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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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186 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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188 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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190 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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192 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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194 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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200 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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202 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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204 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 . 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.

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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

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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.