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7 Health-Care Professionals: Strategies and Actions for Implementation I N THE UNITED STATES, there has been a growing public aware- ness of the role of nutrition in the etiology of many chronic degen- erative diseases and a corresponding demand for information and assistance concerning diet and disease relationships. The U.S. popu- lation looks more and more to health-care professionals to provide clear information confirming this linkage and to establish practical guidelines for dietary regimens that will help to prevent or delay the onset of disease. At the same time, multiple forces, including the need to contain the cost of medical services, may be helping to renew interest among health-care professionals and the public in preventive measures. Good nutrition practices are an essential component of efforts to prevent or control such diseases as atherosclerosis, cancer, hypertension, diabetes, and osteoporosis. Health-care professionals must respond to these increasing needs. The committee defined health-care professionals as those whose work deals primarily with food and nutrition (e.g., registered dietitians, nutritionists, and nutrition educators); those for whom food and nu- trition issues are important but secondary (e.g., physicians and nurses); and scientists whose basic research concerns the role of food in the etiology of disease. Thus, the target audiences for the implementation strategies and actions proposed in this chapter include nutrition scientists and virtually everyone professionally trained in the delivery of health care. Increasing expectations that health-care professionals will include nutritional guidance as an integral component of all primary care 168

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HEALTH-CARE PROFESSIONALS 169 come at a time when both positive and negative forces are at work. The positive forces include a growing awareness of the escalating social and economic costs of preventable disease and disability, the wide scientific consensus on the nature of dietary recommendations, the increased scope and number of programs in health promotion, and growing evidence of the success of such efforts in reducing nutrition- related risk factors for chronic disease. The negative forces include inadequate time and lack of compensation to provide the kinds of nutritional guidance that individuals may desire or need, the perception that many people lack interest in eat- ing better and that they do not follow recommended diets, and inad- equate knowledge and skills needed to teach people how to improve their diets. A major impediment to implementation of dietary rec- ommendations is the inadequate preparation of health-care profes- sionals (primarily those outside the nutrition field) for these new and expanding roles as promoters of good nutrition and providers of ba- sic information on the subject. Inadequate preparation of many phy- sicians for this role has been recognized for many years (Council on Food and Nutrition, 1963; NRC, 1985~. Fortunately, several voluntary organizations, government agencies, and private associations are attempting to help health-care profes- sionals prepare for their expanded role. Examples include the National Center for Nutrition and Dietetics (ADA, 1990), Project LEAN (Low- Fat Eating for America Now) (Henry I. Kaiser Family Foundation, 1988), the Healthy Mothers, Healthy Babies Public Information Program (DHHS, 1990b), and the national campaigns on cholesterol and high blood pressure education (Cleeman, 1989; Lenfant, 1986; Roccella and Ward, 1984~. These and other such programs aim to inform consumers how to improve their dietary practices and to help health-care pro- fessionals become better promoters and teachers of nutrition. How- ever, increased coordination and cooperation among such groups and programs are needed to perform this important and complex task effectively. MULTIPLE ROLES To implement dietary recommendations, health-care professionals must perform multiple roles, including educational, modeling, orga- nizing, advisory, and investigative roles. Not all these professionals have the same needs for nutrition information to perform each of these roles effectively. In their educational role, health-care professionals may serve as re- sources on nutrition, food, and health in a variety of ways such as in

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170 IMPROVING AMERICA'S DIET AND HEALTH the preparation of primary and secondary school teachers, the train- ing of health-care professionals (both students and practitioners in classroom settings and in continuing education programs), the moti- vation and education of individual patients in clinical settings, education of the public, and providing patients with dietary assessments and counseling. Since intellectual acceptance of knowledge by itself rarely fosters lasting change (see Chapter 3), practitioners will need to learn about the forces that govern behavior changes in order to help moti- vate patients and assist them in acquiring the skills needed to achieve and sustain enduring healthful dietary practices. By following dietary recommendations themselves, health-care professionals serve as highly credible role models for patients and the public. In this modeling role, they can provide information and dietary advice based in part on their personal experiences that may help others to improve their eating habits. As organizers, health-care professionals can initiate or contribute to community programs to improve nutrition. To accomplish this, they may act as individuals or work through professional societies or other health care-related organizations. The advisory role of health-care professionals includes providing legislators and government officials with the information needed to promulgate desirable regulations and guidelines pertaining to food, nutrition, and health policy. The investigative role is carried out primarily by health-care pro- fessionals in institutions or organizations involved in basic or applied research. However, community practitioners can play this role as well. As an example, the recognition that contaminated tryptophan supplements may cause serious toxicity was made by a practicing physician (Altman, 1989; CDC, 1989~. There is great need for additional insights into the causal relationships between diet, genetic factors, and organic diseases, for more knowledge of the factors that govern behavior change, and for information on how to mobilize communities to promote healthy behaviors. It is certain that there will be additional discoveries in these areas. Thus, current dietary recommendations, which represent the best understanding of nutrition science to date, may need to be revised in the future. (See Chapter 9 for suggested research topics.) CURRENT STATUS AND FUTURE NEEDS OF SOME HEALTH-CARE PRACTITIONERS In this section, nutritionists, physicians, nurses, health educators, and other health-care practitioners are described in terms of their

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HEALTH-CARE PROFESSIONALS 171 roles and needs in implementing dietary recommendations. The or- dering of these professional groups does not reflect any hierarchy of importance to their respective and complementary tasks. Nutritionists The pool of qualified nutrition personnel needed to implement dietary recommendations is varied. It consists of nutritionists work- ing in a variety of settings, including state and local health departments, community nutrition programs, policy and advocacy organizations, educational institutions at all levels, and research facilities. This pool includes approximately 44,000 registered dietitians (American Dietetic Association, personal communication, 1990), 4,700 public health nutrition personnel (Kaufman, 1989), 2,800 scientists in the American Institute of Nutrition (American Institute of Nutrition, personal communication, 1990), and 270 physicians board certified in nutrition (American Board of Nutrition, personal communication, 1990~. Because some nutrition professionals are members of two or more of these categories and some are not included in any of them, the total number involved in this effort will be different from this total. To deepen the knowledge of nutrition specialists and enhance their skills in teaching a wide variety of publics to base their eating patterns on dietary recommendations, traditional education programs must be improved. For example, curricula must emphasize both the social and behavioral aspects of promoting dietary changes as well as the scientific basis of the recommendations. In addition, curricula should include relevant material from the food and agricultural sciences. This requires a delicate balance. Too much emphasis on the scientific fundamentals could lead to omission of the practical aspects of nutrition and dietary change. Public health and other community-based nutrition specialists who work actively on promoting health among target populations need additional training on how to integrate into their programs the growing evidence on diet and health relationships and how to manage complex community intervention programs. Registered dietitians and other nutrition specialists must be trained adequately to translate dietary recommendations into practical advice and to provide menu alternatives that consumers can understand and adopt. Students who plan to work in institutional food services must learn the techniques for adapting dietary recommendations to all aspects of food service management: menu planning, food purchas- ing, food preparation (including modification of recipes), meal service, and merchandising. Nutritionists and dietitians in food-service man- agement positions have many opportunities to promote public health

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172 IMPROVING AMERICA'S DIET AND HEALTH by helping both clients and food-service providers (e.g., cooks) fulfill their responsibilities to make more nutritionally desirable foods available to the public. As educators, nutrition specialists can help other health- care professionals acquire the information and skills needed to provide basic community nutrition education. Nutritionists and dietitians should be committed to following dietary recommendations and teaching others how to apply them wherever they work, including business and industry, private practice, academia, and government. Physicians A 1985 Food and Nutrition Board (FNB) committee concluded that nutrition education in U.S. medical schools is largely inadequate (NRC, 1985~. Among the schools surveyed, it observed "a distinct lack of organizational structure and administrative support for nutrition programs" (p. 97~. To ensure that nutrition programs become a per- manent part of the medical school curriculum, the committee suggested that responsibility for them be vested in a separate department or division of clinical nutrition. The committee further recommended the establishment of a mechanism to monitor changes, if any, in the status of nutrition education in U.S. medical schools. The 1985 FNB committee proposed explicit guidelines that would best incorporate principles of nutrition in the basic and clinical curricula of medical schools. Because the administrative structures of U.S. medical schools are so diverse, it was acknowledged that each school would be obliged to devise its own nutrition program, implementation strategy, and faculty structure. The committee recognized that a vigor- ous program in nutrition must always incorporate the latest investigative findings and that a mandated, inflexible curriculum is inherently outmoded. Nevertheless, it emphasized that certain broad areas pertaining to nutrition are an indispensable part of medical education. These areas include energy balance, the role of specific nutrients and dietary components, nutrition at different stages of the life cycle, assessment of nutritional status, protein-energy malnutrition, the role of nutrition in disease prevention and treatment, and any risks stemming from poor dietary practices because of individual, social, or cultural idiosyncrasies (Weinsier et al., 1989~. All these areas need to be rethought in relation to dietary recommendations, and the curriculum needs broadening to include elements of preventive medicine. For example, during the clinical training phase of medical school, students could learn basic nutrition counseling skills based on the communication/ persuasion and social learning models described in Chapter 3. The number of U.S. medical schools with required nutrition courses

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HEALTH-CARE PROFESSIONALS 173 dropped from 46 in 1981-1982 to 34 in 1987-1988 (Winick, 1989~. Concomitantly, however, general nutrition education has been strengthened in most medical schools. The framework for an effec- tive program is operating at the Emory University School of Medi- cine in Atlanta, Georgia, where an executive associate dean initiated a Nutrition Planning Committee composed of faculty from both basic and clinical science departments. All committee members have a professional interest in nutrition science, and all are active investigators in this field. The committee coordinates, advises, and participates in matters of curriculum design, recruitment of faculty in the area of nutrition, and guidance of the graduate degree programs in this field. It also supervises the coverage of nutrition throughout the campus. Furthermore, the committee coordinates its intramural activities with the other southeastern medical schools through SERMEN (Southeastern Region of Medical School Educators in Nutrition), which has a central office at the Medical College of Georgia in Augusta and a testing service based at the University of Alabama in Birmingham. Another apparently effective program is operating at the University of Texas Health Science Center in San Antonio (Young, 1988~. A recent paper presents strategies to fit nutrition in the medical curriculum (Kushner et al., 1990~. Summaries and excerpts from the FNB reports Recommended Dietary Allowances (NRC, 1989b) and Diet and Health: Implications for Reducing Chronic Disease Risk (NRC, 1989a) as well as The Surgeon General's Re- port on Nutrition and Health (DHHS, 1988) should serve as resources for medical students learning about the relationships between nutri- ent intake and dietary patterns to the maintenance of health and risk of chronic disease. Other resources will be needed to teach basic nutrition concepts and such topics as nutritional therapies to treat specific diseases. Nurses At present, fundamental nutrition courses are not a prominent fea- ture of baccalaureate or master's degree programs in nursing, although narrow elements of diet planning and disease-oriented diet therapy are incorporated into many required courses in the nursing curricula. Most programs that do provide nutrition courses are part of university medical centers such as the University of Washington (Seattle) School of Nursing (University of Washington, 1989~. In the program descriptions of many nursing schools, there is no mention of nutrition education of patients as being a responsibility of nurses. The inclusion of both basic and applied nutrition courses in nurs

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174 IMPROVING AMERICA'S DIET AND HEALTH ing education has become increasingly important in light of the ex- panding roles of nurses in health care. Nurses often serve as the gatekeepers to patient care in primary health care units. In many clinical settings, for example, nurses conduct entry interviews, record pertinent historical details, act as triage coordinators, and frequently assume responsibility for the exit instructions regarding medications, diet, and other life-style changes. It is likely, then, that nurses (including registered nurses, nurse practitioners, and licensed midwives) work- ing in various sites (e.g., hospitals, schools, clinics, and offices) can influence the eating habits of the public. To do so effectively, however, they must be adequately educated in nutrition, be sufficiently motivated to teach and encourage their patients to make dietary changes, and eat well themselves. Nurses have more daily contacts and interviews with patients in health-care settings than do those in any other professional group and thus have a great potential for influencing their clients. Health Educators Health educators work to promote health and prevent disease in state and local public service departments, even when their primary activities are geared to improving educational systems and social welfare or health-care policies. Their training should place additional emphasis on nutrition concepts and nutrition education methods to prepare them for their expanded roles in implementing dietary recommendations. Chairs of health education departments should draw on faculty out- side the department with expertise in nutrition science and nutrition education to serve as instructors and advisers in the nutrition component of their programs. Practicing health educators should use the services and resources of food and nutrition specialists in their communities. In addition, they should improve their abilities to implement dietary recommendations by having access to electronic networks of nutrition literature and telephone or computer hotlines that could quickly provide them with accurate and practical information needed in specific situations. More effective use should be made of another group of health educators the more than 3,000 home economists with the Cooperative Extension Service (CES) who disseminate nutrition information to consumers on an individual and group basis throughout the United States (Tope, 19901. In 1989, more than 10 million people participated in CES-organized nutrition programs, many of them provided through health departments, schools, churches, and local businesses.

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HEALTH-CARE PROFESSIONALS Other Health-Care Professionals 175 Many other health-care professionals, including dentists, pharma- cists, home economists, physician assistants, and medical epidemi- ologists, can be important sources of dietary information. All have unique opportunities to offer education and practical examples of the need for improved nutrition to their clients and colleagues. For example, dentists might inform their patients about diet-related measures for preventing and controlling dental caries, and pharmacists can help to disseminate the message that healthy people can and should obtain adequate amounts of essential nutrients by eating a variety of foods. Both can speak to colleagues and other health-care providers at con- tinuing education programs about their successes and failures in promoting dietary recommendations. STRATEGIES AND ACTIONS FOR HEALTH-CARE PROFESSIONALS The committee developed three strategies and associated actions for health-care professionals to implement dietary recommendations. STRATEGY 1: Raise the level of knowledge among all health- care professionals about food and nutrition and the relationships between diet and health. ACTION 1: Establish within the faculty of every health-care professional school an identifiable program with overall responsibility for planning and developing a research and education agenda in human nutrition. Considerable attention should be given to the nutrition education of physicians and nurses, since these two groups of professionals customarily represent the first contacts made by people seeking health care. These initial contacts, which number in the millions per day, are an excellent opportunity to provide patients with initial guidance and information about dietary recommendations. Patients who need more elaborate guidance or specific dietary modifications can be referred to qualified nutritionists and registered dietitians who have specialized knowledge and additional skills in this area. One barrier to the successful implementation of this action is the limited number of faculty available to constitute an effective nutrition committee at most health-care professional schools. (Action 2 below is aimed at overcoming this barrier.) Another more difficult barrier is the institutional hesitation to expand curricular coverage (Nestle, 1988~. However, an efficiently coordinated program might not require an increase in the hours spent on nutrition but, rather, an alteration of

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176 IMPROVING AMERICA 'S DIET AND HEALTH the existing hours by rearranging and coordinating coverage. A third barrier relates to coordination. In fields such as nutrition, which cut across many basic and clinical areas, some coordination with the cur- ricula of related subject areas is essential but often difficult to achieve. The establishment of an identifiable program with responsibility for planning, research, and education in human nutrition might be initiated by an individual school or be a cooperative effort among schools at a health center. A visibly supportive role by the university's administrative leadership is needed to ensure the success of the ef- fort. ACTION 2: Establish a program within the Public Health Service to support the training offaculty in nutrition. The goal should be at least one nutritionfaculty member per health-care professional school for each of the licensed graduate programs in the health- care professions. This program might be patterned after the current Preventive Car- diology Academic Award, which has been funded through the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health (NIH) since 1979. It gives a competitively awarded 5-year grant to one faculty member in individual medical schools to develop programs in preventive cardiology. The grant provides up to 50% of the faculty person's salary plus funds to support the development and implementation of the program. The aim of the program is to have the school maintain the program after the completion of the 5- year period. A nutrition award program could support a faculty member with clinical research interests in human nutrition. That faculty member would become an active member of the school's nutrition committee and would be expected to participate in all the campus activities related to nutrition. The award might be funded and administered by more than one NIH institute. The major barrier, beyond the availability of funds, would be the maintenance of an active program on the campus after expiration of the grant. Limited availability of suitable faculty candidates for the award might also be a problem, but one that would diminish as more people in the various health-care professions devote themselves principal- ly or exclusively to nutrition. ACTION 3: Materials emphasizing dietary recommendations for students in the health-care professions should be prepared by curriculum committees, authors, publishers, and others with in- terests in curriculum development. Such materials should include course syllabi at varying levels of complexity, batteries of examination

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HEALTH-CARE PROFESSIONALS 177 questions, relevant bibliographic listings, audiovisual teaching instruments, and self-education computer programs. Some clusters of schools (e.g., medical schools in the southeastern states) have already combined their resources in nutrition education and have made such teaching materials available to other schools (Feldman et al., 1989~. A similar amalgamation of resources in clini- cal nutrition should be established for health-care professional schools. Individual schools and faculty may wish to use only materials devel- oped in house. Resistance to materials generated by outside authorities should be overcome, however, by the availability of authoritative reports such as Diet and Health (NRC, 1989a), The Surgeon General's Report on Nutrition and Health (DHHS, 1988), and the curricular materials developed by broad-based groups. Clinical nutrition issues should be emphasized in such settings as informal nutrition rounds in both inpatient and outpatient settings, conferences, and formal seminars. Printed and audiovisual presentations should be made available to teaching institutions unable to develop such programs. ACTION 4: Expand nutrition education of health-care professionals at all levels. Certification and licensing bodies involved in the education of health-care professionals should require a demonstrated knowledge of nutrition. There is a need to increase the exposure of health-care professionals to clinical nutrition concepts in basic and graduate training as well as in continuing education. Students should be required to demonstrate their knowledge of nutrition and nutrition education methods by re- sponding correctly to test questions on diet and health. Such questions should be incorporated into examinations assembled and sponsored by such professional bodies as the National Board of Medical Exam- iners (Winick, 1988~. As a necessary step in bringing this about, professionals with expertise in nutrition should be asked to serve as advisory board members of licensing and accrediting agencies. More continuing education programs in nutrition should be developed for health-care professionals. One useful example is Rx Nutrition: Good Health in Practice, a 2-year program designed to help physicians bet- ter understand connections between diet and disease and to provide them with practical guidelines to modify their own and their patients' eating habits (Health Learning Systems, Inc., 1989~. This program is based on the recommendations in the Diet and Health report (NRC, 1989a). Barriers to the acquisition of this new knowledge are both concep- tual and practical, especially for physicians. Nutrition is not now identified as a specific component of most medical residency or graduate

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178 IMPROVING AMERICA'S DIET AND HEALTH training programs (Boker et al., 1990). Certain medical specialties (e.g., gastroenterology and pediatrics) cover many elements of nutrition, but their coverage is rarely coordinated or focused. Another practical problem is that many programs in health-care educational institu- tions now compete for a limited allotment of teaching time. Further- more, courses in nutrition do not yet teach students in most of the health-care professions the skills needed to motivate and enable people to make long-term improvements in their dietary patterns. In medical schools, nutrition can be made part of the curricula in virtually all clinical areas (e.g., prenatal nutritional requirements in obstetrics). When nutrition is made an integral part of the broader program of preventive medicine, it is more likely to be accepted and maintained. Moreover, health-care practitioners should be encouraged to use the professional skills of registered dietitians and others with nutrition expertise in educating, motivating, and assessing the nutri- tional status of patients. STRATEGY 2: Contribute to efforts that will lead to health- promoting dietary changes for health-care professionals, their clients, and the general population. ACTION 1: Encourage efforts to implement dietary recommen- dations in a coordinated manner for maximum effectiveness and to avoid unnecessary duplication. Two successful models have been developed for coordinating ac- tivities designed to control hypertension and hypercholesterolemia- the National High Blood Pressure Education Program (NHBPEP) (Roccella and Ward, 1984) and the National Cholesterol Education Program (NCEP) (Cleeman, 1989~. Both programs were established under the direction of the NHLBI. Each consists of a coordinating committee composed of member organizations representing agencies within the federal government as well as major medical associations, voluntary health organizations, and various community programs. These commit- tees mobilize and coordinate the resources and energies of participat- ing organizations to achieve the goals of their respective programs. The success of both NHBPEP and NCEP demonstrates that such coordination is feasible, enabling more effective overall attainment of goals, while avoiding wasteful duplication even as each member or- ganization is encouraged to continue its individual efforts. A recent nutrition initiative based in part on the NHBPEP and NCEP models is Project LEAN (Low-Fat Eating for America Now). Sponsored by the Henry I. Kaiser Family Foundation (1988), its goals are to reduce the fat intake of the U.S. population to 30% of calories by 1998, to increase the availability and accessibility of low-fat foods, and to

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HEALTH-CARE PROFESSIONALS 179 increase collaboration among national and community organizations in achieving these goals. i ACTION 2: Encourage all health-care professionals to integrate nutrition information into their multiple counseling, treatment, skills training, and follow-up sessions with individual clients and patients. Health-care professionals should make the provision of nutrition nformation a prominent part of their hospital exit interviews and office visits with patients. In its recent report on health objectives for the nation, the U.S. Department of Health and Human Services (DHHS, 1990a) recommends that by the year 2000 at least 75% of primary care providers should routinely provide nutrition assessment and counseling to their patients or refer them to nutrition experts. Hospital rounds could also be used to educate both health-care professionals and pa- tients about pertinent nutritional matters. Another means to implement this action is to establish standards for evaluation of nutritional status and instruction in clinical practice, particularly for such critical activities as pregnancy monitoring, child health visits, preemployment and school examinations, and clinical encounters with postoperative patients and elderly people. It is important to note that this action cannot be implemented until third-party payers provide adequate reimbursement for nutrition coun- seling to compensate those whose skills and time would be required. Third-party payers must recognize the potential savings in medical- care expenditures that can accrue if nutrition information conveyed by health-care professionals reduces the prevalence of chronic dis- ease in the United States. ACTION 3: Provide leadership, resources, and personnel for the dissemination of sound nutritional advice. Appropriate health-care professional societies should prepare and disseminate valid information to the media and serve as a permanent, readily available source for those seeking authoritative information and guidance on nutrition. In local communities, there are many opportunities for health-care professionals to carry out this function as individuals, through their professional societies, and through local affiliates of voluntary organizations. For example, they can take leader- ship roles in community organizing around nutrition issues; aid in the creation of a nutrition coalition or consortium that develops and coordinates local nutrition programs; and use newspapers, radio, and television to provide information and articulate their positions, thereby influencing consumer knowledge and behavior. (See Chapter 3 for a discussion of the media.)

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180 IMPROVING AMERICA'S DIET AND HEALTH ACTION 4: Working as individuals or through professional societies, provide guidance to regulatory and legislative bodies concerned with the establishment of dietary standards and with rules and policies governing the production, harvesting, process- ing, preservation, distribution, and marketing offood products. Federal, state, and local legislators need to be better informed about nutrition and food issues. As members of national organizations and local communities, health-care professionals should offer guidance to policymakers on these subjects. For example, they might provide forums on food and nutrition issues for elected officials and link them with relevant activities or proposed initiatives in their local communities. The FNB, whose board and committees are composed primarily of health-care professionals, would continue to provide expert advice when called upon. ACTION 5: Specialists in human nutrition and food science, working through their professional organizations, should distribute practical information such as menus, recipes, and ideas for health promotion initiatives to private and public providers of meals. To implement this action, nutrition and food specialists should begin with their own hospital food services and branch out to school cafeterias, faculty clubs, commercial restaurants, nursing and conva- lescence homes, corporate dining rooms, and other appropriate settings. By providing this kind of practical information, health-care professionals may motivate meal providers to improve the variety of their menu offerings by including more nutritionally desirable foods and constructing meals that adhere to the principles of dietary recommendations. ACTION 6: Serve as role models by following dietary recom- mendations (and practicing ether healthy hchaviors) as often as possible. Health-care professionals should recognize that when they person- ally follow dietary recommendations, they are very likely to improve their own health and longevity, serve as role models for those who seek their professional guidance, and develop competence in the same self-management skills they must teach their patients. Therefore, the principles of dietary recommendations should be followed, for example, in the preparation of meals and snacks served at all meetings of health- care professionals, at client luncheons and dinners, at receptions, and in hospital cafeterias. One organization implementing this action is the American Public Health Association (APHA), which uses the Di- etary Guidelines for Americans (USDA/DHHS, 1985) as a guide for planning meals and snacks at its meetings (APHA, 1987~. ,7

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HEALTH-CARE PROFESSIONALS STRATEGY 3: Intensify research on the relationships between food, nutrition, and health and on the means to use this knowledge to promote the consumption of healthful diets. ACTION 1: Encourage sponsors of research to give high priority to research into diet and disease relationships and to developing innovative ways to use that knowledge in educating health-care professionals and the public about nutrition. In the public sector, intramural and extramural nutrition-oriented investigations should be stimulated through legislative, regulatory, and administrative channels. In the private sector, foundations, charities, and the food industry should be encouraged to participate in the underwriting of nutrition research. Unfortunately, although several public and private agencies and foundations fund nutrition research, few grants are primarily concerned with the dietary components of disease or in the educational and regulatory strategies to implement knowledge of diet and disease relationships. Nlarious food industry associations (e.g., the National Dairy Council, the American Meat Institute, and the Egg Nutrition Center) already fund nutrition research. There is a lack of industrywide collabora- tion in this direction, however, which may preclude the giving of needed attention to research areas that are not of interest to the individual 181 grantors. Moreover, the credibility of research that is supported by industry groups may be questioned by many academicians and the public. Furthermore, the amount of morrey directed to research not oriented to specific products is very modest. Food and beverage companies are encouraged to collaborate to provide generous levels of untargeted funding. For example, if the food industry were to contribute substantially to a central, privately managed nutritional science fund, the research would be seen as more credible, and both industry and the public would benefit. REFERENCES ADA (American Dietetic Association). 1990. NCND thanks and welcomes corporate donors. ADA Courier 29(7):1. Altman, L.K. November 28, 1989. How medical detectives identified the culprit be- hind a rare disorder. New York Times. C3. APHA (American Public Health Association). 1987. APHA meal function guidelines for health conscious caterers. Photocopy. 1 p. Boker, J.R., R.L. Weinsier, C.M. Brooks, and A.K. Olson. 1990. Components of effec- tive clinical-nutrition training: a national survey of graduate medical education (residency) programs. Am. J. Clin. Nutr. 52:568-571.

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182 IMPROVING AMERICA'S DIET AND HEALTH CDC (Centers for Disease Control). 1989. Eosinophilia-myalgia syndrome New Mexico. Morbid. Mortal. Weekly Rep. 38:765-767. Cleeman, J.I. 1989. The National Cholesterol Education Program. Clin. Lab. Med. 9:7- 15. Council on Food and Nutrition. 1963. Nutrition teaching in medical schools. J. Am. Med. Assoc. 6:191-193. DHHS (U.S. Department of Health and Human Services). 1988. The Surgeon General's Report on Nutrition and Health. DHHS (PHS) Publ. No. 88-50210. Public Health Service, U.S. Department of Health and Human Services. U.S. Government Print- ing Office, Washington, D.C. 727 pp. DHHS (U.S. Department of Health and Human Services). 1990a. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Conference edition. Public Health Service, U.S. Department of Health and Human Services. U.S. Gov- ernment Printing Office, Washington, D.C. 672 pp. DHHS (U.S. Department of Health and Human Services). 1990b. Prevention '89/'90: Federal Programs and Progress. Public Health Service, U.S. Department of Health and Human Services. U.S. Government Printing Office, Washington, D.C. 192 pp. Feldman, E.B., P.R. Borum, M. DiGirolamo, D.S. Feldman, J.M. Greene, S.B. Leonard, S.L. Morgan, J.F. Moinuddin, M.S. Read, and R.L. Weinsier. 1989. Creation of a regional medical-nutrition education network. Am. J. Clin. Nutr. 49:1-16. Health Learning Systems, Inc. 1989. Rx Nutrition: Good Health in Practice. Spon- sored by the University of Washington School of Medicine. Health Learning Systems, Inc., Little Falls, N.J. Henry J. Kaiser Family Foundation. 1988. Project LEAN: Low-Fat Eating for America Now. Kaiser Family Foundation Health Promotion Program, Henry J. Kaiser Family Foundation, Menlo Park, Calif. 9 pp. Kaufman, M. 1989. Nutrition services in state and local public health agencies, 1989: Preliminary report of biennial surrey of state activities, 1989. Pp. 5-22 in Empowering Nutritionists for Leadership in Public Health. University of North Carolina, Chapel Hill, N.C. Kushner, R.F., F.K. Thorp, J. Edwards, R.L. Weinsier, and C.M. Brooks. 1990. Imple- menting nutrition into the medical curriculum: a user's guide. Am. J. Clin. Nutr. 52:401-403. Lenfant, C. 1986. A new challenge for America: the National Cholesterol Education Program. Circulation 73:855-856. Nestle, M. 1988. Nutrition in medical education: new policies needed for the 1990s. Nutr. Educ. 20:S1-S6. NRC (National Research Council). 1985. Nutrition Education in U.S. Medical Schools. Report of the Committee on Nutrition in Medical Education, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 141 pp. NRC (National Research Council). 1989a. 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 NRC (National Research Council). 1989b. Recommended Dietary Allowances, 10th edition. Report of the Subcommittee on the Tenth Edition of the RDAs, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 284 pp. Roccella, E.J., and G.W. Ward. 1984. The National High Blood Pressure Education Program: a description of its utility as a generic program model. Health Educ. Q. 11:225-242.

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HEALTH-CARE PROFESSIONALS 183 Tope, N.F. 1990. The role of Extension in helping Americans improve the nutritional quality of their diets. J. Food Qual. 13:55-58. USDA/DHHS (U.S. Department of Agriculture/U.S. Department of Health and Hu- man Services). 1985. Nutrition and Your Health: Dietary Guidelines for Ameri- cans, 2nd ed. Home and Garden Bulletin No. 228. U.S. Government Printing Office, Washington, D.C. 24 pp. University of Washington. 1989. School of Nursing Undergraduate Curriculum Book. University of Washington, Seattle, Wash. Weinsier, R.L., J.R. Boker, C.M. Brooks, R.F. Kushner, W.J. Visek, D.A. Mark, A. Lopez- S., M.S. Anderson, and K. Block. 1989. Priorities for nutrition content in a medical school curriculum: a national consensus of medical educators. Am. J. Clin. Nutr. 50:707-712. Winick, M. 1988. The nutritionally illiterate physician. J. Nutr. Educ. 20:S12-S13. Winick, M. 1989. Report on nutrition education in United States medical schools. Bull. N.Y. Acad. Med. 65:910-914. Young, E.A. 1988. Nutrition education of medical students: problems and opportuni- ties. J. Nutr. Educ. 20:S17-S19.