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2 Introduction THE CENTRAL CHARGE to the Committee on Dietary Guidelines Implementation of the Food and Nutrition Board (FNB) was to determine how to implement most effectively the consensus that has emerged regarding the dietary advice that will best promote the public's health. For almost a century, dietary guidelines for the U.S. population have been promulgated by the federal government and other bodies (Haughton et al., 1987; U.S. Congress, Senate, 1909~. Because the maintenance of human health requires the ingestion of nutrients found in food, much of the early dietary advice focused on urging people to eat the kinds and amounts of foods needed to avoid nutrient defi- ciency diseases. Little attention was given to developing dietary guidance intended to reduce the risk of chronic degenerative disease because there was, until recently, little supporting evidence-other than that linking excess energy intake to obesity to support such guidelines. Over the past 25 years, however, substantial advances have been made in understanding the relationships among dietary patterns, food and nutrient intakes, and the etiology and pathogenesis of many chronic degenerative diseases. The roles of diet in health promotion and risk reduction and in the prevention and control of specific diet-related diseases have now been characterized. Beginning in the early 1960s, various sets of dietary guidelines intended to help the population reduce its risk of certain chronic degenerative diseases began to be widely disseminated. These are described and compared in the FNB's 18

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INTRODUCTION 19 report, Diet and Health: Implications for Reducing Chronic Disease Risk (NRC, 1989c) (hereinafter referred to as the Diet and Health report). The federal government in particular has issued several important sets of dietary guidelines since the late 1970s. Congress, the legisla- tive branch of government, held hearings on dietary patterns and health in the late 1960s and early 1970s that led to the promulgation of Dietary Goals for the United States (U.S. Congress, Senate, 1977a,b), suggesting an eating pattern very similar to that later recommended in the Diet and Health report. The impetus then passed to the execu- tive branch of government. In 1979, for example, the Surgeon General of the United States published Healthy People: the Surgeon General's Report on Health Promotion and Disease Prevention (DHEW, 1979), a landmark document wherein the federal government explicitly recognized the importance of nutrition as a major influence on the nation's health. The following year, this recognition was expanded by the inclusion of 17 specific nutrition objectives in the report Promoting Health/Pre- venting Disease: Objectives for the Nation (DHHS, 1980~. Interest in nutrition as a major component of disease prevention and health maintenance was further emphasized with the publication in 1980 of Nutrition and Your Health: Dietary Guidelinesfor Americans (USDA/DHHS, 1980) a joint project of the U.S. Departments of Agriculture (USDA) and Health and Human Services (DHHS) that became the basis for federal nutrition policies. Until recently, efforts to act on new understandings about diet and health were focused primarily on achieving consensus among scientists on the appropriateness of certain dietary guidelines and on publiciz ing various, somewhat different sets of guidelines. -~ ~~ ~ These efforts cul- minated in the issuance of The Surgeon General's Report on Nutrition and Health in 1988 (DHHS, 1988) and the FNB's Diet and Health report in 1989 (NRC, 1989c). Together, these authoritative reviews of the evidence relating dietary factors to health and disease make it clear that there is now wide-scale consensus in the United States and in the international nutrition community on the overall nature of the dietary modifications needed to reduce the risk of diet-related chronic diseases. Indeed, there is a striking level of agreement at this time among dietary guidelines in the United States and those in other industrialized countries around the world (NRC, 1989c). In this report, the committee promotes the recommendations of the Diet and Health report because they are well suited for implemen- tation. These comprehensive recommendations will be reviewed regularly and revised as needed to incorporate new findings. In addition, they specify quantitative targets (e.g., limit fat intake to 30% or less of calories) and are presented in a priority order that reflects their likely

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20 IMPROVING AMERICA'S DIET AND HEALTH impact on public health. These qualities facilitate their interpretation and translation into specific strategies and actions for implementa- tion and facilitate evaluations of the success of these initiatives. This committee believes that dietary guidelines used as the basis for nutrition policy in the United States should be as quantitative as possible. Therefore, the federal government's progress, albeit slow, in quantifying its dietary guidelines is to be applauded. Examples of quantitation include the following: The report Healthy People 2000: National Health Promotion and Disease Prevention Objectives issued by DHHS (1990) recommends that average total fat intake among people age 2 and older be no more than 30% of calories and that saturated fat intake not exceed 10% of calories. It also advises the daily consumption of five or more servings of vegetables, fruits, and legumes and six or more servings of grain products. The population panel of the National Cholesterol Education Program (NCEP, 1990) recommends that "healthy Americans" beginning at age 2 consume less than 10% of total calories from saturated fatty acids, an average of 30/O or less of calories from total fat, and less than 300 mg of cholesterol per day. The text of the recently issued 3rd edition of the USDA/DHHS booklet, Nutrition and Your Health: Dietary Guidelines for Americans, recommends that total fat intake in the diets of adults not exceed 30% of calories and that saturated fat intake be less than 10% of calories (USDA/DHHS, 1990~. The report notes that this recommendation does not apply to children below age 2. The report also recommends that adults eat daily at least three servings of vegetables, two servings of fruits, and six servings of grain products, and that pregnant women or women trying to conceive axroid alcoholic beverages. The USDA food guide, "A Pattern for Daily Food Choices," sug- gests 6-11 servings per day of breads, cereals, and other grain products; 2-4 servings of fruits; and 3-5 servings of vegetables (including dry peas and beans) (USDA, 1989~. The committee's strategies and actions for implementation are qualitative and therefore apply equally well to the recommendations in the Diet and Health report, The Surgeon General's Report on Nutrition and Health (DHHS, 1988), and Dietary Guidelinesfor Americans (USDA/ DHHS, 1990) (see Appendix A for all three sets of recommendations). Thus, the term dietary recommendations is used throughout this report to refer as a group to these three sets of guidelines. The committee's recommended implementation strategies and actions also apply to most or all of the disease-specific dietary guidelines issued by expert

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INTRODUCTION 21 groups (e.g., by the American Heart Association and the National Cancer Institute), because they are similar to those of the FNB, the Surgeon General, and USDA/DHHS. However, the committee be- lieves that the United States should move toward adopting a single set of dietary recommendations to communicate and promote. One set of recommendations should reduce confusion and provide implementors with a common focus for their activities. PLACING DIETARY RECOMMENDATIONS IN PERSPECTIVE Although this report focuses on improving dietary patterns, the committee emphasizes that diet is only one important determinant of health and well-being. Various personal behaviors (e.g., refraining from smoking and abuse of drugs, engaging in regular exercise, and taking care to avoid accidents) and other factors (e.g., family history of disease, access to health-care services, and the state of the environ- ment) are also strongly linked to risks of disease and should not be neglected in health promotion programs by an overemphasis on diet. Healthful dietary patterns and life-styles will improve the health of many people but will not guarantee good health or long life for any person. The committee hopes that implementation initiatives undertaken in response to the recommendations in this report will be linked with other health-promoting practices whenever possible. A long-term commitment to implementation by promoting incremental changes is more likely to be successful than are drastic, one-shot efforts. Be- cause the food system and public responses to new dietary patterns change slowly, a realistic time frame for implementation will be mea- sured in years rather than months. FROM GUIDANCE TO IMPLEMENTATION Consensus on dietary guidance is an important advance; however, guidelines cannot be effective until a coordinated effort is made to teach consumers how to interpret and apply them and to assist people in overcoming the difficulties in trying to change their eating behav- iors. But the many questions about what should be done, and by whom, and where the effort should be focused have not yet been addressed systematically. This lack is partly a consequence of a com- mon, though incorrect, assumption that once there is widespread awareness of dietary guidelines, most people will adopt and imple- ment them on their own. In this report, the committee addresses

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22 IMPROVING AMERICA'S DIET AND HEALTH these and other questions and presents the components of a compre- hensive plan to implement dietary recommendations. Although most people in the United States do not choose diets that conform to all the dietary recommendations, some people have changed their diets in recent years for what they report to be health reasons (FMI, 1990~. The changes in public attitude and food con- sumption reported in Chapter 3 are often attributed to public aware- ness of various sets of dietary guidelines, but it is clear this is not the entire explanation. Although smoking, as an addictive habit, is very different from eating, the long and continuing effort to reduce cigarette smoking may offer some useful analogies to the task of changing eating habits. The antismoking effort has involved alterations in the physical envi- ronment (by restricting areas in which smoking can occur); positive examples of nonsmoking by highly visible individuals (e.g., physicians and politicians); promotion of tobacco avoidance in public and private education; and assistance to smokers who want to quit. The public and private sectors have devoted effort and money to the cause. Of equal importance, however, may have been the common purpose shown at most levels of government (with continued tobacco subsidies a notable exception) and the vast effort expended by health-oriented voluntary groups such as the American Cancer Society, the American Heart Association, the American Lung Association, and Action on Smoking and Health. Even greater commitments of money, time, political will, and other resources will likely be needed to improve the nation's eating patterns. IMPLEMENTATION AND THE POOR This report is directed to the majority of the U.S. population, which enjoys secure access to food. There is another segment of the population, however, that has tragically little food security and has uncertain or inconsistent access to a wholesome, nutritious food supply. This group includes people who are poor or homeless and people who are disadvantaged and dependent because of disease or other reasons (Mayer, 1990; Stoto et al., 1990~. Their diets may not supply adequate calories and may be low in vitamins and minerals but high in total fat, saturated fat, cholesterol, and sodium. Alcohol abuse may also affect some people in this group. The nutritional status of the poor and disadvantaged can be further compounded by inadequately met medical, housing, sanitation, education, and other basic needs. Minority and disadvantaged groups lag behind the U.S. popula- tion on health status indicators (DHHS, 1990~. For example, black

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INTRODUCTION 23 Americans, compared with the general population, have higher rates of high blood pressure, stroke, diabetes, and diseases associated with obesity (DHHS, 1988~. Native Americans and Hispanics suffer greater disease and mortality burdens than whites (DHHS, 1985~. Surveys indicate that people with the most education and other resources have made and benefited from dietary changes, whereas the poor and less educated have not (Heimbach, 1985~. To lessen the burden of chronic disease and premature death for all its citizens, the nation will need to do more than implement recommendations on diet.) It also needs to be more accommodating to the diverse cultures of its people and focus its health promotion and outreach efforts on segments of the population that are least likely to eat well or practice other healthful behaviors. BARRIERS AND INCENTIVES TO DIETARY CHANGE Attempts to change dietary behavior are confronted with a par- ticular set of problems. First, eating is often social and fun. Thus, many of the food choices that health-care professionals tend to view as undesirable are seen by the public as sources of pleasure. The committee does not wish to have people focus on health alone in deciding what to eat but, rather, to encourage them to modify their eating behaviors in ways that are both healthful and perceived as pleasurable. This is a challenging task. Promotion of dietary change among healthy people may be an especially formidable problem for another reason: modifying eating behaviors, unlike quitting smoking, for example, usually produces few immediate physical or psychological benefits. Moreover, as Carmody and colleagues pointed out, people are being asked to move away {~ YArh - l ,/1ATOO O~ in ohm - mr~1 Aimi v I 11 tell L vv 1 LCI ~ vv "O "1 Led 1~ to Lo 1 two 11 L"1 ~ ~ ~ ~ . . . for the U.S. population rather than to abandon a recognizably pathogenic behavior (Carmody et al., 1986, p. 21~. Events that draw the public's attention to competing risks can be another barrier to dietary change. For example, at the time of release of the Diet and Health report, with its recommendations to consume fruits, vegetables, and poultry, the National Resources Defense Council warned that children were excessively exposed to agricultural chemicals, especially to Alar on apples (NRDC, 1989~. Two weeks later, all fruit imported from Chile was temporarily barred from sale while the U.S. government sought to learn whether the cyanide discovered in two seedless grapes was widely dispersed among fruit distributed throughout the United States (Food Chemical News, 1989a). At about the same time, 400,000 chickens were destroyed in Arkansas because they were found to be contaminated with heptachlor, a cancer-causing pesticide

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24 IMPROVING AMERICA'S DIET AND HEALTH that had been barred from agricultural use 11 years earlier (Food Chemical News, 1989b; Schneider, 1989~. Many health-care professionals see such alarms as a diversion of the public's attention away from more serious food-related issues. They argue that the hazard, if any, from chemical residues is much smaller than the known hazard of excessive fat consumption (NRC, 1989c). However, the evidence shows that the public is generally more concerned about a risk it cannot personally control (like pesti- cide residues) than one it can (like eating less fat) (NRC, 1989d). If health-care professionals want people to accept and follow their advice regarding health-promoting behaviors, they cannot afford to discount- or to view as distractions the risks that most concern the public at any given moment. Given the right incentives, people can surmount barriers to imple- menting dietary recommendations. For the individual, incentives to eat well include the likelihood that healthy dietary patterns especially when combined with other behaviors- will enhance health and reduce the risk of many diseases. Furthermore, there are increasing opportunities today for consumers to select and prepare health-promoting and appealing meals that fit into their ways of life.2 For the private sector, there are financial incentives to address the public's interest in better nutrition by developing more appealing food products with reduced levels of fat, sodium, and sugar. Because dietary improvements can be expected to improve the nation's health, governments and health-care professionals have a powerful reason to serve as role models and agenda setters for efforts to encourage more healthful food consumption practices and to coordinate, study, and monitor implementation efforts. These and other incentives to implement dietary recommendations are dis- cussed in later chapters. THE TASK OF IMPLEMENTATION: GOALS, TACTICS, AND POLICIES Implementation begins with getting information about dietary rec- ommendations to consumers in languages and formats that are relevant and comprehensible to them, given their diversities. The information provided must identify the components of a healthful diet and link such a diet to a life relatively freer of disease and disability. The next and more difficult step is helping people to alter their food consumption practices in more healthful directions. This involves both individual and public responsibility. Society should not ignore the needs of people who have decided to move toward more health- ful food consumption practices but find it difficult to do so. All

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INTRODUCTION 25 sectors of society-including industry, government, and health-care professionals have a responsibility to help individuals make and implement choices that result in the consumption of nutritionally desirable foods. To encourage better eating, health-promoting food choices must be accessible, easy to identify and prepare, economical, enjoyable, and adaptable to various life-styles. The committee's strategies and actions for implementation are designed to make it easier for people to eat healthful diets without sacrificing convenience or de- sired life-styles. Implementation efforts must also take into account the so-called hidden choices that consumers rarely recognize and over which they have little or no control. These choices, which are made by others for consumers, include, for example, the ingredients used by restaurants (e.g., the types of fats and oils in which foods are cooked). Society has an obligation to ensure that such hidden choices are, whenever possible, made in a way that fosters healthful eating. The goal of implementation efforts is to help people whose diets are less than ideal to reduce their intake of certain food components and increase their intake of others, i.e., to increase the prevalence of eating patterns that conform to dietary recommendations. This goal will be met in the following ways: enhancing awareness, understanding, and acceptance of dietary recommendations; creating legislative, regulatory, commercial, and educational en- vironments supportive of the recommendations; and improving the availability of foods and meals that facilitate implementation of the recommendations. The general tactics for increasing the prevalence of healthful eating patterns can be divided into three classes: 1. Altering the food supply by subtraction (e.g., reducing the fat in meat and cheese), addition (e.g., appropriate fortification of foods with nutrients), and substitution (e.g., replacing some of the fat in margarine with water). 2. Altering the food acquisition environment by providing more food choices that help consumers meet dietary recommendations, better in- formation (e.g., more complete and interpretable product labeling), advice at points of purchase (e.g., tags indicating a good nutrition buy in supermarkets or cafeterias), and more options for selecting health- ful diets (e.g. better food choices in vending machines and restaurants). 3. Altering nutrition education by changing the message mix (e.g., presenting consistent messages in education programs, advertisements

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26 IMPROVING AMERICA'S DIET AND HEALTH for products, and public service announcements) and by broadening exposure to formal and nonformal nutrition education (e.g., mandating education on dietary recommendations from kindergarten through grade 12, in health-care facilities, and in medical schools). Although common sense suggests that desirable dietary changes will most likely occur when all these components are made to be mutually reinforcing, there is insufficient research on their individual effectiveness or how they can best be assembled into a package. The attitudes and skills involved in carrying out these various kinds of interventions belong to different academic, institutional, sectoral, and societal domains; no substantial effort has been made until now to ask which combination of approaches offers the best promise of suc- cess in bringing about dietary change on a national level. In Chapter 3, the committee examines the evidence from community-based stud- ies to learn which components of integrated programs of dietary change are associated with success. THE TASK AND THE IMPLEMENTORS In approaching the task of proposing strategies and actions for the nationwide implementation of dietary recommendations in the United States, the committee has taken a somewhat unconventional route. Rather than providing a simple list of all the steps that might be taken to modify diets, it has developed a list of interventions that seem most likely to work given the need to protect free choice and to operate within resource limits. The committee has done this be- cause it believes that consideration of implementation measures without regard to strongly held values and existing resource constraints is of little practical value. At the same time, it recognizes that conclusions regarding both values and resource constraints are subjective. The committee began its work by imagining a wide range of strategies for modifying eating behavior. To the extent possible, each of these was examined in terms of such criteria as history of effectiveness, affordability, political feasibility, public acceptability, and legal and ethical considerations. Together, these criteria served as the basis for selecting implementation strategies and actions that in the committee's judgment are likely to be successful. Much of the committee's work was done by four task forces, each focusing on specific societal sectors: public, private, health-care pro- fessions, and public education. These groupings were an effective mechanism for identifying the main interventions that have been at- tempted to date and for recommending those that might be under- taken in the future. The recommendations of these task forces are presented in Chapters 5 through 8.

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INTRODUCTION 1 1 / ~1- 1- ~ 27 It is clear that the four sectors have overlapping responsibilities. For example, all sectors use the media to inform and educate and to influence the public's diet-related behaviors. Governments make policies related to meat grading, to labeling, and to the kinds of foods offered in the school lunch and other food programs, thereby affecting the food supply, the shopping environment (private sector), and the educational environment. Mandates for nutrition education in the nation's classrooms from Congress or state legislatures obviously have the potential for changing the demands on health-care professionals as well. There is a critical need for substantial government involvement and support in any comprehensive attempt to implement dietary rec- ommendations. A key responsibility of governments is to serve as a role model and agenda setter. Public officials must ensure that all branches of government at all levels (federal, state, and local) work toward implementation of dietary recommendations by these steps: (1) initiate or expand practices that conform to dietary recommenda- tions in dining facilities in government buildings; (2) reconcile legis- lation, regulations, policies, and practices so that they foster the effort; (3) use government's convening, educational, and technical assistance functions to urge private and voluntary groups to improve food se- lection and consumption patterns; and (4) capitalize on government's role in setting the diet and health agenda and its leadership in rally- ing and coordinating support. Actions taken by the private sector are also cross-cutting. The producers, processors, and purveyors of food affect the food supply in many ways. For example, processors and marketers influence the food acquisition and educational environments through the information they provide on their packages and in their advertising messages and by the development and introduction of new food items that vary in their nutritional desirability. (An average of 34 new varieties of food and beverage products were introduced each day in the United States in 1989 iShapiro, 19903.) Producer and processor groups directly influence classroom education through the creation and distribution of educational materials designed for use in schools. It is less appar- ent how much educators can affect the food supply or food acquisition environment, although they could hope to alter consumer demand and thus affect the actions of both the food industry and govern- ments. These interrelationships speak to the need for collaboration and joint planning of implementation efforts. All implementation efforts are constrained by the reality that no government or private or voluntary organization has the power to command the public to adopt a more healthful diet. Thus, the com- mittee has also examined the issue of free choice as it relates to mak

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28 IMPROVING AMERICA'S DIET AND HEALTH ing informed food product choices while the number of choices con- tinues to increase (see Chapter 8~. Governments, industry, and vol- untary health organizations lack financial resources, the ability to coordinate activities among them, and adequate staff and expertise to give technical assistance. At present, implementation is further constrained by insufficient knowledge-not so much of detailed rela- tionships between diet and disease as of the environment in which change is being implemented. Too little is known about people's nutritional health because of the lack of comprehensive nutritional surveillance, and too little is known about the composition of the food supply and how that changes because of inadequate monitoring of these variables. Throughout its deliberations, the committee con- tinually reminded itself of both resource and knowledge limitations and of the inevitable constraints on government effectiveness. Chapter 9 contains the committee's directions for research. These are aimed at generating the knowledge that will improve the ability to design successful implementation strategies and actions. BENEFITS AND COSTS OF DIETARY CHANGE Public health programs are continually starved for resources. Thus, it is important that the resources available be used efficiently and that cost-effective projects, i.e., those that accomplish the goals at the lowest cost, receive first priority. Devoting resources to implementing dietary recommendations is a public health project that must compete with other public health projects for resources. How much should be spent on media campaigns, im- proved labeling, or developing a manual to advise consumers on how to meet dietary recommendations? A careful assessment of the benefits and costs of each action and of the distribution of these ben- efits and costs is needed to make informed decisions about the allocation of resources. Full implementation of dietary recommendations promises consid- erable benefits in improved health and well-being and fewer costs for work absence and disability. Unfortunately, implemention of dietary recommendations will sometimes be difficult and costly. The costs in- clude (1) the monetary costs of establishing and maintaining the programs and structures that educate consumers about dietary recommenda- tions and how to implement them; (2) the costs incurred by the pri- vate sector in changing production, manufacturing, and processing practices to emphasize foods that help people to meet dietary recom- mendations; and (3) the psychological costs that some people will

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INTRODUCTION 29 bear by taking up a new diet that is perceived to be less satisfying and more troublesome to buy and prepare at least in the short run. Because implementation of almost any of the recommendations in this report will have effects that go well beyond nutritional ones, it is important that hidden costs and benefits be identified beforehand, to the extent possible. For example, committee recommendations to modify the formulation of certain foods might raise the price of these products, at least in the short term a hidden cost. Given the time and resource constraints for this study, the benefits and costs of the proposed actions could not be estimated with confi- dence. The primary difficulty is the lack of quantification of the effects of past programs to modify dietary practices or observe the health effects of dietary modifications. The committee recommends strongly that the plan for every action undertaken to modify dietary habits include adequate evaluation, which will require adequate re- sources. Such evaluations would indicate which programs should be expanded, which ones should be modified (and when the modifica- tion is successful), and which ones should be discontinued as unsuc- cessful. NOTES Several reports from the National Research Council and Institute of Medicine address the medical, social, and public welfare needs of the poor in the United States. These reports include: Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing (NRC, 1987), Prenatal Care: Reaching Mothers, Reaching Infants (IOM, 1988b), Homelessness, Health, and Human Needs (IOM, 1988a), Who Cares for America's Children? (NRC, 1990), A Common Destiny: Blacks and American Society (NRC, 1989b), AIDS, Sexual Behavior, and Intravenous Drug Use (NRC, 1989a), Confronting AIDS: Update 1988 (IOM, 1989), Broadening the Base of Treatmentfor Alcohol Problems (IOM, 1990), and Alcohol in America: Taking Action to Prevent Abuse (NRC, 1985). A recent report by the Life Sciences Research Office addresses nutrition problems among disadvantaged, difficult-to-sample populations (LSRO, 1990). 2. Health-care professionals are in general agreement that all foods that contribute to healthful diets are, by definition, health promoting and that any food that supplies energy and nutrients can be nutritionally desirable. There is also gen- eral agreement that dietary recommendations should not prohibit the consumption of any food product and that the nutritional composition of the total diet is of more importance than is that of a single food or meal. However, for practical purposes, the committee uses the terms health promoting and nutritionally desirable to describe foods whose consumption is encouraged to meet dietary recommendations. Examples include fruits, vegetables, and breads. In addition, the committee describes a healthful diet as one that meets dietary recommendations most of the time (and is thereby composed largely of health-promoting foods) and that meets nutrient needs.

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30 IMPROVING AMERICA'S DIET AND HEALTH REFERENCES Carmody, T.P., J. Istvan, J.D. Matarazzo, S.L. Connor, and W.E. Connor. 1986. Appli- cations of social learning theory in the promotion of heart-healthy diets: the Family Heart Study dietary intervention model. Health Educ. Res. 1:13-27. DHEW (U.S. Department of Health, Education, and Welfare). 1979. Healthy People: the Surgeon General's Report on Health Promotion and Disease Prevention. DHEW (PHS) Publ. No. 79-55071. Office of the Assistant Secretary for Health and Surgeon General, Public Health Service, U.S. Department of Health, Education, and Welfare. U.S. Government Printing Office, Washington, D.C. 177 pp. DHHS (U.S. Department of Health and Human Services). 1980. Promoting Health/ Preventing Disease: Objectives for the Nation. Public Health Service, U.S. Department of Health and Human Services. U.S. Government Printing Office, Washington, D.C. 102 pp. DHHS (U.S. Department of Health and Human Services). 1985. Report of the Secretary's Task Force on Black & Minority Health. Volume II: Crosscutting Issues in Minority Health. U.S. Department of Health and Human Services, Washington, D.C. 549 PP DHHS (U.S. Department of Health and Human Services). 1988. The Surgeon General's Report on Nutrition and Health. DHHS (PHS) Publ. No. 88-50210. Public Health Service, U.S. Department of Health and Human Services. U.S. Government Printing Office, Washington, D.C. 727 pp. DHHS (U.S. Department of Health and Human Services). 1990. 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. 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. 70 pp. Food Chemical News. 1989a. FDA announces Class II nationwide recall of Chilean fruit. Food Chem. News 31(6):36-38. Food Chemical News. 1989b. State to warn customers of heptachlor-contaminated feed. Food Chem. News 31(6):42. Haughton, B., J.D. Gussow, and J.M. Dodds. 1987. An historical study of the underly- ing assumptions for United States food guides from 1917 through the Basic Four Food Group Guide. J. Nutr. Educ. 19:169-176. Heimbach, J.T. 1985. Cardiovascular disease and diet: the public view. Public Health Rep. 100:5-12. IOM (Institute of Medicine). 1988a. Homelessness, Health, and Human Needs. Report of the Committee on Health Care for Homeless People. National Academy Press, Washington, D.C. 242 pp. IOM (Institute of Medicine). 1988b. Prenatal Care: Reaching Mothers, Reaching In- fants. Report of the Committee to Study Outreach for Prenatal Care, Division of Health Promotion and Disease Prevention. National Academy Press, Washington, D.C. 254 pp. IOM (Institute of Medicine). 1989. Confronting AIDS: Update 1988. Report of the Committee for the Oversight of AIDS Activities. National Academy Press, Wash- ington, D.C. 239 pp. IOM (Institute of Medicine). 1990. Broadening the Base of Treatment for Alcohol Problems: Report of a Study. Report of the Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Problems, Division of Men

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