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8
Education of the Public:
Strategies and Actions
for Implementation
S INCE EDUCATION about healthful dietary patterns can take place
in so many settings and under so many different circumstances,
the committee found it necessary to clearly identify the nature of the
task to be undertaken before proposing recommendations for inter-
vention. The recommendations developed in this chapter are di-
rected toward individuals and families; home, child-care, and school
meal providers; teachers and school administrators; educational and
professional organizations; and federal, state, and local agencies or
offices.
The analyses and recommendations in this chapter proceed from
an understanding that education includes much more than schooling.
This is neither a new insight nor a contested one. But left unstated, it
is sometimes forgotten. Educators divide the broad term education
intoformal, nonformal, and informal reflecting differences among the
settings in which learning is assumed to occur. Formal education refers
for the most part to schooling. The term nonformal education is usually applied
to organized teaching and learning events that occur individ-
ually or in classes, for example, in community centers, in hospitals or
clinics, and in maternal- and infant-care centers. Informal education
refers to the almost infinite variety of educational experiences any
society provides. Where food is concerned, these range from reading
a newspaper article about dietary fat and fiber or watching food
commercials on television to helping a parent cook dinner. The com
184
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EDUCATION OF THE PUBLIC
185
mittee interpreted its mandate to include activities in all these educa-
tional settings, even though as the above description indicates-
this meant that the range of specific educational activities that could
theoretically be considered was too large for detailed examination.
In light of the vastness of the domain to be surveyed, it was essen-
tial to specify the precise nature of the task to be undertaken. For
this sector more than for any of the other societal sectors discussed in
this report, the recommendations of the committee are constrained
by the environment created by actions of the public and private sec-
tors. The private sector and governments at various levels create and
regulate both the actual foods available to consumers and most of the
information about those foods that can be found in food stores, in
fast-service and other eating establishments, and in advertising. This
accounts for most of the information about food with which the average
citizen comes into regular contact. Since consumers need to learn
how to use available food and food information to enhance their
health, much of the content of the lessons educators at all levels and
in all settings must teach is delimited by an information environment
created by the private and public sectors.
Some educators believe that education can affect both the availability
of foods and the nature of the information available about them by
altering consumer demand. To some extent, this is true. If educators
had the resources to reach large groups of people, they could influence
what such groups would or would not purchase. It is also unques-
tionably true that manufacturers cannot continue to produce a prod-
uct that no one will buy in that sense, consumer demand is essential.
But manufacturers are also educators working, in Galbraith's term, to
"manage demand" (Galbraith, 1967), and through their advertising
they reach a much larger audience than that reached by professional
educators. One consequence of this unequal contest is that consumer
demand does not always lead manufacturers to produce the products
or information actually needed.
A good example of this can be seen in the evolution of the market
response to consumers' interest in the effects of diet on health. The
particular safety and health concerns that emerged in the 1960s and
1970s were translated by some people into a desire to buy what they
believed to be health-promoting foods, often at health food stores.
The food industry responded to this interest by bringing into the
market a succession of foods that were intended to be perceived as
healthy foods with designations such as 100% natural or organic. Since
neither the Food and Drug Administration (FDA) nor the Federal
Trade Commission (FTC) had established regulatory definitions of
the terms natural and organic (FTC, 1978), the consumer who attempted
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IMPROVING AMERICA'S DIET AND HEALTH
to identify health-promoting foods was confronted with food choices
ranging from natural instant bouillon, natural yogurt chips, and natural
batter-covered deep-fried onion rings to natural cigarettes (FTC, 1978;
see also Belasco, 1989~.
Consumers who later became convinced of the need to seek out or
avoid certain specific components of foods could find products labeled
and advertised as lite, cholesterol-free, low salt, or high fiber-designa-
tions that provided health guidance that was at best ambiguous and
at worst misleading. So although consumers may be taught to demand
certain kinds of foods and certain kinds of information about those
foods, the marketplace may not respond in a manner really useful to
those consumers, unless the regulatory apparatus helps it to do so.
Regulators who try to ensure that consumers are provided with
clear information that enables them to make better food choices, thus
making the food marketplace more educationally transparent, are con-
strained by limits on resources. Their task is also enormously complicat-
ed by the process of continual innovation that drives the market.
Some sense of the difficulty of the regulatory task can be derived
from a U.S. General Accounting Office (GAO) report entitled Food
Marketing: Frozen Pizza Cheese Representative of Broader Food Labeling
Issues (GAO, 1988~. This report sheds light on the complex relationship
between the food supply, the food acquisition environment, and the
role of the educator.
Frozen pizzas are regulated by both the U.S. Department of Agri-
culture (USDA) and the FDA- agencies that differ markedly in both
their philosophies and their labeling requirements. The USDA (which
regulates meat-topped frozen pizzas) has ruled that substitute ingre-
dients need to be labeled as such only "if the analog ingredient changes
the organoleptic characteristics [e.g., taste, odor, mouthfeel, color] of
the product" (GAO, 1988, p. 30~; i.e., only if the consumer detects a
difference does the label need to reveal what causes it. The USDA
guidelines thus permit a meat pizza to contain up to 90% cheese
analog (usually made of casein, partially hydrogenated vegetable oil,
salt, food starch, emulsifiers, stabilizers, and other additives) without
triggering any special labeling.
On the other hand, FDA (which regulates frozen pizzas without
meat topping) believes the public most needs information "where
consumers cannot tell if the ingredient in question is 'real' or substi-
tute" (GAO, 1988, p. 23~. FDA, therefore, requires that a nonmeat
pizza must contain all real cheese or indicate prominently on the label
that it contains cheese analog.
Not only are the labeling requirements divergent, they are not
even consistently enforced. When a GAO representative showed FDA
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EDUCATION OF THE PUBLIC
187
a box of vegetarian pizza that contained cheese analog without being
so labeled, the investigators were told by FDA that because of lim-
ited resources the agency could "focus only on labeling issues that
can affect health and on the most flagrant and obvious labeling decep-
tions" (GAO, 1988, p. 30~.
There is no agreement between the agencies involved or between
their respective consumer advocates regarding the nutritional equivalence
of real cheese and cheese analog. The example nevertheless dramatizes
the consumer's dilemma. A consumer who believes that a particular
cheese product is nutritionally superior and therefore wishes to select
it may see side by side in the frozen food case two boxes: a cheese
pizza prominently marked "Contains Cheese Analog," which might
be composed of 90% real cheese, and next to it a meat-containing
pizza or a vegetarian pizza that contained no such label- which could
contain from 90 to 100% cheese analog. The consumer could easily
purchase something she or he did not want.
The confusion of aims that this example suggests is, as the GAO
report indicates, representative. Another example is the terms lite or
light. FDA says that the nonmeat products it regulates must have
33% fewer calories than the regular version to be called light, while USDA
says that the calorie levels need to be only 25% lower for the animal
products it regulates (IOM, 1990~. At the retail level, there is no
consistent meaning for many food label descriptors such as light, lite,
lean, low fat, leaner, and lower fat.
Despite this lack of uniformity and the confusion it produces, labeling
has long been viewed by nutrition educators, consumer advocates,
and sometimes by regulatory agencies as one of the most effective
ways of helping consumers make informed choices. Because such a
large proportion of the food supply is processed and packaged, there
is no way for consumers to judge what they are buying except by
reading what packages reveal about their own contents.
The preceding examples show that the agencies involved in regulating
labeling do not at present agree even on the philosophy that ought to
inform their regulatory thinking; e.g., should consumers be alerted
when they are most or least likely to be misled by the organoleptic
properties of a food product? If labels were more consistent, would
consumers make more use of them? Which of the various pieces of
information contained on food labels do they use and how well can
they apply this information to such specific goals as reducing the fat
content of their diets? These questions and others have recently been
addressed to the extent possible (data are very limited) by another
committee of the Food and Nutrition Board (IOM, 1990~.
Information about specific food products can also be found in the
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IMPROVING AMERICA'S DIET AND HEALTH
mass media, largely in advertising. Television food advertising, es-
pecially that aimed at children, has intermittently aroused public concern
and governmental attention since hunger advocate Robert Choate first
testified in 1970 about the poor nutritional quality of breakfast cere-
als advertised to children (U.S. Congress, Senate, 1970~. It has not
been possible to devise a way to prove that food ads aimed at small
children lead to poor eating habits, or that banning such ads would
improve children's diets. Moreover, there is as yet no convincing
evidence that public service advertisements or countercommercials
for particularly nutritious foods can counteract the effects of advertising
for less nutritious, so-called fun foods, at least partly because so few
of these countercommercials have been aired (Smith et al., 1982~. There
is evidence, however, that antismoking countercommercials were
successful enough to help drive cigarette advertising off the air (Erickson
et al., 1990~. The successful use of media as part of larger social
marketing campaigns to encourage improved eating patterns is discussed
in Chapter 3.
One official attempt to convert television food advertisements into
carriers of nutritionally educational information was made in 1974 by
the FTC in a proposed Trade Regulation Rule that would have required
nutrition information in certain kinds of food ads (Tobin, 1974~. To-
gether with a companion initiative a proposal to restrict some kinds
of television advertising, including food advertising, aimed at children-
the Trade Regulation Rule on Food Advertising provoked intense
food industry opposition and subsequently a congressional refusal to
approve the agency's operating budget. The regulation was ultimately
abandoned (U.S. Congress, House, 1984~.
Such regulatory efforts having failed, health-relevant information
in food advertisements appears at the option of food manufacturers
and their advertising agencies. As noted earlier, increased consumer
interest in personal health has led to a considerable increase in health-
oriented advertising. Currently, such advertising is constrained only
by the requirement that it not purvey factually incorrect information,
but even factually correct information may be misleading or difficult
to interpret. For example, the claim that a vegetable oil-containing
product is cholesterol-free does not help consumers learn that all veg-
etable oils derive their calories from fat, that only some of the fat is
polyunsaturated, and that all are free of cholesterol. Almost inevita-
bly, advertising offers "a truth" rather than "the whole truth" (Manoff,
1986), meaning as the above examples illustrate that even truthful
information may mislead consumers by omitting other relevant in-
formation. While recently enacted food labeling legislation that gives
FDA clear authority to regulate health claims on food labels does not
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EDUCATION OF THE PUBLIC
189
directly apply to advertising (Food Chemical News, l990a,b), it will
undoubtedly influence how products carrying health claims on their
labels will be promoted.
How can educators help consumers learn to make appropriate food
choices in such a complicated and confusing information environment?
Time-constrained consumers may not wish to master the rules for
interpreting labels on the many thousands of processed foods in the
marketplace, even if the labels were made more consistent and com-
prehensive. But perhaps consumers do not need to understand that
many products. Each consumer, after all, buys only a minute portion
of the 50,000 items (GAO, 1988) now on the market. Admittedly,
consumers need to know only about the products they buy, but how
are individuals who are to be taught about certain products to be
identified? Individualized education is impractical. Thus, it is important
to find rules of thumb that members of various sectors of the public
can apply, without individual instruction, to any product they encounter
in the marketplace.
As illustrated by the cheese analog, extra lean beef, and other labeling
confusions, however, such rules of thumb are difficult to discover
because decisions made by the private and public sectors have increased
the complexity of the food supply and the food acquisition environment.
In an environment glutted with small bits of data that do not readily
coalesce into useful information, the only sorts of messages likely to
be heard and remembered are simple, immediately useful ones. Yet
how can simple truthful messages be devised that will enable consumers
to make sense of a complex food supply?
As a mental experiment, we might imagine a world in which a
single powerful individual could demand that nutritionists and con-
sumer advocates create a system to place all foods into one of three
categories: Go, Caution, and Stop (i.e., eat often; eat occasionally; and
eat seldom, if at all). These foods would be marked with green,
yellow, and red stickers. Consumers would be free to eat all red-
labeled foods, but if they did so, they would at least be knowingly
acting against the best advice of those trained to judge the nutritional
worth of the food supply. Educating consumers to choose wisely in
such a marketplace would be pleasantly simple, since it would be per-
ceived that all the difficult decisions had been made by the nutrition-
ists. (The decisions would have been difficult, of course, because
nutritionists would have had much debate over which color of sticker
to put on a food like potato chips.)
In June 1988, the American Heart Association (AMA) announced a
plan to help consumers select foods as part of a balanced diet limited
in fat, cholesterol, and salt (Graff, 1988~. The plan proposed, which
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IMPROVING AMERICA 'S DIET AND HEALTH
involved putting an AHA seal of approval on foods that met certain
"heart-healthy" criteria, was in some respects similar to the imagi-
nary marketplace envisioned above and it raised educationally rel-
evant questions: Will consumers be misled into thinking that only
AHA-approved foods are good and all others are bad? Will they
think they can eat unlimited quantities of foods with an AHA seal?
The program was never implemented, in part because of FDA and
USDA objections that it would mislead consumers to think that labeled
foods in a product category (such as fats and oils) were "good" and
therefore could be consumed in unlimited quantities; similarly, unlabeled
foods might be considered "bad" and thus avoided (Goldsmith, 19891.
These objections illustrate some of the problems that an apparently
simple solution to the consumer's dilemma can create.
Before considering other possible solutions to the need for simple
messages in a complex marketplace, it is important to address at
least one concern that the idea of very simple food labeling schemes
might arouse in some readers the issue of maintaining free choice.
The necessity for free consumer choice is often emphasized by those
who conceptualize education as a process of simply giving information.
They argue that educators should not try to change behavior but,
rather, should simply provide information that can be used by consumers
in making their own food choices. As noted in Chapter 3, however,
information alone is unlikely to be effective in changing dietary pat
terns.
Free choice is usually associated with the consumer's right to select
from the largest variety of food products the market can supply. For
example, the private sector has responded to the consumers' interest
in health by adding new, healthier-seeming products to the market-
not by withdrawing products that are attractive but less health-promoting.
This presumably increases consumers' free choice.
In a democracy, however, free choice usually implies informed
choice, and informedness and variety are to a large extent inversely
related. The more products there are to choose from, the less time
consumers have to learn about any one of them (e.g., choosing wisely
from among 60 different yogurts is undeniably more difficult and
time consuming than choosing wisely from among five different ones).
Thus, the greater the number of choices, the more dependent the
consumer becomes on either grasping at some single piece of information
(e.g., avoid sugar, seek calcium) or trusting someone (e.g., the manu-
facturer, the advertiser, the newspaper food editor, the physician, the
FDA, or the AHA) to provide a simple instruction to buy or reject a
particular product.
In the imaginary marketplace described earlier, information avail
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EDUCATION OF THE PUBLIC
191
able about products could include as many detailed facts, for ex-
ample, about ingredients, nutrient composition, and manufacturing
processes that any manufacturer wished to provide. The red, green,
and yellow labels would simply signal to informed consumers that
someone who cared about their health had judged this product a
good or bad component of their diets. Thus, free choice would not
be constrained.
Although most educators would probably be uncomfortable with
a solution that asked so little of the consumer, knowledgeable teach-
ers recognize that in all educational situations information is inevitably
constrained. In educating about food, for example, it is not possible
to give consumers information about approximately 50 nutrients (as
well as the many nonnutritive substances that may affect their health)
in each of the thousands of items in the food supply and to provide
this information in a context that will enable individuals to relate
their food choices to their health.
Yet a decision to give consumers some kinds of information and
not others inevitably gives value to the information provided. Omission
of information on the amount of added sugars or saturated fats in a
product, for example, implies that these facts are less important in
making food decisions than are the facts presented on the label (e.g.,
that the food contains no cholesterol). On the other hand, displaying
the information that a given product contains 100% or some lesser
percentage of the U.S. Recommended Daily Allowances (USRDA) for
several nutrients may imply that nutrients not listed are less important
or that the product so fortified is highly nutritious. All nutrition
educators, whether they are professors or marketers, must always
choose which information to include in teaching about diet and health.
Some selection of content must occur in all nutrition education, and in that
selection process the educator inevitably expresses his or her assumptions
implicit or explicit- about which pieces of information will be important and
useful to the learner. "Educating" is thus not possible if what is meant by
that word is giving all the facts and nothing but the facts. Such dispassionate
and unselective fact giving may appear theoretically desirable from the point
of view of the discipline of education, but it simply does not exist in practice
(Gussow and Contento, 1984, p. 18~.
Consequently, the major unresolved question about how to teach
consumers to implement dietary recommendations may not be whether
consumer choice can be protected, since that is always limited in
some way, but whether the particular simplifications required to teach
this information can be made acceptable to all those who must coop-
erate in the enterprise. Objections to the imaginary marketplace, in
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IMPROVING AMERICA'S DIET AND HEALTH
other words, would not necessarily be based on a concern that such a
signal system is too limited to give consumers real choice (since, as
has been pointed out earlier, other information could still be available).
Rather, such a system may be viewed as too simplified to be accu-
rate, devoid of essential negative information, or practically and po
litically unattainable.
Nutrition educators might be happier with a less simplified market-
place in which the foods themselves were limited to commodities or
simple recipe foods (e.g., bread) containing all or nearly all (and only)
the nutrients such foods have traditionally contained. In such an
environment, it would be possible to devise a simple food grouping
method (with varying degrees of detail added for more educated
consumers) for teaching food selection. Food education could be
included in general education, beginning in the earliest grades with
simple cooking and eating experiences designed to expand children's
familiarity with, and liking for, different foods. An understanding of
food composition and its relation to human health could be made
part of the basic knowledge of all children and their parents and
would be relatively easy to apply in the marketplace.
The six strategies and associated actions for implementation in this
chapter must be read in light of these observations. Health-related
information about relative or absolute quantities of specific food
components should always be placed within an overall context that
emphasizes food and food choices. It will continue to be difficult for
the public to eat wisely when no simple and immediately self-evident
rules of food composition are applicable. Success is most likely to be
achieved if emphasis is given to the importance of choosing a diet
from among health-promoting foods such as fruits, vegetables, grain
products, lean meats, and low-fat dairy foods. It is much more difficult
to teach consumers about products in which naturally occurring
components have been concentrated or diluted so that the products
can be labeled to appear more desirable. Most consumers are probably
capable of learning to select and prepare foods wisely. The task, then,
is to instruct and motivate them to do so.
STRATEGIES AND ACTIONS FOR EDUCATION
OF THE PUBLIC
STRATEGY 1: Ensure that consistent educational messages
about dietary recommendations reach the public.
ACTION 1: Initiate meetings of leaders and representatives of
national groups (e.g., interest groups, professional associations,
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EDUCATION OF THE PUBLIC
193
and Cooperative Extension Service educatorsJ to explore com-
mon interests in implementing dietary recommendations and to
develop a series of common educational initiatives related to the
attainment of that goal.
Meetings of this kind, perhaps sponsored by a consortium of national
health-related organizations, should decrease the tendency of opinion
makers to focus on the differences rather than the similarities among
various sets of dietary guidelines coming from such organizations as
AHA and the American Cancer Society. Messages that reflect consen-
sus will have greater impact and credibility, but each participating orga-
nization might be concerned that its identity would be obscured or its
importance diminished in the eyes of its supporters if it joined this
consortium. Since many of these organizations use interest in the disease
that they were established to fight and publications addressing that
disease to increase their own visibility and, hence, fund-raising ability,
financial incentives may be required to foster cooperative efforts.
ACTION 2: Review materials on diet and health prepared for
the public by various professional groups and organizations to
achieve consistency and ensure compatibility with dietary rec-
ommendations
The directors of professional groups and organizations should be
prepared to approve the expenditures needed to revise their materials
to emphasize dietary recommendations and how to meet them. This
action is not intended to minimize individuality in style or emphasis
on different diseases in redesigned educational messages. The need
is for consistency in content only.
ACTION 3: Convene an ad hoc committee composed of authors
and publishers of leading nutrition textbooks to develop a series
of broad guidelines that publishers could use to provide in their
publications consistent and authoritative information on dietary
recommendations and their scientific rationale.
This committee would be convened to develop guidelines and ma-
terials on the connections between diet and health, on the food selection
and preparation skills necessary to implement dietary recommendations,
and on placing recommended dietary changes in the context of overall
reduction of health risks. The products of this committee could be
distributed to all major publishers in the fields of health and fitness,
as well as publishers of the major texts in areas such as science,
consumer education, home economics, social studies, psychology, and
others that touch on nutrition or dietary patterns. These publishers
would be encouraged to use the committee's guidance in developing
new or revised publications.
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IMPROVING AMERICA'S DIET AND HEALTH
ACTION 4: Constitute a panel to review and evaluate nutrition
education materials made available to schoolteachers from various
food industry sources.
In light of the chronic financial constraints that affect most schools,
teachers are often tempted to use materials offered free or at low cost
by various segments of the food industry materials that may give
incomplete or inaccurate messages and tend to promote brand-name
food products, i.e., to "sell rather than teach" (Consumers Union
Educational Services, 1990, p. 9; Harty, 1979~. Teachers would benefit
by having evaluations of such materials that come from a group of
food, nutrition, and education professionals with access to a full range
of relevant materials.
The materials should be evaluated to determine whether the con-
tent is explicitly and implicitly compatible with dietary recommenda-
tions. The results should be regularly updated and shared (perhaps
on computerized data bases that are easily accessible) with state boards
of education, with relevant educational associations, and with individual
teachers considering use of particular materials. To improve the useful-
ness to schools of industry-produced educational materials, evaluations
should also be sent on a regular basis to representative industry groups
and various commodity, marketing, and trade associations.
There are no major barriers to this particular action item. A panel
of reviewers may need minimal financial support, however, to cover
travel, meeting, and other miscellaneous expenses. Other groups of
professionals that evaluate various kinds of educational materials outside
the food and nutrition areas may be able to provide guidance on
establishing and maintaining such a review panel.
STRATEGY 2: Incorporate principles, concepts, and skills
training that support dietary recommendations into all
levels of schooling kindergarten through college.
ACTION 1: Design a model curriculumfor teachingfood skills,
nutrition, and hearth from kindergarten through grade 12.
Although a wide range of food, nutrition, and health education ac-
tivities are currently undertaken in elementary, secondary, and high
schools in the United States, they vary considerably in their level of
educational sophistication. Overall, however, these activities tend to
emphasize imparting knowledge of foods and nutrition rather than trans-
mitting food coping skills, and they tend to focus as has much of the
dietary guidance to date on basic commodities such as milk, meat, and
produce. Thus, they do not adequately prepare children to deal with
the extensively processed and packaged food supply of today. The
proposed curriculum would attempt to overcome those limitations.
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EDUCATION OF THE PUBLIC
199
· Review the success and effectiveness of past efforts (e.g., the
Head Start Program) and the current joint efforts of the American
Public Health Association and the American Academy of Pediatrics
in establishing nutrition standards for out-of-home care. Making use
of lessons learned, develop national recommendations for legislation,
regulations, and standards, as well as education and training guidelines
for professionals and the public.
More than 56% of mothers with children under age 6 years and
61% of those with children ages 3 to 5 work outside the home (U.S.
Department of Labor, 19891. An increasing number of these children
are sent to child-care programs. There is only anecdotal information
about the foods provided to these children by their parents for con-
sumption during the day and few studies on what is served by child-
care providers (Briley et al., 1989~. There is even less information
about whether or how these early food experiences help young children
to develop a lifelong respect for both the physical and the emotional
values of food. Health-promoting foods served in a nurturing environ-
ment are more likely to be accepted and enjoyed. Participatory edu-
cation that is, sharing good foods with caring adults in a pleasant
environment is the most powerful way of establishing healthful eating
habits in preschool children (Birch, 1987; Birch and Marlin, 1982; Glaser,
1964~.
Health-care professionals, early childhood specialists, policymakers,
advocates for children, nutritionists, educators, and parents often lack
awareness of how central food is to children's well-being. When the
Child Care Development and Improvement bills (H.R. 3 and S. 5)
were introduced in the 101st Congress, they carried no provisions for
feeding children, training staff, or establishing nutrition standards
for day-care settings. In at least one state there is a trend for child-
care programs not to furnish food (Maryland Register, 1990~. Ignor-
ing preschoolers' food needs in child-care legislation will obviously
save money if the bill becomes law, but it is clearly detrimental to the
needs of children.
ACTION 2: Public policy committees in nutrition, medical,
and other health-related organizations should work to develop
and pass legislation to require that foods served to children help
them to meet dietary recommendations. The Child and Adult
Care Food Program standard (USDA, l990J should be used as a
quality minimum.
Members of the American Dietetic Association, the Society for Nu-
trition Education, the American Public Health Association, the American
Institute of Nutrition, and the American Home Economics Association
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IMPROVING AMERICA'S DIET AND HEALTH
should work with members of the Alliance for Better Child Care to
take the lead on this initiative. Given the budget implications of
such a program, it will be critical to convince Congress of the impor-
tance of spending money early to help establish eating habits that
may save money later through reduced health-care costs.
STRATEGY 4: Enhance consumers, knowledge and the
skills they need to meet dietary recommendations through
appropriate food selection and preparation.
ACTION 1: Develop a consumer manual to present strategies
that can be used to influence local food providers (and others
who play important roles in the food systems to increase the
availability offoods that help people meet dietary recommendations.
The Society for Nutrition Education, the American Dietetic Associa-
tion's National Center for Nutrition and Dietetics, the Consumer
Federation of America, the Cooperative Extension Service, the Consum-
ers Union, and perhaps other professional consumer organizations
should be involved in preparing, publicizing, and distributing the
manual. Such a manual would lay out general principles and strate-
gies for:
· identifying reliable sources of information about food (e.g., the
data bank discussed in Strategy 4, Action 2 below);
· making health-promoting food choices in, and influencing the
menus of, local restaurants and other eating establishments;
· encouraging airlines and other travel-related industries to pro-
vide travelers with meals that follow the principles of dietary recom-
mendations; and
· planning and implementing health-promoting eating events (both
catered and noncatered), such as community potluck meals, fairs,
festivals, and bake sales.
The consumer manual should also offer advice on how to influence
other groups and individuals with the power to influence the food
supply, for example:
· those in charge of selecting both the educational materials and
the foods available in local schools, colleges, churches, health-care
organizations, and hospitals;
· managers of local media who can be urged to present credible
and useful information relevant to dietary recommendations (see also
Strategy 6~; and
· members of Congress or state representatives who can affect
local or national food policies and regulations.
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EDUCATION OF THE PUBLIC
201
The public is bombarded by an enormous amount of information,
much of which is of unknown reliability, and professional advice is
not always readily available when decisions must be made. A manual
such as that proposed would provide a reliable, self-explanatory (i.e.,
minimally mediated), and readily available source of needed infor-
mation. The manual entitled Reducing Dietary Fat issued by Public Voice
for Food and Health Policy (1989) is a useful, if restricted, model.
One possible barrier to the preparation of such a manual is the
need to make it readable and usable by diverse populations with
varying levels of literacy. This problem might be eliminated by pre-
paring several versions of the manual that address different audiences.
Publication and distribution costs might be underwritten by a publisher
interested in selling such a volume at a profit.
ACTION 2: Prepare an inexpensive, continually updatablefoods
data bank to inform consumers, food planners, and others about
the nutritional content, composition, and production/processing
history of the products available to them.
Nutrition education professionals, food manufacturers, trade asso-
ciations, food retailers, food technologists, consumer advocates, and
appropriate government agencies should take the lead in establish-
ing such a data bank as well as determining its content and format,
relying heavily on the results of consumer surveys. Much of the
needed nutritional information would be available from the USDA
Nutrient Data Bank, an information system for storing and summarizing
information on food composition (Perloff, 1989; Perloff et al., 1990~.
Additional information about the sources and processing history of a
wide range of food products, including brand-name products, would
need to be obtained from producers and processors.
The information should be presented in a format that facilitates
comparison with a range of health-relevant criteria (e.g., content of
saturated fat and cholesterol). The food and nutrition data bank
could be made available in supermarkets, on floppy disks for use
interchangeably in home or in store computers, or presented in such
convenient forms as handbooks sufficiently inexpensive for consum-
ers to purchase.
Although many consumers may not now be interested in detailed
information about the composition, provenance, and processing his-
tory of their food products, the committee believes that the existence
of a data bank containing such information and available in a variety
of formats at different locations, including point-of-purchase settings,
would fill a great need by generating consumer interest in the sources
and compositions of foods. Studies should be initiated by FDA to
determine which types of information in what kinds of formats could
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IMPROVING AMERICA'S DIET AND HEALTH
be most readily used. Some formats for the presentation of food pro-
duct information to consumers in magazine format are available, e.g.,
in the Nutrition Action Healthletter from the Center for Science in the
Public Interest and Consumer Reports published by Consumers Union.
Another example is the Eatfor Health Food Guide issued by Giant Food,
Inc. (1990), a Washington, D.C.-based food retailer.
Preparation of the data base may be impeded by incomplete infor-
mation about various products and the difficulty of getting proprietary
information from producers and processors. The rapid emergence
and disappearance of products in the retail marketplace will make
. · ~ ~ . · ~ c1 · 1 ~ _ 1_ _ _ _ 1_ _ r1~ _ L1 _ [~ : 1 _1~1 _
continual updating of thIS data base notn a necessary and a torm~aao~e
task.
STRATEGY 5: Establish systems for designing, imple-
menting, and maintaining community-based interventions
to improve dietary patterns.
ACTION 1: Professional organizations concerned with food,
nutrition, and health should work to engage community leaders
in the development of community-based programs promoting dietary
recommendations.
Local affiliates of national professional organizations concerned
with food, nutrition, and health should provide assistance to local
schools, churches, work sites, hospitals, health departments, and
community groups enabling them to (1) support on a local level the
mass media and other national efforts to promote behavior consonant
with dietary recommendations (see Strategy 6) and (2) revise their
own organizational food practices to ensure that their offices and
staffs serve as models of healthful dietary practices.
To achieve these goals, local community resources must be mobi-
lized. For example, a key member of a local affiliate of the American
Heart Association or the American Cancer Society can initiate the
process of creating a coalition, consortium, or coordinating group to
plan integrated community action in nutrition. Individuals from this
group can then be appointed to serve as links to national resources.
The most important barriers to such coordination arise from the terri-
torial instincts of different community groups. Some fledgling com-
munity consortiums may require direct technical assistance to help
them organize their communities to improve the nutritional savvy of
their people. Assistance can be provided for organizing an assessment
of community nutrition needs and an inventory of community nutri-
tion resources, and for linking community groups as they become estab-
lished to national and regional resources.
Once the organizational and planning barriers are overcome, the
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EDUCATION OF THE PUBLIC
203
community nutrition consortium or coordinating council must deal
with other barriers to implementation. One of these is the lack of
trained personnel. Strategy 5, Action 2 below provides one logical
means to remove this barrier.
ACTION 2: Encourage schools of higher learning in various
regions of the country to develop programs for educating and
updating individuals in the skills needed to play key roles in
community-based nutrition education programs.
The training should focus on teaching methods of community or-
ganizing and program planning and on strategies for ensuring that
community-based programs provide effective education. These pro-
grams should be rigorously evaluated for costs incurred and benefits
provided.
Important components of the training programs should include
how to (1) build coalitions gaining allegiance among all sectors of
the community (i.e., interorganizational cooperation), (2) use and in-
fluence the media, (3) create incentive-based programs, (4) design
point-of-purchase activities, (5) establish nutrition programs in schools
and work sites, (6) develop methods for achieving regulatory and
environmental change, and (7) ensure local relevance. Program fac-
ulty may need special training to enable them to design programs
that meet the needs of their students and to evaluate their programs
to ensure cost-effectiveness.
To properly evaluate the worth of community nutrition education
programs, multiple methods will be needed. Low-cost telephone in-
terviews could be conducted to evaluate consumer knowledge and
determine self-reported behavior change. Measures that track the
community's adoption (institutionalization) of program initiatives are
needed, as are measures that track the secondary spread of influence
(diffusion) of the initiatives. Local schools, work sites, hospitals, retail
food suppliers, voluntary health agencies, health-care professionals,
food producers, political bodies, and media organizations need to
adopt new policies and methods to help members of the community
maintain the improvements they make in their dietary practices that
are likely to reduce their risks of disease. Lack of acceptance of this
responsibility by local institutions and lack of resources for reinforc-
ing the healthful dietary habits of community residents are indirect
barriers to implementing this action.
STRATEGY 6: Enlist the mass media to help decrease
consumer confusion and increase the knowledge and skills
that will motivate and equip consumers to make health-
promoting dietary choices.
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IMPROVING AMERICA'S DIET AND HEALTH
ACTION 1: Develop a series of social marketing campaigns to
disseminate dietary recommendations.
A model for such a campaign is Project LEAN (Low-Fat Eating for
America Now), which is advancing the goal to reduce fat consump-
tion. This project has been developed by Partners for Better Health
with funds provided by the Henry I. Kaiser Family Foundation (1990)
(see Chapter 7~. Another model is California's "5 A Day For Better
Health" campaign, which is attempting to increase fruit and veg-
etable consumption among state residents to five servings per day
- 1
, . ~ ~ ~ ~ , ~ . . ~ .
and at least 5U() lbs per year by the year :zuuu (toerster anct Sal, lYYU)
(see Chapter 6~. The promotion of specific dietary recommendations
in social marketing campaigns should be placed within the context of
overall risk reduction for chronic diseases.
The public and private sectors should collaborate whenever pos-
sible to support social marketing campaigns. The U.S. Department of
Health and Human Services should examine sources of support for
these campaigns that might include, on a national level, a voluntary
$1.00 income tax checkoff, a stipulated percentage of food sales, a
0.5% tax on television food advertising, or a health lottery. At the
state level, health promotion campaigns might be funded by so-called
sin taxes on alcohol and cigarettes. California recently began a
multimillion dollar campaign to reduce smoking in the state funded
by a fraction of its cigarette tax revenues (Bal et al., 1990; Mydans,
1990~. The results of this initiative should be monitored.
ACTION 2: Appoint a committee of experts in nutrition educa-
tion, child development, social influence, and media to review
past attempts to regulate television food advertising to children.
The committee's goal would be to recommend to Congress and the
executive branch what, if any, action ought to be taken to ensure that
the message stream reaching young children supports dietary recom-
mendations. It might recommend (1) no action at all, (2) the introduc-
tion of messages to reinforce the food selection and preparation skills
and nutrition lessons provided in the classroom, or (3) for very young
children (ages 2 through 5), even a ban on the advertising of certain
highly attractive foods whose consumption makes it difficult to meet
dietary recommendations. Private foundations that might support the
work of a children's television review panel could advocate that this
action be implemented and provide some or all of the necessary re
sources.
In a recent promotion to food store managers, a well-known cereal
manufacturer proclaimed that 95°/O of all children ages 2 through 11
would see a particular television spot promoting a particular cereal
an average of 107 times within the first year of the cereal's introduc
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EDUCATION OF THE PUBLIC
205
lion (Franz, 1986~. Even allowing for advertising hyperbole, the cam-
paign described is one of remarkable reach and frequency. Are the
products being sold and the messages being delivered consonant with
the principles of dietary recommendations for children? If not, does
it matter? These are the sorts of questions the proposed panel would
address. Although it is difficult to establish causal efficacy in regard
to advertising aimed at children, it is nevertheless assumed to be
effective by those who continue to advertise. The committee believes
that growing congressional and parental concern over television ad-
vertising aimed at children and widespread awareness of nutritional
problems such as obesity and high serum cholesterol levels among
children make it vital to examine a variety of evidence and opinion
on the question of whether these two phenomena are related.
Two barriers may impede this action. One is the conviction that
nothing can be done to influence television advertising aimed at children,
since past efforts have failed. The other is the pressure exerted by
strong industry groups on Congress and the regulatory agencies.
ACTION 3: Appoint a standing committee to coordinate the
vast number of media activities necessary to increase consumer
knowledge about dietary recommendations and their application
and to decrease consumer confusion.
Among the initiatives that this committee would undertake are the
following:
· Arrange to produce an integrated set of public service announce-
ments (PSAs) that carry simple, repetitive, and consistent messages
designed to alert consumers to the health benefits of eating properly
and the potential risks of not eating right and to direct them to reliable
sources of information. Because PSAs are necessarily short and must
compete for available air time with other good causes, they should
attempt to convey awareness of issues rather than to communicate
substantial nutrition information. Substantive information can better
be conveyed through alternate routes once interest has been generated.
· Generate a list of media spokespeople, much like those who
serve the Scientists Institute for Public Information, who will be available
to reporters, feature writers, and editors to help them interpret the
highly publicized reports about links between various isolated food
components and disease that so confuse the public. These spokespeople
should include people trained to clarify for food page editors how
the new findings can be translated into food and cooking advice.
The American Dietetic Association's Ambassadors Program and the
Office of Scientific Public Affairs of the Institute of Food Technolo-
gists may serve such a role in certain contexts.
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206
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IMPROVING AMERICA'S DIET AND HEALTH
Assist state dietetic associations to work with Cooperative Ex-
tension Service personnel to provide the national, regional, and local
media newspapers, weekly magazines, radio, television with a weekly
food tip, recipe, and menu designed to help people adopt dietary
recommendations. Over radio and television, these tips could be
provided by popular role models whose eating patterns meet dietary
recommendations. Workshops should be conducted to train community
leaders in techniques for working with their local radio and televi-
sion stations and the local press to generate story ideas, assist with
research, and provide resource people and materials.
· Cultivate contacts with the writers, directors, and producers of
popular television series and movies, suggesting ways for them to
plant messages (preferably implicit) about healthful diets within their
programs. Bill Cosby, for example, idly munching a stalk of raw
broccoli as he talks to one of his kids (or nuzzles his wife who is
chewing an apple) would convey a much more powerful message
than would any amount of explicit dietary advice. The promotion of
less desirable behavior was used successfully in the 1950s by model-
ing to glamorize smoking (Erickson et al., 1990) and more recently to
promote brand-name products such as soft drinks and beer (Miller,
1990~. Recently, the tobacco industry has paid movie producers to
portray smokers in movies and to film particular brands of cigarettes
(Miller, 1990~. The placement of brand-name products in movies and
television programs is a large and growing business (Miller, 1990~.
Yet there is little or no modeling of appropriate dietary behavior in
television shows heavily watched by young people. One recent survey
of 11 top-ranked prime-time television series found "pervasive" referen-
ces to food in the programs and the accompanying commercials; in
most cases, the foods shown were of low nutritional quality and con-
sumed between meals (Story and Faulkner, 1990~. Success in obtaining
the cooperation of producers to discourage driving after drinking
alcoholic beverages on popular television shows has been achieved
by Dr. lay A. Winsten and his colleagues from the Harvard Center
for Health Communication (Delong and Winsten, 1990~.
· Retain a skilled public relations consultant to place guests, an-
ecdotes, and stories on radio and television talk shows, news and
news magazine shows, and game shows in support of healthful dietary
patterns. Such placements should be carefully planned so that the
diet and health messages are supported both explicitly and implicitly
by the appearance and reputation of the spokespeople.
Although paid advertising, especially on television, has been used
successfully to sell food products, there have been few efforts to date
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EDUCATION OF THE PUBLIC
207
to use the national and local mass media in err organized way to
promote healthful eating. Since a large portion of the information on
all subjects that reaches the U.S. public comes explicitly or implicitly
through the media, the need to engage this sector in promoting healthful
eating behaviors is evident.
Two major barriers to implementing this action are the large cost
of an initiative of the size described and the resistance of large and
powerful segments of the food industry to negative statements about
its food or beverage products.
ACTION 4: Establish a taskforce of social scientists to examine
the utility of national entertainment television as a community-
organizing tool that can be used to enhance efforts of local health
agencies in encouraging appropriate dietary changes.
Television tends to be viewed primarily as entertainment and very
secondarily as an educational medium. The only sustained attempt
in the United States to use national television to modify eating behavior
in a healthful direction (among other goals) was "Feeling Good," a
Children's Television Workshop health show that aired in 1974 and
1975. Although the show was critically judged to be a failure, it
apparently provided community organizations with an opportunity
to organize around specific health issues. There is evidence that
several of its nutrition messages were effective (Levine and Gussow,
In press), even though the intended programming was never completed.
REFERENCES
Bat, D.G., K.W. Kizer, P.G. Felten, H.N. Mozar, and D. Niemeyer. 1990. Reducing
tobacco consumption in California: development of a statewide anti-tobacco use
campaign. J. Am. Med. Assoc. 264:1570-1574.
Belasco, W.J. 1989. Appetite for Change: How the Counterculture Took on the Food
Industry, 1966-1988. Pantheon Books, New York. 311 pp.
Birch, L.L. 1987. The role of experience in children's food acceptance patterns. J. Am.
Diet. Assoc. 87:S36-S40.
Birch, L.L., and D.W. Marlin. 1982. I don't like it; I never tried it: effects of exposure
on two-year-old children's food preferences. Appetite 3:353-360.
Briley, M.E., A.C. Butler, C. R. Roberts-Gray, and A. Sparkman. 1989. What is on the
menu at the child care center? J. Am. Diet. Assoc. 89:771-774.
Consumers Union Educational Services. 1990. Selling America's Kids: Commercial
Pressures on Kids in the 90's. Consumers Union of United States, Inc., Mount
Vernon, N.Y. 23 pp.
DeJong, W., and J.A. Winsten. 1990. The use of mass media in substance abuse
prevention. Health Affairs 9:30-46.
Erickson, A.C., J.W. McKenna, and R.M. Romano. 1990. Past lessons and new uses of
the mass media in reducing tobacco consumption. Public Health Rep. 105:239-244.
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.
OCR for page 208
208
IMPROVING AMERICA'S DIET AND HEALTH
Food Chemical News. 1990a. Health claims additional re-proposal seen likely. Food
Chem. News 32(37):3-6.
Food Chemical News. 1990b. Hutt hits need for FDA clearance of new health mes-
sages. Food Chem. News 32(37):43-45.
FTC (Federal Trade Commission). 1978. Proposed Trade Regulation Rule on Food
Advertising. Phase I. Staff Report and Recommendations. Federal Trade Commission,
Washington, D.C. 367 pp.
Franz, J. 1986. General Mills pours out 3rd cereal. Advertising Age 57:2.
GAO (U.S. General Accounting Office). 1988. Food Marketing: Frozen Pizza Cheese
Representative of Broader Food Labeling Issues. Report No. GAO/RCED-88-70.
U.S. General Accounting Office, Washington, D.C. 47 pp.
Galbraith, J.K. 1967. The New Industrial State. Houghton Mifflin, Boston. 427 pp.
Giant Food, Inc. 1990. Eat for Health Food Guide. Giant Food, Inc., Landover, Md.
230 pp.
Glaser, A. 1964. Nursery school can influence foods acceptance. J. Home Econ. 56:680-
683.
Goldsmith, M.F. 1989. 'HeartGuide' food-rating program attracts 114 applications as
controversy continues. J. Am. Med. Assoc. 262:3388, 3391.
Graff, V. 1988. "A bold move": AHA to begin approving food products in 1989. Am.
Heart News 5:2-4, 11.
Gussow, J.D., and I. Contento. 1984. Nutrition education in a changing world. World
Rev. Nutr. Diet. 44:1-56.
Harty, S. 1979. Hucksters in the Classroom: A Review of Industry Propaganda in
Schools. Center for Study of Responsive Law, Washington, D.C. 190 pp.
Henry J. Kaiser Family Foundation. 1990. Idea Kit for State and Community Pro-
grams to Reduce Dietary Fat. Project LEAN: Low-Fat Eating for America Now.
Henry J. Kaiser Family Foundation, Menlo Park, Calif. 126 pp.
Hinton, A.W., J. Heimindinger, and S.B. Foerster. 1990. Position of the American
Dietetic Association: domestic hunger and inadequate access to food. J. Am. Diet.
Assoc. 90:1437-1441.
IOM (Institute of Medicine). 1990. Nutrition Labeling: Issues and Directions for the
1990s. Report of the Committee on Nutrition Components of Food Labeling, Food
and Nutrition Board. National Academy Press, Washington, D.C. 355 pp.
Kalina, B.B., C.A. Philipps, and H.V. Minns. 1989. The NET Program: a ten-year
perspective. J. Nutr. Educ. 21:38-42.
Levine, J., and J.D. Gussow. In press. Better than we think? A reassessment of
"Feeling Good." J. Nutr. Educ.
Manoff, R.K. 1986. Health claim? Less is best. Advertising Age 57:18, 22.
Maryland Register. 1990. Child Care Center Licensing. Title 07, Office of Child Care
Licensing and Regulation, Department of Human Resources. Md. Reg. 17:1362-
1374.
Miller, M.C. 1990. Advertising: end of story. Pp. 186-246 in M.C. Miller, ed. Seeing
Through Movies. Pantheon Books, New York.
Mydans, S. April 11, 1990. California uses tobacco tax for ads attacking smoking.
New York Times. A1, B5.
NRC (National Research Council). 1989. 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, Washing-
ton, D.C. 284 pp.
Perloff, B.P. 1989. Analysis of dietary data. Am. J. Clin. Nutr. 50:1128-1132.
Perloff, B.P., R.L. Rizek, D.B. Haytowitz, and P.R. Reid. 1990. Dietary intake method
OCR for page 209
EDUCATION OF THE PUBLIC
209
ology II. USDA's Nutrient Data Base for Nationwide Dietary Intake Surveys. J.
Nutr. 120:1530-1534.
Public Voice for Food and Health Policy. 1989. Reducing Dietary Fat: Strategies for
State and Local Community Leaders. Public Voice for Food and Health Policy,
Washington, D.C. 14 pp.
Smith, K.W., S.K. Nelson, and J.J. O'Hara. 1982. Food for Thought Project: Final
Report. Office of Policy, Planning and Evaluation, Food and Nutrition Service, U.S.
Department of Agriculture, Alexandria, Va. 95 pp.
Story, M., and P. Faulkner. 1990. The prime time diet: a content analysis of eating
behavior and food messages in television program content and commercials. Am.
J. Public Health 80:738-740.
Tobin, C.A. 1974. Food advertising: proposed trade regulation rule. Fed. Reg. 39:39842-
39862.
U.S. Congress, House. 1984. FTC Review (1977-84). Subcommittee on Oversight and
Investigations, Committee on Energy and Commerce, Subcommittee on Oversight
and Investigations, U.S. House of Representatives. Committee Print 98-CC. U.S.
Government Printing Office, Washington, D.C. 394 pp.
U.S. Congress, House. 1988. Child Nutrition Programs: Issues for the 101st Congress.
Subcommittee on Elementary, Secondary, and Vocational Education, Committee on
Education and Labor, U.S. House of Representatives. Serial No. 100-CC. U.S.
Government Printing Office, Washington, D.C. 220 pp.
U.S. Congress, Senate. 1970. Open Hearing ret Nutritional Aspects of Dry Breakfast
Cereals and the Related Advertising Practices of Cereal Manufacturers. Subcom-
mittee on the Consumer, Committee on Commerce, U.S. Senate. Hearing No. 91-
72. U.S. Government Printing Office, Washington, D.C. 284 pp.
USDA (U.S. Department of Agriculture). 1986. USDA Comprehensive Plan for a
National Food and Human Nutrition Research and Education Program. A Report
to Congress. Publication 1987-180-917/60064. U.S. Government Printing Office,
Washington, D.C. 91 pp.
USDA (U.S. Department of Agriculture). 1990. Child and Adult Care Food Program.
U.S. Department of Agriculture, Alexandria, Va. 5 pp.
U.S. Department of Labor. 1989. Handbook of Labor Statistics. Bulletin 2340, August
1989. U.S. Bureau of Labor Statistics, Washington, D.C.
Representative terms from entire chapter:
nutrition education
