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6 Private Sector: Strategies and Actions for Implementation M EMBERS OF THE private sector must play a large role in helping consumers select more health-promoting foods. They are pre- sented with both opportunities and challenges by the scientific con- sensus that specific changes in eating habits are likely to reduce sub- stantially the public's risk of heart disease, cancer, and many other diet-related chronic diseases. Food labels and consumer information programs as well as specific product formulations and promotions need to be examined creatively with this in mind. For the purposes of this report, the private sector is defined broadly as including producers of several major commodities (fruits and vegetables, grains and legumes, dairy products, meat, poultry, fish and seafood, and eggs); food manufacturers and processors and retail- ers; food service establishments (restaurants, fast-service food estab- lishments, and institutional food-service providers); and work sites (cafeterias and vending machines in office buildings and factories). The private sector is, thus, not a monolith, but a collection of inter- ests often competing for the same consumer dollar. Since any single consumer can eat only a given amount of food each year, the ques- tion of who will provide that food becomes a matter of great economic importance. The entire private sector from producer to retailer greatly influ- ences what consumers purchase and consume. In addition, it adapts its products and marketing strategies not only to anticipate and respond to consumer demand but also to create the demand for specific products and services. The committee recognizes that the private sector is in 140

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PRIVATE SECTOR 141 business to sell products and services and make a profit doing so. It therefore recognizes that dietary recommendations will be implemented to the extent that they facilitate, or are not in conflict with, these objectives. The marketer's goal is to sell products, yet implicit in this goal is the responsibility to provide consumers with sufficient prod- uct choice and the necessary information to make informed selections. Many nutrition programs and food products consistent with the principles of dietary recommendations are either already available or under development by the private sector and have been created in response to a growing public interest in health and nutrition. Most of the committee's recommendations in this chapter have already been heard by this societal sector. The committee believes, however, that the various segments of the private sector supermarkets, food- service establishments, and other purveyors of food can be encour- aged to compete with each other in offering to consumers practical advice on implementing dietary recommendations as well as products devel- oped or modified to be lower in fat, cholesterol, and salt and higher in complex carbohydrates than those currently on the market. INCENTIVES AND BARRIERS TO IMPLEMENTATION BY THE PRIVATE SECTOR IN GENERAL Important incentives and barriers that apply to the private sector across the board are discussed below. Incentives Competitive Advantage It is common, although technically inaccurate, to speak of the food industry as though it were monolithic. In reality, as discussed earlier, it is a heterogeneous collection of private-sector entities that compete for a share of the market for similar or related food product lines. It seems increasingly likely that a company will gain a competitive ad- vantage by introducing nutritionally desirable and appealing prod- ucts that meet the public's growing interest in purchasing health- promoting foods. Consumers are likely to purchase good quality products that help them to meet dietary recommendations as they become more informed and as the organoleptic properties (e.g., taste, odor, mouthfeel, and color) of health-promoting foods and the conven- ience of their preparation are perceived to improve. According to a national survey conducted by the Food Marketing Institute (FMI) in January 1990, 97% of respondents reported that nutrition is "very" or

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142 IMPROVING AMERICA 'S DIET AND HEALTH "somewhat important" to them when they shop for food; 90% re- ported that they and their families pay at least some attention to the nutritional content of what they eat; and 40% reported that fat content is the nutritional attribute of food to which they pay the most attention (FMI, 1990~. Consumer Confidence Manufacturers and companies that offer nutritionally desirable foods, products that have complete nutrition labeling, or other useful nutrition information will likely increase customer satisfaction and confidence in their products, thus increasing their sales through new and repeat bus- iness. Well-informed customers are generally confident in their product choices and loyal to products recognized as health promoting. Enhanced Image and Credibility Image and credibility are very important to all companies. Com- panies that offer to their customers nutrition information programs as well as health-promoting products, and that market them as such, would be perceived positively by consumers seeking to improve their diets. Positive word-of-mouth advertising by health-care profession- als, community organizations, consumer groups, and individual con- sumers can be as effective as paid advertising in contributing to a company's image. Cost Reduction and Improved Programs Through Cooperative Efforts Cooperation and collaboration in implementing dietary recom- mendations among the private sector, government agencies, health- care professionals, consumer and voluntary organizations, and academia are to be encouraged. This would reduce redundancy, and thus the costs of implementation programs, and would increase their quality by drawing on the combined expertise of those who are part of these various sectors. Barriers Restrictive, Confusing, or Nonexistent Government Standards Some government standards of identity may limit or prohibit the development of new or modified products that are lower in fat, cho- lesterol, and sodium. Thus, changes in these and in federal or state regulations will be necessary if more nutritionally desirable products

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PRIVATE SECTOR 143 with easily recognizable names are to be manufactured. In addition, the lack of uniform definitions for descriptors on food product labels such as low fat, low cholesterol, or lite creates confusion among con- sumers and in the private sector itself (IOM, 1990; NRC, 1988~. Inadequate Federal Guidance on Health Claims The lack of specific federal guidance creates uncertainty in the private sector about how best to communicate knowledge of the con- nections between diet and health in relation to individual products, thereby permitting the use of confusing, incomplete, or misleading statements to stimulate consumer purchases of certain products. On February 13, 1990, the Food and Drug Administration (FDA) proposed specific guidelines on health claims (Benson and Sullivan, 1990), but no final rule has been issued as of this writing. Recently enacted food labeling legislation gives FDA clear authority to regulate health claims on foods (Food Chemical News, 1990c,d). Lack of Guidance on Implementation The lack of practical guidance on how to implement dietary rec- ommendations limits the private sector's ability to make changes in the food supply. Many companies do not employ registered dietitians or nutritionists to evaluate the nutrient content of foods, to develop high-quality and accurate informational materials on healthy eating, or to prepare the nutrition-related statements for product labels and advertising. Chefs and food-service personnel often do not have sufficient background or training in nutrition or in recipe or menu modification. Cost of Product Development and Research Considerable research must be undertaken before a company can reasonably decide whether or not to invest in the development and marketing of a nutritionally desirable product. Financial risk can be minimized by thorough assessments in which the most effective re- search tools are used. Consumer Concerns about Food Safety According to the national survey conducted by FMI in 1990, 20% of respondents reported that they were "somewhat" or "mostly doubtful" that the food in their supermarket is safe (FMI, 1990~. Both the private and public sectors are responding to the concerns of this group by continuing to take steps to protect the food supply and enlisting the assistance of food scientists and the nutrition community to inform

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144 IMPROVING AMERICA'S DIET AND HEALTH the public about issues related to food safety. Specific widely publi- cized incidents can erode consumers' confidence level regarding the safety of the food supply, but it appears to rebound to initial levels rather quickly. In April 1989, for example, consumer confidence dropped to 73% as a result of media reports about contaminated imported grapes and the use of pesticides and growth regulators in produce. By January 1990, the level of consumer confidence had rebounded back to 79/O (FMI, 1990~. STRATEGIES AND ACTIONS FOR THE PRIVATE SECTOR Two general strategies, each of which consists of three actions, are proposed for the private sector. The first strategy focuses on providing consumers with information on how to improve their dietary patterns and motivating them to do so, while the second concerns the produc- tion, manufacture, and marketing of nutritionally desirable foods. STRATEGY 1: Promote dietary recommendations and motivate consumers to use them in selecting and prepar- ing foods and in developing healthful dietary patterns. ACTION 1: Make consumers aware of dietary recommendations and their importance and how available products and services can be used to meet them. Advertising, public relations, and special promotions can inform consumers about dietary recommendations and thereby help to develop markets for health-promoting foods. They can also enhance the reputation of companies and brand-name products that provide accurate and practical information to consumers. The private sector can play a major role in cooperative efforts involv- ing health-care professionals; academicians; consumer, health, and civic organizations; and governments to develop a variety of consumer informa- tion and education programs and materials that would explain ways in which eating patterns can be adapted to meet dietary recommenda- tions. The programs must emphasize the total diet as well as gradual changes in eating habits; messages should be simple, balanced, and consistent. Chapter 4 identifies some of the major dietary principles that should form the basis of these programs and materials. Use of the combined expertise of individuals involved in these joint ventures has already resulted in the development of nutrition information programs that go beyond what any individual group can accomplish. An example is the collaborative effort of the Kellogg Company with the National Cancer Institute to promote increased consumption of fiber-rich cereals (Freimuth et al., 1988~. In addition

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PRIVATE SECTOR 145 to pooling their expertise, the participants should be encouraged to combine their resources, thereby reducing the costs to each. In advertising and in other consumer materials, health-promoting foods should be displayed together (e.g., vegetables and fruits should be shown with low-fat meats, skinless poultry, seafood, nonfat and low-fat dairy products, and whole grains). This will help consumers to visualize the kinds of foods and menus that are recommended to promote good health. Promotional materials should advocate low fat cooking techniques such as baking, broiling, poaching, steaming, microwaving, or grilling, rather than frying. The private sector should be encouraged to develop incentive pro- grams for corporations and businesses to promote nutrition messages responsibly. Special awards programs could be established, for ex- ample, to increase the visibility of companies that are judged to pro- mote responsible nutrition messages in effective ways. ACTION 2: Contribute to efforts to improve the nutrition la- beling offood so that it better assists consumers in making informed, nutritionally desirable food choices. It is recognized broadly that nutrition labels on food products can help consumers to design diets that meet dietary recommendations. To be more useful, however, they need to be available on more food products and improved in both content and format. The private sector has been actively involved in seeking a solution to current concerns in several areas. For example, they have distributed informa- tion to consumers on how to make use of nutrition labeling. An increasing number of foods-now estimated at approximately 60% of all packaged food products carry nutrition labeling (IOM, 1990~. In addition, consumers have been surveyed by segments of the private sector about their interest in and use of food labels and their suggestions for improved labeling (see, for example, FMI, 1990, and Opinion Re - search Corporation, 1990~. Some segments have also developed posi- tion statements and provided comments in response to regulatory and congressional efforts to revise food labeling (IOM, 1990~. The private sector should continue these activities and avidly support new labeling regulations as issued. As an example, the National Food Processors Association recently organized the Food Label Edu- cation Coalition to help consumers use the new food labels that are developed (Coleman, 1990; NFPA, 1990~. The coalition is composed of representatives of government agencies; education, consumer, and health organizations; and the food industry. Another committee of the Food and Nutrition Board has addressed nutrition labeling of foods in depth (IOM, 1990~.

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146 IMPROVING AMERICA 'S DIET AND HEALTH ACTION 3: Provide consumers with information at points of purchase so that they may assess quickly some of the nutrition attributes of specific products and brands According to a national survey of consumers by FMI in 1989, the preferred methods of providing nutrition-related information in stores were, in order of priority, pamphlets, nutrition tags on shelves near food items, recipe cards, and in-store demonstrations or videos; but only 55/O of those surveyed responded that supermarkets do an excellent or good job in this respect (FMI, 1989b). It appears that food retailers have an opportunity to improve their performance in this area. STRATEGY 2: Continue to increase the availability of a wide variety of appealing foods that help consumers to meet dietary recommendations. ACTION 1: Develop more nutritionally desirable products that appeal to consumers. The private sector has been modifying traditional products as technology permits to make them more nutritionally desirable-usually by reducing their total fat, saturated fat, sodium, or sugar content or by increasing their fiber content. In addition, the private sector is developing an increasing number of nutritionally desirable food pro- ducts that are appealing. Examples include whole-grain, ready-to-eat cereals with no added sweeteners; low-fat dairy products; fat-free or very-low-fat pastries and baked goods; frozen dinner entrees low in total fat, saturated fat, and sodium; and lower-fat hamburger patties served in fast-service food establishments. Of course, each food need not meet specific target levels specified in dietary recommendations (e.g., 30/O or less of calories from fat; see chapter 4~. Nevertheless, consumers are more likely to meet these recommendations if their diets are composed largely of nutritionally desirable products. ACTION 2: Contribute to efforts to revise, or develop as appro- priate, food-quality criteria (such as standards of identity and grading), pricing structures, andfood product descriptors to promote the production of more nutritionally desirable food products. Standards of identity developed by the government specify man- datory ingredients for many common foods such as catsup, cheese, ice cream, frankfurters, bread, and mayonnaise. These standards have helped to ensure the quality and consistency of products by prohibiting manufacturers from substituting less expensive ingredients. Food products that deviate from these standards (e.g., ice cream with less fat than specified) must be renamed in most cases (e.g., frozen des- sert) or labeled as imitation (e.g., imitation ice cream). Thus, standards

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PRIVATE SECTOR 147 of identity can inhibit the replacement of high-fat or high-cholesterol components of foods with nonfat or low-fat ingredients. They should be updated whenever possible to promote the production of more nutritionally desirable versions of food products. The FDA is allow- ing the test marketing of several products that deviate from their standards of identity but still carry their traditional names (e.g., nonfat cottage cheese iShank, 1990al, light eggnog [Shank, 1990b], lowfat ice cream Mood Chemical News, 1990b], and light sour cream [Food Chemical News, 1990a]) to measure consumer acceptance. The carcasses of red meat animals are graded to indicate the qual- ity of table meats. Yet the current U.S. grading system, which is basic to the marketing and pricing of red meat, deters the production of lean meat by linking quality grades to fat content. The nomencla- ture is not identical for beef, pork, and lamb, but generally, the higher the fat content of the muscles (marbling), the higher the quality grade, since marbling improves the chances of the meat being flavorful, juicy, and tender when cooked (NRC, 1988~. Prime and Choice are the two highest grades, but most meat sold is Choice and Select. A marketing system that promoted the leaner grades, primarily Select, would increase the availability of lower-fat meats, which consumers say they want (Sweeten et al., 1990~. ACTION 3: Engage in practices leading to the greater availability of nutritionally desirable products that will assist consumers in meeting dietary recommendations. The private sector should fund and conduct research on nutritional attributes of products as well as on consumer attitudes, knowledge, and practices for ideas to provide consumers with products they want and need. They should also conduct marketing and informational campaigns to increase consumption of health-promoting products. It is important that this research be wide-ranging and help commodity producers, manufacturers, processors, retailers, and food-service establishments learn how to improve their products and their promotional campaigns. This information should be shared throughout the private sector, including supermarkets and the media, as well as with health-care professionals. STRATEGIES AND ACTIONS APPLIED TO SPECIFIC SEGMENTS OF THE PRIVATE SECTOR Fruits and Vegetables (Produce) The committee recommends that the produce industry implement a national fruit and vegetable campaign based on social marketing

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148 IMPROVING AMERICA'S DIET AND HEALTH approaches with extensive use of the media to promote consumption of five or more servings of fruits and vegetables daily as a goal to be reached by the year 2000. The goal should be to increase consumer awareness of the health benefits of fruits and vegetables; to motivate people to eat more of them while emphasizing their convenience, taste, great variety, and relatively low costs; and to provide tips on how to incorporate at least five servings of these foods into the diet each day. Successful implementation of this campaign will require leadership and coordination from both the Produce Marketing Asso- ciation and the United Fresh Fruit and Vegetable Association; large commodity producer groups and fruit and vegetable corporations; and leaders from the food industry, public health agencies, and vol untary health organizations. There is precedent for such a campaign. In 1988, the fruit and vegetable industry, in cooperation with the California Department of Health Services and the California Department of Food and Agricul- ture, began a 3-year statewide campaign to promote the consumption of five servings of fruits and vegetables per person per day and at least 500 lbs of produce per person per year by the year 2000 (Foerster and Bal, 1990~. This California initiative, entitled "5 A Day For Better Health," has been very successful in generating positive media coverage and encouraging the participation of supermarkets and other segments of the produce industry in promoting and implementing the campaign. The creation of a national, federally mandated research and promotion program for all produce would provide a mechanism for raising funds from growers and the produce industry to enhance the positive image of fruits and vegetables through paid advertising and would ensure the necessary cooperation among the produce industry (especially the leading producers), its trade associations, and the U.S. Depart- ment of Agriculture (USDA). In the past, promotion programs for beef, milk, watermelon, and potatoes have led to increased sales (Hits, 1977; Mayer, 1990~. The produce industry should promote and support government efforts to develop innovative programs that will help low-income families attain greater access to fruits and vegetables. For example, 10 states have received federal funds as part of a demonstration project to provide participants in the Special Supplemental Food Program for Women, Infants, and Children (the WIC program) with coupons that can be used to purchase fresh fruits and vegetables at local farmers markets (U.S. Congress, 1988; USDA, 1990~. If implemented more broadly, this program could increase the consumption of fruits and vegetables by those with economic limitations.

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PRIVATE SECTOR 149 Some consumers are concerned about residues of pesticides on some foods (FMI, 1990), and may therefore be reticent to eat more fruits and vegetables. The produce industry should promote the mes- sage that the health benefits of produce outweigh any possible nega- tive effects from pesticides or other residues. The food industry is responding to consumers' pesticide fears in several ways, for example, public education about the safety and benefits of pesticides and ef- forts in the agricultural sector to reduce their use (Ravenswaay, 1989~. Grains and Legumes Consumption of grain products in the United States has increased over the past two decades. This has been in forms that include cere- als, pastas, and baked goods. The formulation of grain food prod- ucts involves millers, wholesale bakeries, food processors, cereal manufacturers, and food retailers with their in-store bakeries. The number of in-store bakeries grew from 18,850 in 1987 (Boisisio et al., 1990) to an estimated 23,007 in 1990 (Malovany, 1990~. Wholesale bakers are producing more varieties of bread and reformulating their products to contain less-saturated fats and oils (Malovany, 1990~. The committee encourages the baking industry to expand its output of whole-grain and lower-fat products, such as whole-grain, low-fat breads, rolls, bagels, pitas, and pastas, and baked rather than fried grain- based snacks, such as corn chips. Consumption of legumes (i.e., dried beans and peas; see Chapter 4) increased from 6.9 lbs per capita in 1970 to 8.3 lbs in 1987 (Putnam, 1989~. Producer-supported organizations such as the American Dry Bean Board and the USA Dry Pea & Lentil Industry have developed promotional materials that include product information and recipe ideas for use by food editors in the media, food and nutrition profes- sionals, restaurants, and consumers in an effort to increase consump- tion of legumes. Budget constraints limit the scope and reach of these promotional initiatives (Dry Pea & Lentil News, 1990; Hays, 1990~. In light of the dietary recommendation to increase consumption of grains (particularly whole grains) and legumes, both industries should consider a campaign similar to that recommended for the produce industry to encourage consumption of these products. Since these segments of the private sector are relatively fragmented, such cam- paigns should include regional components and other efforts applicable to the similarly dispersed fish and seafood industry. Both should begin to promote dietary recommendations to encourage consumption of their products.

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150 IMPROVING AMERICA'S DIET AND HEALTH Dairy The dairy industry and companies that sell dairy foods should promote more aggressively nonfat and low-fat dairy products and explain to consumers the differences in their fat and calorie contents. In the committee's judgment, the industry has not promoted adequate- ly these products in its advertising and educational materials, nor in some cases has it made them widely available. For example, con- sumers in California did not have 1% fat milk in the marketplace until January 1990 (CMAB, 1990; Times Delta, 1990~. At that time, however, the California Milk Advisory Board made a commendable effort to educate consumers by comparing the nutrient contents of fresh milk with different levels of fat. The committee concluded, after discussion with several dairy economists, that one of the major barriers to promoting nonfat and low-fat dairy products may be an unwillingness by some segments of the dairy industry to imply that their full-fat product line (whole milk, cheese, butter, and ice cream) the focus of their traditional image may be less nutritionally desirable. The impetus for making changes has evolved from recognition of the need to reduce the fat content of dairy products to take advantage of consumers' increasing interest in diet and health. A recent report commissioned by the National Dairy Council suggested that it would be "self-defeating" for the dairy industry to continue to "ignore" or "fight" the growing scientific consensus on reducing dietary fat (NDC, 1989, p. 5~. This industry should work with voluntary health and professional organi- zations to develop consumer education materials that promote the consumption of a variety of nonfat and low-fat dairy products that help people to meet dietary recommendations. The committee believes that dietary recommendations and national campaigns to encourage the U.S. population to reduce substantially its dietary fat intake should be perceived by the dairy industry as an opportunity rather than as a threat, since many low-fat products are available. These include low-fat (and, in some cases, fat-free) milk, cheese, yogurt, ice cream, and sour cream. The committee encourages the dairy industry to work toward chang- ing the milk pricing system to encourage dairy producers to breed, feed, and manage their herds for production of lower-fat milk in ac- cordance with changing consumer demands. loins initiative, willing- ness, and action by the dairy industry and USDA will be required to change the current price support system for dairy products. Admit- tedly, a change that reduces the price for the butterfat component of the milk will penalize dairy farmers whose cows produce milk with a

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PRIVATE SECTOR 157 low in sodium or high in fiber). FMI (1989a) has compiled a list and brief description of nutrition information programs in supermarkets across the United States. One example of a successful collaborative industry-sponsored con- sumer information program is Meat Nutri-Facts, which was developed by FMI, the American Meat Institute, and the National Live Stock and Meat Board in 1985 (FMI/AMI/NLMB, 1985~. In 1987, this pro- gram was joined by Poultry Nutri-Facts, produced by FMI with the National Broiler Council and the National Turkey Federation (FMI/ NBC/NTF, 1987), and in 1988 it was joined by Seafood Nutri-Facts, developed by FMI and the National Fisheries Institute (FMI/NFI, 1988~. Elements of these programs, which are available in many su- permarkets throughout the United States, provide point-of-purchase consumer information, including nutrient and calorie data and recipes, on various products and cuts. This information is conveyed by store signs, recipe cards, brochures, and videos that identify relatively low fat cuts of animal flesh as well as low-fat cooking methods and nutrition information for a 3-oz cooked serving. Information derived from this program is also supplied to the industry and to health-care professionals. The results of consumer surveys conducted by retailers on the effec- tiveness of their nutrition information programs should be shared with government agencies and health-related organizations. Supermarket trade associations can also play a key role in evaluating consumer nutrition information programs and disseminating results widely. The committee encourages retailers and their trade associations to go even further by conducting, funding, or collaborating on research to deter- mine consumer attitudes about nutrition, the effectiveness of point-of- purchase nutrition information programs, and topics related to di- etary recommendations. This information should be shared throughout the food industry as well as with health organizations, educators, and governments. The FMI annual Trends report (FMI, 1990) and its cooperative research studies on nutrition and food trends in conjunction with Better Homes and Gardens magazine (FMI/BHG, 1988a,b,c,d, 1989) are two examples of an ongoing effort by the retail food industry to monitor consumer attitudes. Supermarket trade associations should continue to provide their members with information and studies on nutrition issues from a variety of sources. An increasing number of retailers are preparing their own prod- ucts in the store (such as salads, entrees, and desserts) and thus can modify the ingredients used and the methods of preparation to reduce fat and sodium. Some of them have their own processing facilities (e.g., a bakery, dairy, ice cream plant, or canning facility). Retailers can use these resources to produce more nutritionally desirable prod

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158 IMPROVING AMERICA'S DIET AND HEALTH ucts. They should also ask suppliers of store-brand products to modify the products to make them more nutritionally desirable. In some cases, retailers can develop specifications for items they are willing to purchase. If efforts are made to ensure that the products are ap- pealing, consumer demand for them should increase. In some parts of the United States (e.g., very small towns, rural areas, and economically deprived areas of cities), people may depend heavily on a small area supermarket or grocery store for their food purchases. The committee believes that these small retailers have a special responsibility to stock as great a variety of health-promoting foods as they are able at reasonable prices to help their patrons meet dietary recommendations. Food-Service Establishments The average U.S. consumer eats one of every five meals away from home (Sweet, 1989~. The food-service share of a consumer's food dollar has risen from 25% in 1950 (NRA, 1988) to more than 40/O in 1987 (NRA, 1989~. Thus, food providers (e.g., restaurants, fast-service food establishments, and institutional food-service companies) provide a substantial share of the U.S. diet, and their policies and procedures can have a considerable impact on the foods that are consumed. They can thus have an important role in helping consumers make health- promoting food choices. Their future profits may well depend on how well they accommodate the increasing number of people who wish to eat nutritiously when they eat out (Granzin and Bahn, 1988~. Restaurants, fast-service food establishments, institutional food-ser- vice providers, and even caterers have special opportunities and in- centives to improve the nutritional quality of their menus and prod- uct offerings. For example, they can make available one or more items for each course (e.g., entree and dessert) that are consistent with the principles of dietary recommendations and, in general, initiate chang- es in food preparation practices to comply with dietary recommenda- tions. Increased customer satisfaction, loyalty, or increased sales pro- vide the major incentive for restaurants to make changes that are consistent with the principles of dietary recommendations. Accord- ing to a 1986 Gallup Poll, 4 of 10 consumers said they were trying to consume more vegetables and fewer fats, meats, and fried foods when they ate out (NRA, 1990~. Fifty-nine percent of respondents in a 1988 poll conducted for the National Restaurant Association (NRA) said they rank nutritious menu items second on a list of 10 features they like to see in a restaurant (Sweet, 1989~. At present, approximately 40/O of restaurants offer menu items that are reduced in fat, calories,

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PRIVATE SECTOR 159 salt, and cholesterol (Sweet, 1989~. In mid- and upscale restaurants, health-promoting items account for 15% of all sales (Regan, 1986~. Many of the expensive to moderately priced restaurants that have added nutritionally desirable menu items are achieving success, as reflected in increased sales (Framkin, 19881. Experimental pilot projects have shown that the addition of health-promoting items to a menu need not require extensive effort and expense and that they can re- sult in increases in sales (Scott et al., 1979~. Food-service establishments should also accept a social responsi- bility to make health-promoting foods easily accessible both to those who explicitly seek them and to those who do not. For example, managers could add fresh fruit alternatives to menus or dessert carts so that they would not have to be specially requested. Some nutritionally desirable items may not have sold well in the past simply because diners were unaware that they were available. Restaurateurs should encourage the NRA to (1) develop a manual with health-promoting alternatives, including specific information on ingredients, preparation, training, costs, and successful introduction in various markets; (2) track and publish the types of health-promoting alternatives that are most popular with consumers; and (3) engage in research on the most effective means of presenting dietary informa- tion on menus. In addition, the industry should encourage its trade magazines to carry more stories on dietary recommendations and to provide examples of successful and unsuccessful means of imple- mentation. These actions will help convince restaurant owners and chefs that the adoption of healthful alternatives is feasible and economi- cal and will assist them in determining the best times (primarily in terms of public acceptance) to introduce new items and how to do it. The NRA's Nutrition Guidefor the Restaurateur (NRA, 1986) is one step that has already been taken in this direction. Waiters and waitresses should be given basic information about how the restaurant's chefs prepare various dishes so that they can respond knowledgeably to questions asked by consumers trying to follow dietary recommendations. Many food-service establishments may find this recommendation difficult to implement because of fre- quent staff turnover. The menus themselves could be more descrip- tive by containing information on how foods are prepared. In their publicity and advertising, food-service establishments should highlight the availability of menu items that help consumers meet dietary recommendations. This information should also be con- veyed to local restaurant reviewers, food editors, and health organizations to inform consumers where nutritionally desirable foods can be obtained. Messages to consumers should focus not only on the health

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160 IMPROVING AMERICA'S DIET AND HEALTH promoting features of these foods but also on their good taste and appealing presentation. Restaurants, fast-service food establishments, and food-service providers (e.g., cafeterias at work sites and hospitals), can also help consumers by providing certain information (e.g., total calories, calo- ries from fat, and types of oils used in preparation) on menus or on display cards. Many consumers might be surprised to learn that the salad dressing added to a garden salad at a fast-service food restaurant could supply the same number of calories as a roast beef sandwich and trench fries but as much as 50% more fat, depending on the type and amount of dressing used. It is important that consumers know not only the total fat content but also the kind of fat contained in the food. Managers of fast-service food establishments could also display signs notifying consumers that they will prepare items in special ways upon request (e.g., eliminating mayonnaise-based sauces). Fast-service food restaurants enjoy great popularity. On any day, 20% of the U.S. population is estimated to consume their products; young families with children are most likely to frequent these restau- rants (ACSH, 1985), and three in five report they are worried about the nutritional value of such food (Consumer Reports, 1988~. The major incentives for making changes in the fast-service food industry are similar to those for table-service restaurants. That is, the major chains may benefit by increasing customer satisfaction, loyalty, and sales. Fast-service food purveyors have less of a problem in implementing changes than table-service restaurants do because their menus are more limited and food preparation is more standardized. There is evidence that health-promoting changes in fast-service food offerings can be successful. 1 (A ~ ~ For example, the introduction of salads has met with considerable success. At McDonald's, salads account for sales of seven cents of every dollar (Consumer Reports, 1988~. Other examples of newly introduced products include skinless grilled or baked chicken in addition to hamburger, lower-fat hamburgers, low-fat or fat-free frozen yogurt in addition to ice cream, and 1% or skim milk instead of 2% or whole milk (NRA, 1990; Sugarman, 1990~. Confidence in the success of such changes has led to new initiatives in this industry, such as the development by McDonald's of a prominently displayed listing of the ingredients and nutrient content of its offerings. Restaurants and other meal providers should move toward 100% vegetable shortening in all frying and should adopt other food prepara- tion methods (e.g., reducing fat and salt content in trench fries) to help consumers follow dietary recommendations. For fast-service food chains, specific long-term goals should be set as a matter of company policy. Some have already done so. In 1985, most major fast-service

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PRIVATE SECTOR 161 food chains fried with an oil mixture containing beef fat (Jacobson and Fritschner, 1986~. They have now shifted to vegetable oil for frying (Food Chemical News, l990e; Sugarman, 1990~. Representatives of the restaurant industry (e.g., the NRA) and the managers and owners of restaurants should encourage schools that train chefs and cooks to place greater emphasis on dietary recom- mendations, and they should reward the schools that comply by hir- ing their graduates. Restaurants could also help to defray (or-pay) the costs of tuition for employees who take courses in nutrition and new ways to prepare foods. Meals consistent with the principles of dietary recommendations are not likely to become available in restau- rants unless chefs and cooks understand the importance of these rec- ommendations and how to implement them into their food selection and preparation practices. There are several successful models for this action. For example, the Culinary Institute of America in Hyde Park, New York has in corporated the principles of nutrition into its curriculum and runs a public restaurant specializing in nutritious foods (CIA, 1990~. Diners are provided with a computer printout showing the amounts of nutrients in each course and the percentage of their meal that is fat, protein, and carbohydrate. The American Culinary Federation Educational Insti- tute has also incorporated a mandatory nutrition component into its curriculum. Community college and technical schools should also provide nutrition education to those planning to enter the restaurant business. Approximately 1,800 food-service operations in the United States supply meals to businesses, schools, and other institutions. Among these are a few national companies (e.g., ARA Services and Marriott), which control much of the market. For example, Marriott's InFlite Services (which it sold in late 1989) prepared approximately 150 million meals a year for 150 different airlines (Gibbs, 1989~. These large companies currently offer a line of health-promoting food alternatives; for example, ARA Services has developed Treat Yourself Right, a nu- trition education program that merchandises healthful eating at its contracted facilities (Alice Smitherman of ARA Services, personal communication, 1988~. Food-service companies can do more to sell the benefits of health- ful eating to their client companies. Benefits to these companies would include increased sales to employees interested in health-promoting food choices, employees' perception that the company cares about their health, and the potential for savings in medical and other com- pany expenses for employees who eat properly. Nutritionally desir- able food items should be incorporated into the regular food-service

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162 IMPROVING AMERICA'S DIET AND HEALTH program, thereby obviating the need for people to make a special effort (e.g., stand in a special line) to obtain them. Hospitals, voluntary health associations, local health departments and government agencies, and other community-based associations should enlist the help of food-service establishments to (1) develop and advertise health-promoting food alternatives for the community, (2) sponsor seminars for cooks and chefs emphasizing dietary recom- mendations, and (3) sponsor tastings, food fairs, and contests, award- ing and recognizing food-service establishments that support dietary recommendations. Liaisons between restaurant chefs and dietitians also can be successful (Renggli, 1986~. Work Sites An excellent opportunity for implementing dietary recommenda- tions exists within the business world. Many companies maintain restaurants, cafeterias, snack bars, or vending machines for their employ- ees and provide special meals for meetings, employee recognition events, and other occasions. Through these food-providing activi- ties, they exert an influence on the eating habits of millions of U.S. citizens. Work sites are, therefore, excellent channels for health pro- motion efforts, including the provision of nutrition services and in- formation (ADA/SNE/DHHS, 1986; Glanz, 1986; see also Chapter 3~. According to a national survey of work-site health promotion ac- tivities by the U.S. Department of Health and Human Services in 1985,66% of work sites with more than 50 employees had at least one health promotion activity (DHHS, 1987~. Unfortunately, programs on weight control and general nutrition education were among the ac- tivities cited least often (in 15 and 17% of work sites, respectively). Although few work-site health promotion activities have been for- mally evaluated, most employers reported that program benefits out- weighed costs; among the benefits cited in this survey were improved health and productivity among their employees and reduced health care costs. Comprehensive health promotion programs have been established at many work sites, although nutrition activities, if present, have been low-cost, low-intensity programs aimed primarily at increasing employee awareness and knowledge (ADA/SNE/DHHS, 1986; DHHS, 1987; Glanz, 1986~. Such programs are not designed to facilitate eat- ing behavior changes, even though work sites offer the opportunity for long-term interventions as well as environmental and structural changes that can enhance educational messages and support individ- ual behavior changes. Management might be reluctant to make a long

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PRIVATE SECTOR 163 term commitment of resources to implement comprehensive programs and to contract time with health-care professionals to implement the educational programs, assist in the development of appropriate new policies, and work with the food-service staff to improve the nutri- tional quality of foods made available to employees. The committee recommends that corporations provide authorita- tive information to employees on the relationship of dietary practices to health promotion arid disease prevention and promote dietary rec- ommendations. Depending on their size and the resources at their disposal, employers could provide this information to their employ- ees through such means as classes, brown bag seminars, payroll stuffers, newsletter articles, contests, posters, displays, articles in in-house publications, and health-promoting menu offerings in company cafeter- ias. Corporations should consider offering incentives to employees who modify their dietary practices and consistently make health-pro- moting food choices, and their executives should serve as models of healthful eating. See Chapter 3 for a further discussion of nutrition education programs at work sites. Corporations should establish a corporate nutrition policy that con- firms the company's commitment to healthy dietary practices consistent with dietary recommendations and specifies that stated standards will be applied to meals served in company food-service operations and at company functions. Small corporations without policies should also provide healthful meals at all opportunities, and those without food- service operations should, at Me least, offer more fruits, vegetables, whole grams, and low-fat, low-sodium foods in their vending machines. NOTE 1. In 1980, FDA published voluntary guidelines for manufacturers to promote the rational fortification of foods (Goyan, 1980). This committee supports those guidelines and encourages manufacturers and processors to comply with them. According to FDA, fortification is appropriate (1) to correct a dietary inadequacy recognized by the scientific community to result in a deficiency disease; (2) to restore nutrient levels to those present in a food before conventional processing and storage; (3) to balance the protein, vitamin, and mineral content of the food in relation to the calories it supplies; and (4) to ensure that a substitute food is nutritionally similar to the traditional food it replaces (NRC, 1989; Quick and Murphy, 1982). FDA does not consider it appropriate to fortify fresh produce; meat, poultry, or fish products; sugars; or snack foods such as candies and carbonated beverages. REFERENCES ACSH (American Council on Science and Health). 1985. Fast Food and the American Diet. American Council on Science and Health, Summit, NJ. 34 pp.

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164 IMPROVING AMERICA'S DIET AND HEALTH ADA/SNE/DHHS (American Dietetic Association/Society for Nutrition Education/ U.S. Department of Health and Human Services). 1986. Worksite Nutrition: A Decision-Maker's Guide. American Dietetic Association, Chicago, Ill. 57 pp. Benson, J.S., and L.W. Sullivan. 1990. Food labeling; health messages and label state- ments; reproposed rule. Fed. Reg. 55:5175-5192. Bishop, R.V., and L.A. Christensen. 1989. America's poultry industry. Natl. Food Rev. 12(1):9-13. Block, G., C.M. Dresser, A.M. Hartman, and M.D. Carroll. 1985. Nutrient sources in the American diet: quantitative data from the NHANES II survey. Am. J. Public Health 122:27-40. Boisis~o, M., J. DeQuattro, B. Hardin, J.K. Kaplan, D. Senft, and N. Wood. 1990. Wheat, a crop in transition. Agric. Res. 38(9):5-17. CIA (Culinary Institute of America). 1990. The General Foods Nutrition Center at the Culinary Institute of America. Press releases and miscellaneous materials. Culinary Institute of America, Hyde Park, N.Y. CMAB (California Milk Advisory Board). 1990. Extra light milk debuts called "the milk of the 90's." Milk Advisor. Winter, pp. 1, 10. Coleman, R. 1990. NFPA food label education project & consumer research. Presented at the American Heart Association Meeting, Label Use Project, August 28. Public Communications Office, National Food Processors Association, Washington, D.C. Consumer Reports. 1988. A survival guide to the greasy kid stuff. Consumer Rep. 53:355-361. DHHS (U.S. Department of Health and Human Services). 1987. National Survey of Worksite Health Promotion Activities. A Summary. Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Hu- man Services. Office of Disease Prevention and Health Promotion, National Health Information Center, Silver Spring, Md. 51 pp. Dicks, M.R., and D. Harvey. 1989. Issues behind mandatory seafood inspection. Natl. Food Rev. 12(4):30-33. Dry Pea & Lentil News. 1990. Domestic marketing materials get facelift. Dry Pea & Lentil News 1(1):1. FMI (Food Marketing Institute). 1989a. FMI Supermarket Directory, Nutrition & Health Programs, 1989. Consumer Affairs Department, Food Marketing Institute, Washington, D.C. 21 pp. FMI (Food Marketing Institute). 1989b. Trends: Consumer Attitudes & the Supermar- ket, 1989. Conducted for Food Marketing Institute by Opinion Research Corpora- tion. The Research Department, Food Marketing Institute, Washington, D.C. 65 pp. FMI (Food Marketing Institute). 1990. Trends: Consumer Attitudes & the Supermar- ket, 1990. Conducted for Food Marketing Institute by Opinion Research Corporation. The Research Department, Food Marketing Institute, Washington, D.C. 68 pp. FMI/AMI/NLMB (Food Marketing Institute/American Meat Institute/National Live Stock and Meat Board). 1985. Meat Nutri-Facts. FMI/AMI/NLMB, Washington, D.C. FMI/BHG (Food Marketing Institute/Better Homes and Gardens). 1988a. Information Sources, Planning and Purchasing, 1988. Conducted for Food Marketing Institute and Better Homes and Gardens Magazine by Opinion Research Corporation. The Research Department, Food Marketing Institute, Washington, D.C. 16 pp. FMI/BHG (Food Marketing Institute/Better Homes and Gardens). 1988b. A Study of Food Patterns and Meal Consumption, 1988. Conducted for Food Marketing Institute and Better Homes and Gardens Magazine by Opinion Research Corporation. The Research Department, Food Marketing Institute, Washington, D.C. 16 pp.

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PRIVATE SECTOR 165 FMI/BHG (Food Marketing Institute/Better Homes and Gardens). 1988c. A Study of Nutrition, 1988. Conducted for Food Marketing Institute and Better Homes and Gardens Magazine by Opinion Research Corporation. The Research Department, Food Marketing Institute, Washington, D.C. 16 pp. FMI/BHG (Food Marketing Institute/Better Homes and Gardens). 1988d. Time, Con- venience and Entertaining, 1988. Conducted for Food Marketing Institute and Bet- ter Homes and Gardens Magazine by Opinion Research Corporation. The Research Department, Food Marketing Institute, Washington, D.C. 16 pp. FMI/BHG (Food Marketing Institute/Better Homes and Gardens). 1989. Dinnertime USA, Executive Summary, 1989. Conducted for Food Marketing Institute and Bet- ter Homes and Gardens Magazine by Total Research Corporation. The Research Department, Food Marketing Institute, Washington, D.C. 16 pp. FMI/NBC/NTF (Food Marketing Institute/National Broiler Council/National Turkey Federation). 1987. Poultry Nutri-Facts. FMI/NBC/NTF, Washington, D.C. FMI/NFI (Food Marketing Institute/National Fisheries Institute). 1988. Seafood Nutri- Facts. FMI/NFI, Washington, D.C. Foerster, S.B., and D.G. Ball 1990. California's "5 A Day For Better Health" cam- paign. Chronic Dis. Notes Rep. 3(1):7-9. Food Chemical News. 1990a. Another temporary permit granted for light sour cream. Food Chem. News 32(27):49. Food Chemical News. 1990b. FDA-ers hope to publish lower fat ice cream document. Food Chem. News 32(30):56. Food Chemical News. 1990c. Health claims additional re-proposal seen likely. Food Chem. News 32(37):3-6. Food Chemical News. 1990d. Hutt hits need for FDA clearance of new health mes- sages. Food Chem. News 32(37):43-45. Food Chemical News. 1990e. Three fast food chains switch to vegetable oils for frying. Food Chem. News 32(22):42-43. Framkin, P. 1988. Lite and healthy. Restaurant Bus. 87:193-208. Freimuth, V.S., S.L. Hammond, and J.A. Stein. 1988. Health advertising: prevention for profit. Am. J. Public Health 78:557-561. Giant Food, Inc. 1988. Eat for Health: Poultry Guide. Form 232 (12/88 CMX). Giant Food, Inc., Landover, Md. 12 pp. Gibbs, N.R. 1989. You want me to eat this?. Time 133:75-76. Glanz, K. (ed.). 1986. Nutrition at the worksite. J. Nutr. Ed. 18:Sl-S92. Goyan, J.E. 1980. Nutritional quality of foods; addition of nutrients. Final policy statement of the Food and Drug Administration. Fed. Reg. 45:6314-6324. Granzin, K.L., and K.D. Bahn. 1988. The role of consumers' attitudes toward nutrition in restaurant patronage. J. Nutr. Ed. 20:56-62. Hays, S. 1990. The Nebraska Dry Bean Commission; the American Dry Bean Board; American Dry Bean Board Members. August 28, 1990. Photocopies. Hitt, C. 1977. The potato: something good that's good for you. Case study No. 4-577- 093 of the Department of Nutrition, Harvard School of Public Health, and the Harvard Business School. Photocopy. 48 pp. IOM (Institute of Medicine). 1990. Nutrition Labeling: Issues and Directions for the 1990s. Report of the Committee on the Nutrition Components of Food Labeling, Food and Nutrition Board. National Academy Press, Washington, D.C. 355 pp. IOM (Institute of Medicine). 1991. Seafood Safety (Prepublicahorl Copy). Report of the Committee on Evaluation of the Safety of Fishery Products, Food and Nutrition Board. National Academy Press, Washington, D.C. 446 pp.

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166 IMPROVING AMERICA'S DIET AND HEALTH Jacobson, M.F., and S. Fritschner. 1986. The Fast-Food Guide. Workman Publishing, New York. 225 pp. Levy, A.S., O. Mathews, M. Stephenson, J.E. Tenney, and R.E. Schucker. 1985. The impact of a nutrition information program on food purchases. J. Public Policy Market. 4:1-13. T ;^h~ R Baas The Oral ton hoof Hydration N1ltr portico H~nithl~tter 15(8):8 1_ 1 = Lo 1 1 t HI 1 L ~ 1~ . 1 ~ V V . ~ ~ L `_ ~ ~ ~ ~ 45 ^ ~ ~ ^ ~ r ~ ~ ~ ^ 9. Light, L., J. Tenney, B. Portnoy, L. Kessler, A.B. Rodgers, B. Patterson, O. Mathews, E. Katz, J.E. Blair, S.K. Evans, and E. Tuckermanty. 1989. Eat for Health: a nutrition and cancer control supermarket intervention. Public Health Rep. 104:443-450. Malovany, D. 1990. The search for new ideas. Bakery 25(7):44-46. Mayer, C.E. June 20, 1990. Here's the pitch: From nuts to spuds, Congress helps farmers promote their bounty. Washington Post. E1, E8. Morrison, R.M. 1990. The market for fat substitutes. Natl. Food Rev. 13(2):24-30. NDC (National Dairy Council). 1989. Final Report: The Bridge Project. Translation of Nutrition Research Information into Marketing Strategies for the Dairy Industry. National Dairy Council, Rosemont, Ill. 56 pp. NFPA (National Food Processors Association). August 16, 1990. New coalition to develop nutrition education program. Press release. Association, Washington, D.C. National Food Processors NMFS (National Marine Fisheries Service). 1988. Fisheries of the United States, 1987. National Oceanic and Atmospheric Administration, U.S. Department of Commerce. U.S. Government Printing Office, Washington, D.C. 116 co. NMFS (National Marine Fisheries Service). 1990. Fisheries of the United States, 1989. National Oceanic and Atmospheric Administration, U.S. Department of Commerce. U.S. Government Printing Office, Washington, D.C. 112 pp. NRA (National Restaurant Association). 1986. A Nutrition Guide for the Restaura- teur. National Restaurant Association, Washington, D.C. 72 pp. NRA (National Restaurant Association). 1988. 1988-1989 Foodservice Industry: Na- tional Restaurant Association Pocket Factbook. National Restaurant Association, Washington, D.C. 8 pp. NRA (National Restaurant Association). 1989. Foodservice Industry: 1987 in Review. National Restaurant Association, Washington, D.C. 8 pp. NRA (National Restaurant Association). 1990. Nutrition Awareness and the Foodservice Industry: Current Issues Report. National Restaurant Association, Washington, D.C. 20 pp. NRC (National Research Council). 1988. Designing Foods: Animal Product Options in the Marketplace. Report of the Committee on Technological Options to Improve the Nutritional Attributes of Animal Products, Board on Agriculture. National Academy Press, Washington, D.C. 367 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, Washington, D.C. 749 pp. Opinion Research Corporation. 1990. Food Labeling and Nutrition: What Americans Want. Survey conducted by Opinion Research Corporation for the National Food Processors Association. National Food Processors Association, Washington, D.C. 178 pp. Putnam, Jo. 1989. Food Consumption, Prices, and Expenditures, 1966-87. Statistical Bulletin No. 773. Economic Research Service, U.S. Department of Agriculture, Washington, D.C. 111 pp.

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PRIVATE SECTOR 167 Quick, J.A., and E.W. Murphy. 1982. The Fortification of Foods: A Review. Agricul- ture Handbook No. 598. Food Safety and Inspection Service. U.S. Department of Agriculture, Washington, D.C. 39 pp. Ravenswaay, E.V. 1989. The food industry responds to consumers' pesticide fears. Natl. Food Rev. 12(3):17-20. Regan, C. 1986. Operators responding to consumer nutrition concerns. Restaurants U.S.A 6:39-41. Renggli, S. 1986. The Four Seasons Spa Cuisine. Simon and Schuster, New York. 348 PP Scott, L.W., J.P. Foreyt, E. Manis, M.P. O'Malley, and A.M. Gotto, Jr. 1979. A low- cholesterol menu in a steak restaurant. J. Am. Diet. Assoc. 74:54-56. Shank, F.R. 1990a. Cottage cheese deviating from identity standard; temporary per- mit for market testing. Fed. Reg. 55:32473. Shank, F.R. 1990b. Eggnog deviating from identity standard; temporary permit for market testing. Fed. Reg. 55:39728-39729. Sugarman, C. July 31, 1990. Lower-fat fast food: chains feature healthier fare. Wash- ington Post Health. 16. Sweet, C.A. 1989. Rethinking eating out. FDA Consumer 23:8-13. Sweeten, M.K., H.R. Cross, G.C. Smith, J.W. Savell, and S.B. Smith. 1990. Lean beef: impetus for lipid modifications. J. Am. Diet. Assoc. 90:87-92. Times Delta. November 3, 1989. New milk to increase nutrition. Times Delta (Visalia, Calif.). U.S. Congress. 1988. The Hunger Prevention Act of 1988. Public Law 100-435. U.S. Government Printing Office, Washington, D.C. 35 pp. USDA (U.S. Department of Agriculture). 1990. Farmers' market coupon demonstra- tion projects, background. Unpublished document.