of them is already being implemented to some extent, it believes that progress can and should be accelerated. 1. Governments and health-care professionals must become more active as policymakers, role models, and agenda setters in implementing dietary recommendations. As described above, governments at the federal, state, and local levels have many opportunities to encourage, em- power, and enable more people to improve the quality of their diets. The opportunities come largely from their control over the spending of public funds and, at least as important, by their ability to set public policy (e.g., enact legislation and revise laws, standards, regulations, and rules) and to bring public attention and interest to issues they deem important. The federal government, for example, is reviewing or revising its policies on food labeling, standards of identity and grading of food, and distribution of surplus food commodities as a result of knowledge and concerns about diet and health. The com- mittee believes that greater interest and action by governments in promoting healthy life-styles will contribute greatly to improving di- etary patterns in the United States particularly if top government leaders become involved (e.g., the President, Congress, governors, and mayors) and if governments take opportunities to participate in implementation efforts developed by other societal sectors. Health-care professionals, who are viewed by the public as cred- ible authorities on matters of health and disease, also have many opportunities to encourage and instruct people on how to improve their dietary habits and other health-related behaviors. As described earlier, health-care professionals, working alone and collectively through their societies and associations, should use their knowledge of diet and disease connections and their practical applications to improve their own diets and the diets of their clients. Health-care profession- als should also be active in creating or encouraging initiatives to improve dietary patterns in their communities. Finally, they can cre- ate opportunities to contribute to local, state, and national policies

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14 IMPROVING AMERICA'S DIET AND HEALTH that regulate access to nutritionally desirable foods and to the estab- lishment of social environments that encourage healthy eating. 2. Improve the nutrition knowledge of the public and increase the oppor- tunities to practice good nutrition. If individuals are to be encouraged to take responsibility for adopting and maintaining healthy behaviors, they need information (to identify problem behaviors and how to improve them), motivation (to make the changes), and supportive environments (to maintain the changes). Because food habits are formed to a great extent during childhood, incorporating the principles of food, nutrition, and health into pre- school, elementary school, and secondary school education- and providing children with health-promoting meals in those settings- offer major opportunities to encourage the development of healthful eating patterns. These efforts must begin in preschool and child-care settings, where an increasing number of children are receiving care. In addition, colleges and institutions of higher learning should make available to students a course in nutrition or healthy life-styles. Health- care professionals also need adequate training about the role of diet in disease prevention and treatment and the practical applications of dietary recommendations at their educational institutions and in con- tinuing education programs. Even schools that train chefs and cooks should place emphasis on dietary recommendations and how they can be used to prepare nutritious and health-promoting meals. Expected improvements in the nutrition labeling of foods provide further justification for comprehensive nutrition education programs. Although updated nutrition labels will supply important information to interested consumers, the information alone is not sufficiently complete for making wise dietary choices and constructing healthful diets. An important component of nutrition education programs will be to help consumers understand the proper uses and inherent limitations of food labels in planning healthful diets. In addition to formal schooling, there are many other opportuni- ties that can be used to inform consumers on the connections between diet and health and how to develop healthy food habits. Work sites provide unique opportunities for health and nutrition education because the programs are convenient to employees and the availability of social support from coworkers for changes in behavior is often great. Many food retailers and food-service establishments can provide nutrition information and literature to their customers as well as important point-of-purchase information near specific products. The communications media (e.g., television, radio, and popular magazines) exert powerful influences on people's lives. Organized campaigns to disseminate, explain, and promote dietary recommen

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SUMMARY 15 cations through a variety of media offer great potential for improv- ing eating patterns in the United States. Funds for campaigns will have to come from both the public and private sectors. Such campaigns should be directed to the general public as well as to selected sub- groups of the population, including schoolchildren, disadvantaged and minority populations, the media itself, health-care professionals, and opinion leaders (e.g., celebrities and public officials). In design- ing media campaigns, emphasis should be placed not simply on de- veloping public service messages and documentaries but also on modifying the contents of programs so that both participants and plots support good eating habits. If media campaigns are to be successful, however, they will have to be coordinated with community-based health promotion efforts. Local communities provide people with education, work, family and social life, and important services, and can therefore be a power- ful force that shapes people's life-styles and health behaviors. There- fore, community-based interventions and programs have an enormous potential for improving dietary patterns in the United States. Effec- tive community-based health promotion programs consist of mul- tiple interventions directed at multiple levels (e.g., individuals, small groups, organizations, and entire communities). Interventions include the development of nutrition education programs at such places as work sites, schools, places of worship, and city or county health de- partments as well as the provision of information on diet and health at these sites and in local supermarkets, restaurants, government of- fices, offices of health-care professionals, and many other locations. Communities could, for example, establish nutrition and health com- mittees to generate and coordinate local activities. Membership in the committees should be broad and include interested citizens, health- care professionals, government officials, and local businessmen. 3. Increase the availability of health-promotingfood. The U.S. food supply is both abundant in variety and high in quality. This is particularly evident in supermarkets in most areas, where people who wish to eat according to dietary recommendations can select from a wide variety of high-quality vegetables and fruits; whole-grain breads and cereals; legumes; lean meats, poultry, and fish; low- or nonfat dairy products; and foods low in added salt and sugar. The private sector has been modifying many traditional products to make them more nutritionally desirable as technology permits and as marketing opportunities are identified. Yet successful implementation of dietary recommendations will require that consumers have greater access to health-promoting foods on those occasions when they are unable or unwilling to prepare it.

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16 IMPROVING AMERICA'S DIET AND HEALTH The industries and personnel who provide and prepare food in hos- pitals, at work-site cafeterias, at airlines, and in vending machines should examine their policies and practices to determine how they can conform to the principles of dietary recommendations. The same applies to food services and food programs administered by federal, state, and local governments, including U.S. Department of Veterans Affairs medical centers, General Services Administration cafeterias, and the school lunch and elderly feeding programs. Restaurants, cafeterias, and fast-service food establishments have special respon- sibilities to promote better eating by providing foods and meals, prepared in attractive and tasty ways, that help people to meet dietary recom- mendations. Institutional food-service suppliers should reevaluate their inventories so they are able to supply eating establishments with an increased variety of health-promoting foods. It may be especially difficult for people in some parts of the country (e.g., very small towns, rural areas, and economically deprived areas of cities) to eat in ways that meet dietary recommendations if they must depend heavily on small nearby supermarkets or grocery stores for their food purchases. These retailers have a special responsibility to stock as great a variety of nutritionally desirable foods as they are able at reasonable prices. DIRECTIONS FOR RESEARCH Continued research is essential to establish a better base for de- signing cost-effective, efficient, and effective implementation strate- gies and for assessing their costs and benefits. The committee identified six broad areas of research in which more activity is required to achieve these goals. They are described in Chapter 9 and are identi- fied below. 1. Improve methods to characterize what people actually eat, especially over long periods during which dietary patterns change. 2. Increase understanding of the existing and potential determi- nants of dietary change and how this knowledge can be used to pro- mote more healthful eating behaviors. 3. Continue research to develop new food products and modify both the production and processing of traditional products to help consumers more easily meet dietary recommendations. 4. Review and improve government and private-sector policies that directly and indirectly affect the availability of particular foods and the promotion of healthful dietary patterns. 5. Determine how implementors of dietary recommendations at

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S UMMARY ., 7 all levels (e.g., supermarket managers, physicians, and high school health teachers) can more effectively teach the basis of the recom- mendations and motivate people to follow them. 6. Investigate the costs and benefits of implementing dietary rec- ommendations as proposed by this committee and by others. LESSONS LEARNED AND PROCESS FOR FUTURE A turning point in nutrition history has been reached. Wide-scale consensus now exists on the types of dietary patterns that promote health and reduce the risks of common degenerative diseases, and at the same time there is great public interest in diet, nutrition, and health issues. Many millions of Americans have modified their diets in desirable directions as a result of past and current implementation efforts. Yet considerable challenges lie ahead if the majority of the U.S. population is to eat in ways that conform to dietary recommen- dations. Achievement of this overall objective will require unprec- edented levels of collaboration among the many entities involved in providing nutrition information, education, and food to the public. It is time to accelerate efforts to improve America's diet and health. REFERENCES DHHS (U.S. Department of Health and Human Services). 1988. The Surgeon General's Report on Nutrition and Health. DHHS (PHS) Publ. No. 88-50210. Public Health Service, U.S. Department of Health and Human Services. U.S. Government Printing Office, Washington, D.C. 727 pp. NRC (National Research Council). 1989. Diet and Health: Implications for Reducing Chronic Disease Risk. Report of the Committee on Diet and Health, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washing- ton, D.C. 749 pp. USDA/DHHS (U.S. Department of Agriculture/U.S. Department of Health and Hu man Services). 1990. Nutrition and Your Health. Dietary Guidelines for Ameri- cans, 3rd ed. Home and Garden Bulletin No. 232. U.S. Department of Agriculture/ U.S. Department of Health and Human Services, Washington, D.C. 28 pp.