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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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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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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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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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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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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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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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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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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.
Representative terms from entire chapter:
dietary patterns
