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5 Public Sector: Strategies and Actions for Implementation WHO SHOULD implement the growing consensus on dietary recommendations? Governments exist to provide for the common good and the welfare of their citizens-and by extension the public's nutritional health. Therefore, governments at all levels have special obligations to implement dietary recommendations both by example and by the unique actions that they can take. Governments at all levels can promote implementation directly through legislation and rule-making; provision of information and education; awarding of research and demonstration grants; intramu- ral research, education, and extension programs; food assistance and farm programs; their own vast meal service functions; and through acting as role models by providing examples of implementation in government facilities, by government officials, and at government- funded events. The public sector can also encourage this effort indi- rectly by setting an agenda for the implementation of various strate- gies, initiating dialogue with the private sector and voluntary organizations, and coordinating implementation efforts. This array of efforts must be pursued in the legislative and executive branches at federal, state, and local levels. The committee focuses here on the role of the federal government, but it should be emphasized that many of the committee's recom- mendations are applicable at state and local levels as well. Moreover, it will be necessary for those who are intimately aware of the special characteristics of each local situation to apply them. Involvement by 112
PUBLIC SECTOR 113 state and local governments as well as other societal sectors discussed in this report is essential if implementation is to become a reality. GOVERNMENTS AS IMPLEMENTORS Throughout this chapter, reference is made to government activi- ties under way to encourage people to eat healthful diets. These activities include provision of qualitative advice as found in Dietary Guidelines for Americans (USDA/DHHS, 1980, 1985, 1990) (hereinafter referred to as the Dietary Guidelines report) and quantitative recommendations from the National Cholesterol Education Program (NCEP, 1990) and in the report Healthy People 2000: National Health Promotion and Dis- ease Prevention Objectives (DHHS, 1990a). The U.S. Department of Agriculture (USDA) issued suggestions to state school food service directors on ways to implement the Dietary Guidelines in their school lunch programs (see, for example, USDA, 1983~. In addition, studies on human nutrition related to the Dietary Guidelines report have been undertaken by USDA (1987) and the National Institutes of Health (NIH) (NIH, 1989~. But there are formidable barriers to implementing dietary recom- mendations in the public sector, including politics, bureaucracy, and costs. The political obstacles to change include pressures from food producers, processors, distributors, retailers, and industry, and other interest groups who believe they would be adversely affected eco- nomically if dietary patterns were to change or if current food service functions were required to offer options that they believe would be less acceptable to consumers, although more desirable from the stand- point of dietary recommendations. Government farm subsidies can exacerbate the situation by encouraging the production of less desir- able food alternatives. Cost is a major factor when nutritionally desirable foods are more expensive than alternative products. None of these barriers is easily overcome. First, the outside pres- sures and the bureaucratic and economic barriers to change must be acknowledged by governments at all levels. Second, current practices and activities that could be modified to foster implementation need to be identified, modified appropriately, and the benefits of such change evaluated. Plans for achieving each of these steps should be developed in cooperation with all those who are influenced by, or have a special interest in, the outcomes. Development of these goals and plans will require patience, political skills, and good will on the part of public officials and others involved in the political process. One example of such a successful effort was the preparation of the report Healthy People 2000: National Health Promotion and Disease Pre
114 IMPROVING AMERICA'S DIET AND HEALTH vention Objectives (DHHS, 1990a). These national objectives were for- mulated through a public process that involved federal, state, and local governments as well as private and voluntary groups. The objectives were also published in draft form for public comment (DHHS, 1989~. Such open and inclusive processes are needed in developing nutrition policy to ensure support by all sectors. PRINCIPLES THAT SERVE AS ~ BASIS FOR IMPLEMENTATION It is desirable that initiatives to implement dietary recommenda- tions in the public sector adhere to a set of principles. These principles, described below, were developed by the committee to help public institutions make nutritionally desirable food choices available, iden- tifiable, and acceptable. These principles have also been applied in devising many of the committee's other recommendations described in Chapters 6 through 8. Provide Information and Education Governments must initiate and participate in comprehensive pro- grams to inform consumers about dietary recommendations and about ways to integrate them into eating patterns. For example, government cafeterias should provide information that identifies eating patterns that conform to dietary recommendations. In addition, consumers should be given advice on how to follow the principles of the recom- mendations wherever they eat; and food producers, processors, dis- tributors, and retailers should be advised on how to make the rec- ommendations apply at, for example, farms, processing plants, supermarkets, and eating facilities. Private- and voluntary-sector participation in similar activities is essential. Ensure Freedom of Choice Coercion in food choices is rarely acceptable, especially for people who are institutionalized in government facilities or who are otherwise dependent on the government for their basic economic support. Thus, although information on dietary recommendations and menus conform- ing to their principles should be offered, selection should be as much as possible the responsibility of each individual. When government agencies formulate eating patterns and develop menus to implement dietary recommendations in food assistance and other programs, ev
PUBLIC SECTOR 115 ery attempt must be made to ensure that the cost of the recommended diet does not appreciably exceed the alternatives. Foster Long-Term Commitment and Incremental Approaches Experience with clinical dietetics, clinical trials, and community- based intervention studies has shown that incremental change is the most successful way to achieve long-term dietary adherence (see Chapter 3~. Thus, to fully implement dietary recommendations without major disruptions to the food system or people's current eating preferences, incremental changes will need to be encouraged over years or decades- not weeks or months. Food producers, processors, marketers, and caterers should be strongly encouraged to initiate incremental changes conforming to the principles of dietary recommendations over a 5- to 10-year schedule. More rapid change is, of course, desirable and should be attempted when feasible. Facilitate Access to Health-Promoting Foods The special obligation of governments to implement dietary rec- ommendations extends beyond education and the provision and co- ordination of information. It also involves ensuring that every U.S. citizen has access to the foods that can be used to meet these recom- mendations. In all government food-service operations and in dining areas in all government-supported institutions, foods should be offered that can be used to meet dietary recommendations, thereby providing an example for the private sector. Consumers should be given menu choices, but among those choices there should be at least one that is identified as helping people to meet dietary recommendations. When alternatives cannot be made available, the set menu should be one that helps people meet dietary recommendations. Present Healthful Eating in a Context of Total Health Promotion Dietary changes are adjuncts to, not substitutes for, a comprehen- sive system of health promotion, disease prevention, disease treatment, nutrition support, and social welfare measures, including economic and food assistance. Because governmental institutions have a special obligation to provide access to the basic needs of daily life and health, they should present good eating patterns as one of many life-style factors, such as cessation of smoking, reducing blood pressure, achieving ideal body weight, lowering serum cholesterol, and increasing physi- cal activity, that can decrease chronic disease risk.
116 IMPROVING AMERICA'S DIET AND HEALTH Involve All Interested Parties Public officials at all levels of governments should work with rep- resentatives of interest groups in the public, private, and voluntary sectors to implement dietary recommendations. Collaborative efforts are likely to be most successful when many different people support the change and believe that their efforts will turn out favorably for them. Ensure Palatability of Healthful Diets Food plans designed to meet dietary recommendations must be made appealing to consumers in order to be accepted. The committee recognizes that the population's taste preferences may gradually shift with increasing exposure to meals that help it to meet dietary recom- mendations, but menu revisions must consider people's present food preferences. In addition, the palatability and acceptability of menus based on the principles of dietary recommendations should be tested in target populations for prolonged periods (i.e., weeks or months, not days). Health-promoting meals must be at least as appealing as the meals they are replacing. Encourage Convenience Health-promoting meals should be relatively convenient in com- parison with current offerings with regard to purchasing, preparation, delivery, and consumption. Any proposed menus (especially least-cost menus and food plans) based on the principles of dietary recommen- dations should be tested in populations to ensure that they are acceptably convenient and appealing before being disseminated. Planning, pre- paring, and perhaps serving new menus may be less convenient at first, but will become more routine over time. Encourage the Incorporation of Health-Promoting Foods in Food Programs Foods rather than vitamin and mineral supplements should serve as the sole sources of nutrients to meet dietary recommendations in government food programs. It would not be acceptable to this com- mittee were the government to suggest as a cost-cutting measure the use of dietary supplements or their equivalent (highly fortified products) instead of the planning of menus which meet, or come close to meeting, the Recommended Dietary Allowances (RDAs) (see Chapter 4~.
PUBLIC SECTOR Implement the Recommendations with Minimal Disruption of Food Preferences 117 In implementing dietary recommendations, menus and meal plans that entail the fewest disruptions to current food preferences are preferable. In addition, choices within food groups should be preserved when- ever possible. Occasionally, however, consumers may need to make major changes in food preferences. The key to success in these cases is mapping out gradual changes and providing the needed transition period. STRATEGIES AND ACTIONS FOR THE PUBLIC SECTOR The committee developed five strategies and associated actions to assist governments at all levels in promoting the nutritional health and welfare of the public. STRATEGY 1: Improve federal efforts to implement dietary recommendations. The full potential benefits of implementing dietary recommendations can be approached by a federally coordinated effort, collaboration with state and local governments, and participation of the private sector, professional and voluntary organizations, and consumer advocacy and community groups. The committee recognizes that the federal government has done much to encourage Americans to eat well; many of these activities are mentioned in this report. For example, it has prepared and distributed many reports and consumer information materials on diet and health (see, for example, NCI/NHLBI, 1988, and USDA, 1981, 1984, 1986b,c, 1988a, 1989a). In addition, government- wide interagency committees were formed to coordinate activities related to nutrition monitoring and human nutrition research. Within USDA and the U.S. Department of Health and Human Services (DHHS), subcommittees serve as departmental focal points for coordinating the preparation and dissemination of information and publications and for providing technical assistance on dietary guidance. To date, however, there is no governmentwide nutrition policy that provides a coherent blueprint for fostering healthful dietary patterns. ACTION 1: The executive branch should establish a coordi- nating mechanism that would promote the implementation of d ietary recommendations. The executive branch has taken steps to coordinate many of its nutrition-related activities by establishing specific inter-and intra-agency groups. The Interagency Committee on Human Nutrition Research,
118 IMPROVING AMERICA'S DIET AND HEALTH which coordinates government-sponsored nutrition research, is co- chaired by an assistant secretary from both USDA and DHHS; it in- cludes representatives from USDA, DHHS, Department of Commerce, Department of Defense, Agency for International Development (AID), National Aeronautics and Space Administration, National Science Foundation, Office of Science and Technology Policy, and the De- partment of Veterans Affairs (DNIA). The Interagency Committee on Nutrition Monitoring, which works to enhance the effectiveness and productivity of federal nutrition monitoring efforts, is also cochaired by an assistant secretary from both USDA and DHHS. It consists of representatives of USDA, DHHS, AID, DOD, DVA, Bureau of the Census, and the Department of Labor. Because most nutrition-related activities of the federal government take place in USDA and DHHS, both departments have established administrative structures to ensure that food and nutrition information emanating from their various agencies are consistent with the Dietary Guidelines report (U.S. Congress, House, 1989b). The Dietary Guid- ance Working Group at USDA, established in 1986, is composed of representatives of at least eight USDA agencies (e.g., the Cooperative Extension Service, the Human Nutrition Information Service, and the National Agricultural Library) (USDA, 1986a). Similarly, the Nutrition Policy Board Subcommittee on Dietary Guidance in DHHS, established in 1987, consists of representatives from the NIH, the Food and Drug Administration (FDA), and the Centers for Disease Control (CDC) (DHHS, 1990b; U.S. Congress, House, 1989b). Each group has a liaison representative from the other agency to promote consistent and complementary messages on dietary guidance. In two important respects, however, the federal government's efforts to implement dietary recommendations are insufficient. First, the charters of the interagency coordinating committees restrict them to narrow areas. The four administrative structures described above are not empowered to assume responsibility for implementing dietary rec- ommendations, an effort that involves much more than providing information on diet and health, conducting nutrition research, and monitoring the nutritional status of the food supply and U.S. population. Secondly, these four groups are frequently criticized for failing to fulfill their narrowly-defined missions. For example, there is still no comprehensive nutrition surveillance system in place to adequately monitor trends in dietary intake, determine the nutritional status and knowledge of the population (particularly among high-risk minority groups and the disadvantaged and homeless), and report results in a timely fashion (Nestle, 1990~. Government publications on diet and health too often are not available in ample quantities at the community
PUBLIC SECTOR 119 level or may be too expensive for many people to purchase. In addi- tion, little priority may be given to the dissemination of these materials by the local agencies that sponsor implementation activities. The lack of a coordinating mechanism at the federal level to imple- ment dietary recommendations has had unfortunate consequences. In some cases, nutrition policy decisions are made in a fragmented manner that can result in policies that are inconsistent from a public health perspective. Federal policies on alcohol, farm subsidies for some commodities, and means of grading and payment for certain commodities (e.g., by fat content) are examples. The heads of the agencies with responsibilities in food and nutrition need to establish a suitable mechanism to ensure that all their policies and programs directly or indirectly related to these areas are compatible with the principles of dietary recommendations. The mechanism will need to (1) coordinate government efforts to implement dietary rec- ommendations, (2) maximize each agency's independent ability to promote these recommendations, (3) establish consistent food and nutrition policies across government agencies, and (4) initiate and encourage collaborative efforts between government and outside agencies (including the states, the private sector, and voluntary groups). The committee suggests that the executive branch consider establishing a single, high-level entity to coordinate and direct government nutrition activities. This was proposed as early as 1969 at the White House Conference on Food, Nutrition, and Health (White House, 1970~. As an example, a committee could be established for this purpose, com- posed of a very senior-level person from each of the eight relevant cabinet-level departments (Agriculture, Commerce, Defense, Educa- tion, Health and Human Services, Interior, State, and Veterans Affairs). The representatives would have a small professional and support staff and major responsibilities in their departments for some aspect of the food system or for feeding people. ACTION 2: Encourage members of the U.S. Congress and state legislative bodies to play active roles in the implementation of dietary recommendations. Legislative bodies have special opportunities and responsibilities to devote some of their attention, interest, insights, and expertise on matters that affect the diet and health of their constituents. Many members of the U.S. Congress are becoming more cognizant of the key role that dietary patterns play in the general well-being of the public. Bills introduced in Congress pertaining to food and nutrition cover a broad range of activities and include legislation to reauthorize food assistance programs and legislation related to food labeling,
120 IMPROVING AMERICA'S DIET AND HEALTH nutrition monitoring, nutrition research, commodity food distribu- tion programs, health promotion and disease prevention programs, and education and training programs. Members of the U.S. Congress can assist in efforts to implement dietary recommendations in the various agencies through oversight hearings, authorizations and appropriations, conference report language, and other legislative actions. Support from the legislative branch will encourage high-level administrators in the executive branch de- partments to give priority and resources to dietary recommendations in policy guidelines, technical assistance programs, education and information initiatives, and other activities addressing the food, nutrition, and health needs of consumers. The farm bill, which comes before Congress every 4 to 5 years, should be reviewed and revised with dietary recommendations in mind. Nutrition educators, registered dietitians, physicians, and other health-care professionals, working through their associations, should advise Congress during these periodic reviews. The 1990 farm bill is a landmark piece of legislation that mandates policies and programs governing many areas relevant to dietary recommendations: (1) extending and revising agricultural price support and related programs (e.g., for milk and sugar); (2) providing for agricultural export, resource conservation, farm credit, agricultural research, and related programs (e.g., human nutrition research, extension service, and land-grant in- stitutions); (3) continuing certain food assistance programs to low- income people (e.g., food stamps and commodity distribution programs); and (4) ensuring consumers an abundance of food at reasonable prices (e.g., through commodity promotion, research, and information) (U.S. Congress, House, 1990; U.S. Congress, Senate, 1990~. State legislatures have many opportunities to promote the imple- mentation of dietary recommendations. In September 1989, for example, California enacted legislation (Assembly Bill No. 2109) mandating its State Department of Education to "develop and maintain nutrition guidelines for school lunches and breakfasts, and for all food and beverages sold on public school campuses" (California Legislature, 1989, p. 3~. These "guidelines shall include guidelines for fat, saturated fat, and cholesterol, and shall specify that where comparable food products of equal nutritional value are available the food product lower in fat, or saturated fat, or cholesterol shall be used" (p. 3~. STRATEGY 2: Alter federal programs that directly influence what Americans eat so as to encourage rather than impede the implementation of dietary recommendations. This effort should affect food assistance, food safety, and nutrition programs, as well as farm subsidy, tariff, and trade programs.
PUBLIC SECTOR 121 The primary federal food assistance programs are administered by USDA and DHHS together with state governments and local agencies. Two nutrition services for older Americans (congregate meals and home-delivered meals) are administered at the federal level by DHHS; others (e.g., the Food Stamp Program, School Lunch and Breakfast programs, the Child Care Food and Summer Food Service programs, and the Special Supplemental Food Program for Women, Infants, and Children tWIC]) fall under the jurisdiction of USDA. State departments of education usually have responsibility for food programs serving children in schools, child-care centers, and summer recreation centers. State departments of health, welfare, and agriculture usually have responsibility for programs providing food stamps or supplemental foods to families or individuals. The meals programs for elderly people are administered by state and area agencies on aging. The potential for reaching vast numbers of the country's citizens who receive benefits through these programs is tremendous. For example, the School Lunch Program serves lunch to 24 million children each day, about half of them from low-income families (U.S. Congress, House, 1989a). At present, the nutritional standard for meals served under this program is limited to the requirement that they meet one- quarter to one-third of the RDAs (NRC, 1989b) over time through the choice of foods within a prescribed meal pattern. The committee recommends that nutrition guidelines for this and all other food assistance programs be tied to dietary recommenda- tions in a practical fashion. Participants in these programs should be able, if they desire, to eat diets that meet dietary recommendations in the normal course of their day-to-day living and not only by extraordinary effort. They should be able to receive appealing and easy-to-understand educational materials (of appropriate levels of comprehension and cultural sensitivity) about dietary recommendations and how to improve their eating habits with the help of the foods supplied by various assistance programs. ACTION 1: Revise current USDA regulations governing the child and family nutrition programs to comply with dietary rec- ommendations and train federal, regional, state, and local personnel administering the programs to implement the recommendations. Many implementation efforts can be achieved without legislative or regulatory changes, while others require changes in laws and regulations. The committee's recommendation to ensure that nutrition programs adhere to dietary recommendations is one that requires statutory and regulatory change. For example, while only the School Lunch Program must offer students whole milk and at least one of the following: low-fat milk, skim milk, or buttermilk, the other child nu
122 IMPROVING AMERICA 'S DIET AND HEALTH trition programs (e.g., the Special Milk, School Breakfast, Summer Food Service, and Child Care Food programs) require only that milk be fluid and pasteurized and that it meet state and local standards. It may be unflavored or flavored whole milk, low-fat milk, skim milk, or cultured buttermilk. The committee supports requirements that options be made available, with the caveat that low-fat and skim milk not be served to infants and children under age 2 without direction by a pediatrician (see Chapter 4~. To ensure that government nutrition programs adhere to dietary recommendations, it will also be necessary to provide training and other forms of technical assistance to those who administer the programs. Designers of training programs must recognize that the United States has a very decentralized, heterogeneous, multiethnic, multicultural system, which makes implementation difficult. Managers and cooks in all child and family food assistance programs should be trained in all critical aspects of food preparation and services. At a minimum, they should be taught menu planning, food purchasing, food prepa- ration, and service techniques that support dietary recommendations. Governments must encourage private-sector contributions to such training programs. The WIC food packages for women and children from age 2 and older should be reviewed for conformance with the principles of dietary recommendations. Fruits, vegetables, whole-grain products, and le- gumes should be included whenever possible. The committee recog- nizes that uniformity and cost issues must be addressed in modifying the WIC package. Relevant government agencies working with WIC nutritionists should prepare information and educational materials for WIC recipients on healthful ways of feeding their families to meet dietary recommendations. These materials should include caveats concerning the applicability of these recommendations to infants and children under age 2 and should address special issues (e.g., alcohol consumption) related to the health of pregnant and lactating women. Food Stamp Program allotments are based on the cost of the Thrifty Food Plan, a nutritionally adequate set of food allowances developed by USDA for people of very limited financial means (Cleveland and Kerr, 1988~. However, the committee believes that many low-income families lack the money (owing to other high fixed costs like shelter and transportation); food planning, purchasing, and preparation skills; and knowledge of food and nutrition to follow the Thrifty Food Plan so as to ensure the consumption of nutritionally adequate diets that meet dietary recommendations. The committee believes that dietary change in healthful directions would probably be fostered among low-income families if food stamp allotments were to be based on a
PUBLIC SECTOR 123 more generous standard, such as USDA's Low-Cost Food Plan. This plan is approximately 20% greater in cost than the Thrifty Food Plan and would enable the purchase of a greater variety of foods. Recently, the American Dietetic Association recommended that food stamp al- lotments be based on USDA's Moderate-Cost Food Plan (Hinton et al., 1990), which is 40% more costly than the Thrifty Food Plan. ACTION 2: Revise current regulations governing the Nutrition Program for Old er Americans (which provid es congregate meals and home-delivered mealsJ to conform to the principles of dietary recommendations and train federal, regional, state, and local personnel ad ministering the programs accord ingly. Aging is accompanied by a variety of changes that can compro- mise nutritional status (DHHS, 1988a,b). These changes may be physiologic (e.g., decrease in sense of smell and dental problems), psychologic (e.g., depression), economic (e.g., declines in income), and social (e.g., living alone or in an institution). Elderly people who consume diets that meet dietary recommendations will reduce their risks of developing many degenerative chronic diseases, especially if they have eaten well in the past and engage in other health-promo/in behaviors. General principles for training cooks and other food service personnel described in other sections of this report also apply here. In addition, menu plans for the nutrition programs that feed elderly people should (1) be ethnically and biologically appropriate for the low-energy in- takes characteristic of this group; (2) be appropriate for, and adaptable to, the physical and biological limitations of elderly people in preparing their food; and (3) be compatible with dietary and drug therapies (e.g., should not lead to adverse drug-nutrient interactions, which are common among the elderly). The fact that most elderly people have limited incomes and live in small families also should be taken into account. The nutritionist's position at the Administration on Aging's (AOA) central office in DHHS has remained unfilled for nearly a decade. This position was and is vital for implementing standards and providing technical assistance to nutrition programs for elderly people. The committee believes that this important position must be restored and the office fully staffed. The AOA needs a nutrition adviser at the federal level to assist its program operations with implementation of dietary recommendations. The nutrition-related recommendations resulting from the Surgeon General's Workshop on Aging (DHHS, 1988b) as well as some of the specific nutrition-related programs at DHHS on healthy aging need
124 IMPROVING AMERICA'S DIET AND HEALTH to be implemented. Coordination between offices in USDA and DHHS (e.g., NIH, AOA, and CDC) and private-sector coalitions will be needed to accomplish this. The major goal is to emphasize healthful eating in the context of overall health promotion, disease prevention, and disease treatment. The committee urges those segments of the private sector involved in providing food for food assistance and other government programs to take an offensive rather than a defensive stand in implementing dietary recommendations. Producers and distributors must more actively consider these recommendations in developing new and modified foods for the elderly and for those who are part of other food assistance programs. ACTION 3: USDA and DHHS should ensure that food and health programs serving all special populations conform to dietary recommendations. Several food assistance programs serve many special populations, including Native Americans and those of Puerto Rico and other U.S. territories. As an example, the two largest programs serving Indians are the Food Stamp Program (FSP) and the Food Distribution Program on Indian Reservations (FDPIR). As an alternative to food stamps, FDPIR provides commodity foods to eligible households located on reservations. Because of high unemployment rates and low incomes, the federal programs are the major source of food in many of these households. Reservations are often located in remote areas of the country where lands are not suitable for farming. As a result, many tribes cannot provide all their own food, especially when economic resources are limited. From 1988 through 1990, the GAO investigated the effectiveness of public and private programs in alleviating hunger and promoting the nutritional welfare of residents on Indian reservations. In their two reports to Congress on this matter (GAO, 1989, 1990), GAO stated that four major diet-related health conditions existed on the reserva- tions studied: obesity, diabetes, heart disease, and hypertension. It also noted that "Although USDA improved the nutritional content of the FDPIR food package in 1986, tribal and . . . Indian Health Service . . . officials believe that the fat and sodium content of many of the available food items should be reduced further" (GAO, 1989, p. 4~. Furthermore, it stated, "Food assistance programs can improve diets on Indian reservations by making available more nutritious foods and nutrition education" (p. 6~. The important role of nutrition education to ensure that FDPIR and FSP recipients get help with their dietary needs also was mentioned
PUBLIC SECTOR 125 in the GAO reports. The committee urges the federal government to keep this in mind when establishing priorities and time frames for upgrading the nutritional quality of commodities to meet dietary rec- ommendations. The importance of the cultural relevance and com- patibility with the concept of gradual change cannot be overempha- sized in the implementation of this action. The committee also supports the provision of greater resources to the Indian Health Services in its work to decrease morbidity in the Native American population. ACTION 4: Ensure that the education and information components of the foregoing federal food assistance and nutrition programs are consistent with dietary recommendations. Each of the previously mentioned food assistance and nutrition programs does or should have a nutrition education component. The committee recommends that higher priority be given to implementing dietary recommendations in education programs throughout the United States. Suggestions for improving nutrition education are found in Chapters 7 and 8. The USDA's Nutrition Education and Training (NET) Program, if adequately funded (see Chapter 8), could provide ample opportunity to accomplish this action for schoolchildren. Each fiscal year, the state education agencies must submit a plan for their NET programs for approval by the USDA. They base their plans on an ongoing assessment and evaluation of the plans from previous years. Some of the activities that should be built into the NET Program plan of each state include reaching all children in the state with information on diet and health, providing in-service training for school food-service management personnel, offering teacher training in nutrition, and disseminating information to school officials and parents. Some states, such as Texas, have evaluated the effectiveness of their NET Program (Roberts-Gray, 1987~. The committee encourages such action, especially after dietary recommendations have been integrated into state plans and programs. A spring 1989 survey among a nationally representative, randomly selected sample of district school food-service directors revealed a great deal of uncertainty concerning the scientific consensus on daily fat intake levels. Respondents reported having limited access to written materials or training programs explaining how to purchase (e.g., preparing specifications for supplies) or modify recipes to reduce fat content. They also frequently mentioned the need for improved education and training to help lower the fat content of school meals (Shotland, 1989). Another important government education program is the Expanded
126 IMPROVING AMERICA'S DIET AND HEALTH Food and Nutrition Education Program (EFNEP) of USDA's Coop- erative Extension Service, which was started in 1968 to help low- income families in all states, especially those with young children, acquire the knowledge, skills, attitudes, and behavior changes necessary to improve their diets (Chipman and Kendall, 1989~. In 1970, the program was extended to serve low-income youths in the 4-H Program. These youths are taught nutrition-related skills, enabling them to improve the adequacy of their diets. EENEP home economists provide on- the-job training and supervise paraprofessionals and volunteers who teach the low-income homemakers and youths. The paraprofession- als often live in the communities where they work and enroll homemakers in individual or group teaching sessions (USDA, 1984~. Ethnically appropriate materials (e.g., food and nutrition informa- tion tailored to cultural subgroups) should be made more available to guide food selection in accord with the principles of dietary rec- ommendations. The committee recognizes that money and other re- sources must be provided and that creative ways need to be devised to make these materials available to consumers. Outreach efforts for many public assistance programs can assist in the dissemination of information on diet and health to low-income families in every county of the nation. Full funding on a continuing basis plus a high-priority status conferred at the departmental level is needed if these programs are to fulfill their mandate and keep the country's citizenry informed of new knowledge about diet and health. ACTION 5: Incorporate dietary recommendations into current rules and regulations governing commodity purchases. To stabilize the prices that farmers and ranchers receive for many of the foods they produce, the federal government purchases the surplus production and distributes such commodities at no or low cost to several food assistance programs. About 30% of the value of all foods purchased for school meals comes from surplus food commodities donated to schools by USDA or purchased by them at reduced prices (USDA, 1989b). Because many food-service directors rely heavily on government commodities to help them stretch their food budgets, the nutritional quality of school meals can depend greatly on the types of commodities received. In addition, numerous emergency food pro- grams across the United States depend on government surplus food commodities provided through the Temporary Emergency Food As sistance Program. USDA has already taken a number of steps to make commodity foods more compatible with the principles of dietary recommendations. Efforts have been made to lower fat content, restrict the use of highly
PUBLIC SECTOR 127 saturated fat, provide whole grains and fresh fruit, and to purchase lower-fat foods and commodities with reduced levels of salt and sugar (USDA, 1989b). Despite these efforts, a national survey by the advo- cacy group Public Voice for Food and Health Policy revealed that school food-service directors view commodity foods as a real barrier to implementing dietary recommendations (Shotland, 1989~. Two-thirds of the directors identified USDA's Commodity Donation Programs as major obstacles to reducing fat in menus. Subsequently, Public iloice evaluated school lunch programs in schools across the country to assess the availability of low-fat options (Morris, 1990~. It concluded that "too much fat is being offered our children in school lunches" (p. 2) and made recommendations for improvement. The Citizens Commission on School Nutrition (1990) recently issued a report with recommendations for improving the nutritional quality of the school lunch program. The committee recommends that USDA continue its efforts to bring the nation's donated and surplus foods programs into closer compli- ance with the principles of dietary recommendations whenever possible. For example, the programs might try to include more whole-grain products, fruits and vegetables, low-fat rather than high-fat cheeses, lean rather than high-fat meat, poultry, legumes, and low-sodium products. Health-care professionals in communities could advise lo- cal food-service directors about foods to purchase that would nutritionally complement the commodities received, enabling the preparation of menus that help people to meet dietary recommendations. Dietary recommendations should be a consideration in specifying and awarding processing contracts between the agencies distributing or receiving donated and surplus foods and processors, who convert the donated foods into finished items such as pastas and bread. Con- tracts should specify the nutritional profile of the end product and the amount and proportion of its ingredients. The committee believes that dietary recommendations should serve as an important specification in these contracts. STRATEGY 3: Change laws, regulations, and agency practices that have an appreciable but indirect impact on consumer dietary choices so that they make more foods to support nutritionally desirable diets available. Examples are food grading and labeling laws and standards of identity for a number of food products. ACTION 1: Improvefood labeling andfood description, production, and processing regulations to permit consumers to make better informed choices. Consumers cannot make informed food choices unless they know
128 IMPROVING AMERICA'S DIET AND HEALTH how their dietary patterns contribute to health and risk of disease and how to improve their diets. Without this knowledge, consumers cannot know whether they are meeting dietary recommendations or what kinds of dietary trade-offs they may need to make so they can keep eating some favorite high-fat foods. Nutrition information pro- vided on food labels is perhaps the most important and direct means of conveying such information. The current framework for the nutrition labeling of foods in the United States was established in 1973. Under current regulations, nutrition labeling is voluntary for manufacturers, unless a nutrient is added or a nutritional claim is made for a product. Regulation of food labeling is currently shared by two federal agencies: USDA for meat, poultry, and egg products and the FDA for all other foods. The Federal Trade Commission is responsible for food advertising (IOM, 1990~. Among current concerns about food labeling are the proliferation of health claims, the lack of full nutrition labeling for macronutrients, the limited extent to which foods are covered by labeling, and its complexity for many consumers (see Chapter 8~. There is general consensus that food labels should be updated and modified to provide consumers with important information to assist them in choosing healthful diets. FDA and USDA have devoted con- siderable effort to studying the issues, drafting proposed modifica- tions for the content and format of labels, and planning for reform. On July 19, 1990, for example, FDA proposed standard serving sizes for foods according to product category (Benson and Sullivan, 1990), an action the committee applauds. Congress has also shown consid- erable interest in food labeling by holding hearings, drafting legisla- tion, and publicly calling for label improvements; it culminated in the passage of the Nutrition Labeling and Education Act of 1990, which was signed into law by the President in November 1990. The private sector and health-care professionals have also contributed importantly to the debate and process of reform. A recent report of the Food and Nutrition Board (IOM, 1990) provides a detailed over- view of the U.S. system of food labeling and many recommendations to improve it. This committee urges implementation of the recom- mendations in that report as well as continued study of ways in which food labels can be used to improve dietary patterns. ACTION 2: Develop and adopt regulations governing food de- scriptions, grading, and nomenclatural practices. These regulations would relate to standards of identity and qual- ity grades for products such as meat and milk. Appropriate federal agencies should support the following three specific components of this action item:
PUBLIC SECTOR 129 A. Review standards of identity, changing or discontinuing them as appropriate. These standards should be consistent with and promote the principles of dietary recommendations. With the intent to prevent economic fraud, the Federal Food, Drug, and Cosmetic (FD&C) Act requires FDA to establish standards of identity that define the composition of certain foods. Under current provisions of the FD&C Act, it is very difficult to change a standard once it has been adopted (IOM, 1990~. Therefore, some standards have not kept up to date with advances in food technology and nutrition. For example, fat was considered to be a valuable component of food at the time that most standards were adopted, so standards of identity for cheese are based largely on its fat content. A cheese product with lower fat than required by the standard must be named something other than cheese (although it need not be labeled "imitation" if it is not nutritionally inferior to the standardized food). Consumers may be less willing to try products that do not have standardized names, even though some of them may fit more easily into diets meeting dietary recommendations. FDA has sought comments on possible approaches to addressing problems with current food standards and will address this area under its current food labeling initiatives (Food Chemical News, 1990~. B. Review price supports for milk and examine the implications of in- creasing the dollar value of the nonfat portion and reducing the dollar value of the butterfat portion while keeping milk price constant. Dairy products are a major food item in the U.S. diet, and there has been a gradual increase in the purchase of low-fat milk. If the population is to lower its fat intake to 30% or less of total caloric intake, more low-fat dairy products need to be made available. At present, however, the price for milk paid to producers is based on the butterfat content. As an initial step toward decreasing the butterfat content of milk, the committee recommends that USDA study the economic implications to consumers and the dairy industry of increasing the dollar value of the milk solids component and decreasing the dollar value of the fat component. Adjustments in the milk pricing system should provide an impetus to dairy producers to start breed- ing, feeding, and managing their herds for decreased fat production (NDC, 1989~. C. Review and, if necessary, change quality grades of meat and develop uniform nomenclaturefor ground beef to make these products more compat- ible with dietary recommendations. The grading system for beef and lamb has rewarded fatty meat with appealing grade names that encourages producers to fatten ani
130 IMPROVING AMERICA'S DIET AND HEALTH mats and deters them from producing lean meat. The grades are a vestige of the time when well-marbled meat meant better meat to consumers. The grading system needs to be reviewed in light of modern knowledge of diet and disease relationships. In 1987, a positive change in the U.S. grading system was the renaming of U.S. Good grade to U.S. Select (Clarke and Wise, 1988~. By establishing a more positive grade name, the meat industry was given an opportunity to improve marketing of beef with less marbling than that in the Prime or Choice grade. A similar beneficial change is the action by the USDA's Agricultural Marketing Service to alter the Institutional Meat Purchase Specifications (IMPS) for fresh beef (USDA, 1988b). IMPS are voluntary guidelines for cut definitions and trimming practices used by the meat industry to help standardize quality control proce- dures. The IMPS now call for more fat to be trimmed from various cuts of beef than was designated in the past. The external fat on cuts of beef such as steak was reduced from one-half to one-quarter inch, and for the first time, the term practically free offal was quantified as meaning that at least 75% of lean meat is exposed on the surface of the cut. A national standard for grading and labeling lean ground beef should be adopted. Currently, individual states and supermarkets set their own standard for lean, very lean, and other terms to describe ground beef, and the actual fat content can vary considerably. This confuses consumers who are trying to decrease the fat in their diets. National uniform standards for the fat content in ground beef should be developed. ACTION 3: Improve the nutritional attributes of animal products. In 1988, a committee of the National Research Council's Board on Agriculture released its report Designing Foods (NRC, 19881. Many of the policy and research recommendations to improve the nutritional attributes of animal foods are supportive of dietary recommendations (see Chapter 6~. This committee therefore suggests that governments review the report and adopt those recommendations that have a direct impact on the implementation of dietary recommendations. STRATEGY 4: Enable government feeding facilities to serve as models to private food services and help people meet dietary recommendations. In their roles as major food-service providers, governments (espe- cially the federal government) have responsibilities to set a good ex- ample by offering meals that help people to meet dietary recommen- dations. In addition to developing implementation and demonstration
PUBLIC SECTOR 131 projects, governments can exercise their leadership and educational roles by serving as models for the voluntary, private, and public sectors. Such projects can be instructive to key institutions in the country, including corporations, colleges and universities, correctional facilities, and hospitals. Through the efforts of the secretary of DHHS, several federal government facilities might serve as model programs. The NIH Clinical Center, a "showcase" hospital, could make changes in all nontherapeutic diets. The cafeteria in Building 31 on the NIH campus in Bethesda, Maryland, serves the visiting biomedical community and hospital and would be an excellent locus for a model program that implements dietary recommendations. It is unrealistic to expect others to change when government agencies (and private institutions that depend largely on federal funding) do not do so themselves. The cafeteria in the Hubert H. Humphrey Building in downtown Washington, D.C., which serves high-ranking federal and other health- care personnel, and the cafeterias of USDA have recently implemented changes that are in accord with dietary recommendations and might serve as models to other government-managed eating places. Several issues associated with the implementation of dietary rec- ommendations require further study. It is crucial to have informa- tion on technical problems that might be experienced in demonstra- tion projects (e.g., in private-, voluntary-, and public-sector settings) in order to develop more effective implementation strategies. In the committee's judgment, two barriers confront the implemen- tation of Strategy 4. Perhaps the most fundamental barrier is the lack of political will. In the case of smoking, governments acknowledged the scientific evidence linking the habit to heart disease, lung cancer, and other diseases and took actions to restrict or eliminate smoking in their facilities. The committee hopes that as governments become more convinced of the connections between diet and health, they will become more active in implementing the principles of dietary recom- mendations in their own feeding facilities. The second barrier to implementation is the possibility that the civil liberties of the less fortunate are being infringed, e.g., by limiting the choice of foods available to those who are dependent on governments for subsistence, such as patients in hospitals, the very poor, and prisoners. Ways of protecting the rights of these people while encouraging them to adopt healthful dietary practices must be found. One way to avoid even the appearance of taking advantage of the less fortunate is to start implementation programs among independent groups rather than the indigent and dependent. For example, employee dining rooms in government facilities should be tackled before attempts to implement dietary recommendations are made with the hospitalized or the poor.
132 IMPROVING AMERICA'S DIET AND HEALTH ACTION 1: The Office of the Secretary of the U.S. Department of Veterans Affairs ¢DVA) should direct its health-care personnel to follow dietary recommendations in all of its food and health care systems. During fiscal year 1988, the U.S. Department of Veterans Affairs (formerly the Veterans Administration) maintained a total of 172 medical centers (hospitals), 119 nursing homes, and 26 domiciles for veterans and treated more than 1 million patients in these facilities (DVA, 1989~. The DVA should incorporate dietary recommendations into all aspects of their food operations menu planning, food purchasing, preparation, and service. The present clinical nutrition and dietetic personnel should be retained in the DVA system to provide the technical assistance needed to implement dietary recommendations. Federal agencies, such as NIH through its National Cancer Institute or National Institute on Aging, should collaborate with the DVA medi- cal system to develop grant mechanisms to establish demonstration pro- jects for implementing dietary recommendations and other activities directed toward achieving the national health promotion and disease prevention objectives of DHHS by the year 2000 (DHHS, 1990a). Likewise, DVA and private hospitals should work cooperatively as often as possible to develop and coordinate research and training initiatives to accomplish this particular action. More recommendations about the training of health- care professionals are discussed in Chapter 7. Several specific steps can be taken to further strengthen the use of diet and health principles in the DVA system. The first priority should be implementation of dietary recommendations in the food environment for the well patients and visitors in the DVA system; sufficient choice of foods should be available so that those who want to eat in a man- ner consonant with dietary recommendations are able to do so. Changes in the diets of sick patients need to be made on a case-by-case basis, since other therapeutic considerations may take precedence. In addition, the following actions should be considered: · Provide more central direction and support for clinical nutrition within the DVA system. Take more action to implement dietary rec- ommendations in canteens within the DVA. Baseline surveys should be conducted to assess current implementation efforts in canteens and elsewhere in the DVA. · Develop policies and guidelines for implementing dietary rec- ommendations. Implementation plans must then be put into effect at local levels. Without the support of medical and nursing staffs, little is likely to be accomplished. The dietetic services have no direct responsibility over the cafeterias and canteens in the DVA system.
PUBLIC SECTOR 133 · Encourage grant proposals for research and demonstration grants that enhance implementation of dietary recommendations. ACTION 2: The surgeons general of the Army, Navy, and Air Force within the Department of Defense (DODJ should develop a plan for implementing dietary recommendations in all aspects of the DOD food and health-care systems. The DOD feeds thousands of people each day. It offers meals in dining halls, in other eating facilities, and in the hospitals and clinics it operates around the world. Because of these huge feeding operations, DOD purchases immense quantities of food and thus has a large influence on the country's food supply. The DOD assistant secretar- ies for health and the surgeon general of each service are charged with maintaining the health and fitness of enlisted personnel and their families. Thus, DOD has many opportunities to provide good examples of implementing dietary recommendations. The committee commends the DOD for making substantial advances in addressing nutritional concerns of military personnel over the past two decades. Since 1985, there has been an evaluation of the systems of feeding military populations to determine the nutritional adequacy of the diets consumed (DHHS,l989~. Results of this assessment serve as the basis for modifying menus, standardizing recipes, designing cook training programs, and developing specifications for the purchase of food and combat rations. In a recent assessment of basic Army train- ees at Fort Jackson, South Carolina, mean dietary fat intakes by both the men and women for 7 days were less than 35% of total calories. The "absence of a short-order line and limitation on high-fat, high- calorie bakery items (donuts, pastries, etc.) may have assisted in the attainment of this goal" (U.S. Army, 1989~. This assessment represents a single evaluation in a highly controlled environment. More attention needs to be paid to continuing evaluation, surveillance, and imple- mentation of all aspects of dietary recommendations rather than on fat consumption alone. Nutrition-related regulations for the nation's active and reserve military services have been in existence for decades. These regulations have three major purposes: (1) to establish dietary allowances for military feeding, (2) to prescribe nutrient standards for packaged ra- tions, and (3) to provide basic guidelines for nutrition education. They were last revised in 1985 and will be reviewed again now that the 3rd edition of the federal government's Dietary Guidelines for Americans report (USDA/DHHS, 1990) has been released. Because these regulations are used by cooks in the military as well as by the vendors who supply packaged rations, the committee recommends
134 IMPROVING AMERICA'S DIET AND HEALTH that the manual of regulations provide more emphasis on practical ways to meet dietary recommendations. Special efforts must be made to motivate cooks and vendors to alter their products and make them more compatible with the principles of dietary recommendations. ACTION 3: The DOD'sfood and beverage services and practices should be revised to conform to dietary recommendations. Mess halls, officers' clubs, clubs for enlisted personnel, and other private food services on military facilities should be encouraged to serve at least one identified meal choice, among the several offered, that conforms to the principles of dietary recommendations. The committee believes that the DOD should also develop a plan to implement dietary recommendations in its food and health services, including canteens and officers' clubs. The emphasis should not be placed upon changing combat rations or other special feeding situations. The enormous complexity of the implementation process within the DOD is recognized. Yet at the very least, efforts in DOD facilities should match those of other federal facilities. ACTION 4: Urge the director of the Federal Bureau of Prisons to examine the feasibility of providing diets in line with dietary recommendations, recognizing the complexity of the correctional system and the special role offood in correctionalfacilities. The Federal Bureau of Prisons is responsible for ensuring the ad- equacy and healthfulness of diets served in the large network of federal correctional facilities under its jurisdiction. The social milieu of cor- rectional institutions is complex, and changes in prison life are diffi- cult to administer. Food has a great deal of symbolism in correctional institutions, and the mess hall is a place where violence occurs. Oc- casionally, correctional officials have instituted diets limiting sugary and sweet foods in the hope that they will prevent or treat violent and disruptive behavior, but this has been to no avail (Gray, 1986~. The American Correctional Association, which reviews correctional facilities, suggests that menus meet the RDAs. These menus should also help prisoners to meet dietary recommendations. Groups including registered dietitians, nutrition educators, health educators, correctional officials, and inmates should convene to discuss and take action on designing acceptable prison diets that meet dietary recommendations. ACTION 5: The General Services Administration (GSA) should ensure that food contracts and monitoring systems are made to conform to the principles of dietary recommendations. Those who work in or visit government offices often dine in fed- eral facilities. Others attend catered functions sponsored by govern
PUBLIC SECTOR 135 ment agencies. Many government cafeterias are operated by the GSA, which in turn contracts with providers of food, catering, and vending services. Technical assistance to food producers and preparers should be provided or built into GSA contracts so that these people will be able to provide appealing products and menus that help employees and other consumers meet dietary recommendations. Voluntary, short- term technical assistance will not be sufficient. Rather, long-term innovations in service, education, and surveillance are likely to be required. Quality assurance programs for foods purchased by gov- ernments should be adapted whenever possible to include standards consistent with the principles of dietary recommendations. ,_ , ~ ~ ACTION 6: Department secretaries should encourage government employees to consume diets that meet dietary recommendations. Department secretaries have initiated programs to promote fitness and discourage smoking in their departments. It is entirely fitting that similar programs encouraging employees to eat in accord with dietary recommendations be initiated together with educational pro- grams to assist them in learning how to accomplish this goal. ACTION 7: The U.S. government personnel ultimately responsible for funding official meal functions should offer meals that are consistent with the principles of dietary recommendations. This recommendation is applicable to all branches of governments (executive, legislative, and judicial) at all levels (federal, state, and local). STRATEGY 5: Develop a comprehensive research, moni- toring, 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. ACTION 1: The secretaries of USDA and DHHS should man- date increased amounts of intramural research that relate to implementation of dietary recommendations and give high priority to thefunding of extramural research in this area. Governments as well as the private sector, foundations, and vol- untary organizations can perform or fund research that will expedite the implementation of dietary recommendations and surveys that will monitor the progress of implementation and evaluate its impact. Such research would include intervention studies to further understand- ing of the potential for chronic disease reduction (DHHS, 1988a; NRC, 1989a), social and behavioral studies to elucidate factors that moti- vate people to modify their food habits over the long term, and tech
136 IMPROVING AMERICA'S DIET AND HEALTH niques to enhance the availability of foods that help people to meet dietary recommendations. A discussion of directions for future research is provided in Chapter 9. ACTION 2: Improve the National Nutrition Monitoring System and provide it with adequate resources. The National Nutrition Monitoring System consists of a diverse set of surveys and surveillance activities conducted by 12 agencies within six federal departments DHHS, USDA, DVA, DOD, Commerce, and Labor (DHHS/USDA, 1986, 1989~. It provides data on the per-capita availability of foods and nutrients; household and individual food intakes; prevalence of under- and overnutrition using anthropometric, biochemical, and hematological Indicators of nutritional status; prevalence of chronic diseases and risk factors for those diseases; and mortality. However, different program obligations and logistical requirements have led to differences in the methods used to collect and present the information (DHHS/USDA, 1989~. Budget constraints have led to delays in the start of some surveys and to cuts in the sample sizes. Some groups are frequently excluded from surveys of the civilian noninstitutionalized population, including active-duty military, Native Americans, and people without fixed addresses (including the home- less and migrant families who might have limited access to food iNestle, 19903~. Other groups, such as racial minorities, are not included in sufficient numbers to permit valid estimates of their nutritional status or health (DHHS/USDA, 1986, 1989~. Little information is collected about the population's knowledge of and attitudes toward food and its relationship to health. Better information on the status of the population with respect to recommended dietary patterns will help to plan and target interventions, thus maximizing the budget that will be allocated. REFERENCES Benton, J., and L.W. Sullivan. 1990. Food labeling; serving sizes. Fed. Reg. 55:29517 29533. California Legislature. 1989. Assembly Bill No. 2109. California Legislature 1989-90 Regular Session. 4 pp. Chipman, H., and P.A. Kendall. 1989. 20 Years of EFNEP: changes and challenges. J. Nutr. Educ. 21:265-269. Citizens Commission on School Nutrition. 1990. White Paper on School-Lunch Nutri tion. Center for Science in the Public Interest, Washington, D.C. 19 pp. Clarke, G., and J.W. Wise. 1988. USDA adopts "select" beef grade name. Natl. Food. Rev. 11(1):26-27. Cleveland, L.E., and R.L. Kerr. 1988. Development and uses of the USDA food plans. J. Nutr. Educ. 20:232-238. DHHS (U.S. Department of Health and Human Services). 1988a. The Surgeon General's
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