Eating Right: Keeping America Healthy

A healthy nation is a well-nourished nation, in which all people eat enough of what they need to and avoid, as much as possible, foods that are not healthful. For the United States, this remains an ideal. The nation has made progress toward this goal, but falls short in a number of areas and even has slipped backward in some instances.

The Institute of Medicine (IOM) has a long history of examining the nation’s nutritional well-being—where things stand, what is going right, what needs to be done. Two key areas have received particular attention: improving nutrition among children and adolescents, who are developing rapidly and thus are especially sensitive to nutritional shortcomings, and coming to grips with the epidemic of obesity that is spreading among many sectors of the population.

Educating children and teens

Students in southwestern Kentucky are proving to be wily innovators in improving their own health, through a program sponsored by the IOM and the Healthy Weight Kids Coalition in Kentucky, and their efforts may chart a way for other young people to take charge of their eating habits. The program traces back to an IOM project in 2006 during which students in a number of middle and high schools in and around Bowling Green, Kentucky, gathered information about the food and beverage marketing practices in their region. In thinking about how healthful foods might be marketed better, particularly toward youth, one student suggested providing incen-



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eating right: Keeping America Healthy A healthy nation is a well-nourished nation, in which all people eat enough of what they need to and avoid, as much as possible, foods that are not healthful. For the United States, this remains an ideal. The nation has made progress toward this goal, but falls short in a number of areas and even has slipped backward in some instances. The Institute of Medicine (IOM) has a long history of examining the nation’s nutritional well-being—where things stand, what is going right, what needs to be done. Two key areas have received particular attention: improving nutrition among children and adolescents, who are developing rapidly and thus are especially sensitive to nutritional shortcomings, and coming to grips with the epidemic of obesity that is spreading among many sectors of the population. educating children and teens Students in southwestern Kentucky are proving to be wily innovators in improving their own health, through a program sponsored by the IOM and the Healthy Weight Kids Coalition in Kentucky, and their efforts may chart a way for other young people to take charge of their eating habits. The pro- gram traces back to an IOM project in 2006 during which students in a number of middle and high schools in and around Bowling Green, Kentucky, gathered information about the food and beverage marketing practices in their region. In thinking about how healthful foods might be marketed better, particularly toward youth, one student suggested providing incen- 

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 INforMINg THe fuTure: Critical Issues in Health tives to use “healthy smart cards”—magnetized cards approved specifically for purchasing healthful food items—when eating at local restaurants. The idea caught hold. Through its Kellogg Health of the Public Fund and in partnership with the Healthy Weight Kids Coalition and Western Kentucky University, the IOM began a new effort to explore the potential of healthy smart cards in helping young people make better food choices. Program coordinators identified food options at local restaurants, recruited restaurants to participate in the program, developed educational and pro- motional materials, and procured community support. They developed the cards that students could use, designed and distributed point-of-purchase displays and other materials for restaurants, installed card readers and trained workers on how to use them, and looked for ways to encourage stu- dent participation. After learning from students that a website would be help- ful in educating students about the program and also hosting other program resources, the team developed both a paper guidebook and a website to help youth identify the healthy options available at various local restaurants. Ten restaurants (including McDonald’s and Chick-fil-A franchises) committed to displaying information about the program, installing card readers, and offering discounts on healthful food purchases when students presented their cards. Supporters lined up, including most city and county schools, local hospital systems and health care providers, the local restau- rant association, and the city’s mayor. The Smart Bites Card Program, as it is called, rolled out in January 2009 with great fanfare, with more than 50 percent of the eligible students signing up to participate. Over the long term, the IOM hopes the program will prove to be replicable across the United States. In addition to educating young people about healthful foods, the nation also must find ways to ensure that children have the opportunity to make healthy choices. The IOM has tackled this issue through many recent activities: the establish- ment of a new committee to help guide the IOM’s work on obesity prevention; an evaluation of the national school meal program and assessment of how it might be updated; and hosting a workshop to discuss “food deserts”—low-income neighborhoods with limited access to affordable, nutritious food; in addition to other nascent studies.

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 eating right: Keeping America Healthy fighting fat Despite progress over the past century in improving the health of the nation’s children, recent years have seen a new threat emerge and spread— an epidemic of childhood obesity. It is occurring in boys and girls in all 50 states, in younger children as well as adolescents, across all socioeconomic strata, and among all ethnic groups—though specific subgroups, including African Americans, Hispanics, and American Indians, are disproportion- ately affected. Nationwide, approximately 9 million children over the age of 6 are Nationwide, approximately considered obese, and health profession-  million children oer the age als and policy makers now rank childhood of  are considered obese, obesity as a critical public health threat. and health professionals To help in slowing, and ultimately and policy makers now reversing, this epidemic, the IOM has exam- rank childhood obesity as a ined childhood obesity on numerous occa- critical public health threat. sions. For example, Preventing Childhood Obesity: Health in the Balance (2005) played a landmark role document- ing the severity of the problem and the complexity of and need for many sectors to work together to find solutions. Food Marketing to Children and Youth: Threat or Opportunity? (2006) offered recommendations for differ- ent segments of society—government, schools, families, food and restau- rant industries, and the media, among others—to guide the development of effective marketing and advertising strategies that promote more health- ful foods, beverages, and meal options. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth (2007) outlines nutritional standards for the availability, sale, content, and consumption of foods at school. The standards are designed to promote consumption of fruits, veg- etables, whole grains, and nonfat or low-fat dairy products and limit the consumption of saturated fat, salt, added sugars, caffeine, and total calories. The IOM’s report Progress in Preventing Childhood Obesity: How Do We Measure Up? (2007) took stock of progress since 2005 and found that while inno- vative and encouraging actions were happening across the United States, many efforts are fragmented and small in scale. The report’s recommenda-

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0 INforMINg THe fuTure: Critical Issues in Health tions emphasize the need for a collective responsibility and collaborative actions among all who have a stake in reversing the epidemic, and it pro- vides a framework to evaluate how projects are working. To build on this foundation, the IOM established the Standing Com- mittee on Childhood Obesity Prevention in 2008, with support from The Robert Wood Johnson Foundation. Bringing together experts representing a range of fields and drawn from government, academia, and the corporate sec- tor, the committee serves as a focal point for national and state-level discus- sions. By convening workshops in targeted areas and helping to select topics for study by outside independent committees, the aim is to foster effective, comprehensive, and coordinated efforts to combat this growing problem. A Framework for Decision Making for Obesity Prevention: Integrating Action with Evidence was generated in collaboration with the standing com- mittee. This report, expected in spring 2010, will determine a framework for policy makers and community leaders to make decisions about obesity prevention, specifically how they might affect food, eating, and physical activity environments. reiewing national school meal programs Improving the school lunch and breakfast programs can have a direct impact on the health of youth. Tens of millions of students nationwide receive as much as half of their daily caloric intake from school meals, including breakfasts and lunches, provided through federal programs. For children in families facing limited resources, school meals provide a critical safety net. Yet the programs’ meal requirements and Tens of millions of students nutrition standards have gone unchanged nationwide receie as much for more than a decade, making them out of as half of their daily caloric step with recent guidance about the nutri- intake from school meals, tional needs of children and adolescents. including breakfasts and Early on, the programs focused primarily lunches, proided through on overcoming nutrient deficiencies and federal programs. underconsumption. But as many overt defi- ciencies in children’s diets largely have been eliminated, other nutrition-related concerns have emerged, most notably a high prevalence of childhood obesity. At the request of the U.S. Department of Agriculture, which adminis- ters the meals programs, the IOM is evaluating the programs and will rec-

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 eating right: Keeping America Healthy ommend updates to improve their performance. The recommendations are intended to reflect new developments in nutrition science and to increase the availability of key food groups offered in the programs. The study com- mittee will work in two phases, the first of which was completed in 2008. Nutrition Standards and Meal Requirements for National School Lunch and Breakfast Programs: Phase I. Proposed Approach for Recommending Revisions (2008) provides an overview of the school meal programs and their partici- pants, reviews what is known about children’s food and nutrient needs and deficiencies, and describes the committee’s proposed planning model and analytic methods for developing its recommendations. The second report, foods and Nutrients under Consideration in Children’s Diets Foods for Which Intakes Are Nutrients for Which Nutrients for Which Inadequate, Intakes Are Inadequate Intakes Are Excessivea Age Male and Category Female Male Female Male Female Potassium Potassium Sodium Ages Fruit Sodium 6–8b Fiber Fiber Saturated Total Saturated fat vegetables fat Total fat Dark green Total fat and orange Energyc Energyc vegetables and legumes Whole grains Total meat and beans Milk Magnesium Calcium Sodium Sodium Age 9–13 Fruit Energyc Potassium Magnesium Cholesterol Total vegetables Vitamins Phosphorus Saturated Total fat fat A, E Dark green Potassium Saturated and orange Fiber fat Zinc vegetables Vitamins and A, C, E legumes Fiber Whole grains Total meat and beans Milk continued

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 INforMINg THe fuTure: Critical Issues in Health Continued Foods for Which Intakes Are Nutrients for Which Nutrients for Which Inadequate, Intakes Are Inadequate Intakes Are Excessivea Age Male and Category Female Male Female Male Female Magnesium Age Fruit Calcium Sodium Sodium 14–18 Potassium Total Iron Cholesterol Cholesterol vegetables Vitamins Magnesium Saturated Saturated A, C, E Dark green fat fat Phosphorus and orange Energyc Total fat Total fat Potassium vegetables Fiber Zinc and Vitamins legumes A, C, E, Whole grains B6, B12 Total meat Folate and beans Thiamin Milk Energyc Fiber NOTE: Excessive energy intakes for some age-gender groups may not have been identified because of underreporting. Excessive amounts of discretionary calories were consumed from solid fat and added sugars; this a also constitutes concern relative to recommendations to be made by the committee. Usual intakes of added sugars could not be estimated because relevant data were not available in School Nutri- tion Dietary Assessment Study-III. Furthermore, while intakes of trans fatty acids also could not be measured, trans fatty acids will be considered as appropriate by the committee during Phase II. Data for children age 5 years were included in the food intake data. b It is difficult to accurately estimate energy intakes because of under- and overreporting of food c intake and a lack of accurate information about customary levels of physical activity. SOURCE: Nutrition Standards and Meal Requirements for National School Lunch and Breakfast Programs: Phase I. Proposed Approach for Recommending Revisions, p. 10. which is expected in fall 2009, will specify the updated nutrition standards and meal standards. Determining nutrient needs For consumers to make the best choices about what they eat, they need sound information about food and nutrition. The National Academies has been providing such information for nearly seven decades. The IOM’s Food and Nutrition Board has issued more than three dozen sets of guidelines— first called Recommended Daily Allowances and recently replaced and

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 eating right: Keeping America Healthy expanded as Dietary Reference Intakes (DRIs). Developed by U.S. and Canadian scientists, the DRIs provide quantitative estimates of the amounts of nutrients that individuals need to optimize their health and prevent dis- ease and deficiencies, as well as estimates of tolerable upper intake levels to help people avoid adverse effects from consuming too much of a nutrient. DRIs are widely used by a range of health professionals and policy makers, including federal nutrition officials who develop policies and programs, dietitians and health practitioners who counsel individuals and groups, and researchers who are working to advance the state of nutrition knowledge. The IOM convened a workshop in 2007—attended by research sci- entists, nutrition practitioners, government officials from the United States and Canada, and industry representatives, among others—to survey a decade-long slice of this experience. The Development of DRIs 1994–2004: Lessons Learned and New Challenges: Workshop Summary (2008) explores a variety of issues that emerged during this period and outlines how past experience can help guide decisions about the next phase in developing DRIs and putting them to work in promoting the public’s health. New and relevant research on vitamin D and calcium has prompted the U.S. and Canadian governments to request a review of DRIs for vita- min D and calcium. The work is under way and a report is expected in spring 2010.

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