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Improving America's Diet and Health From Recommendations to Action A report of the Committee on Dietary Guidelines Implementation Food and Nutrition Board Institute of Medicine Paul R. Thomas, Editor NATIONAL ACADEMY PRESS Washington, D.C. 1991

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NATIONAL ACADEMY PRESS · 2101 Constitution Avenue, N.W. · Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was established in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Samuel O. Thier is president of the Institute of Medicine. This study was supported by the Henry J. Kaiser Family Foundation through Grant No. 87-4338 and by the National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services, through Contract No. N01-CN-85072. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Dietary Guidelines Implementation. Improving America's diet and health: from recommendations to action / a report of the Committee on Dietary Guidelines Implementation, Food and Nutrition Board, Institute of Medicine; Paul R. Thomas, editor. p. cm. Includes bibliographical references. Includes index. ISBN 0-309-04139-2 1. Diet-Standards-United States. 2. Nutrition policy-United States. 3. Health. I. Title. [DNLM: 1. Diet. 2. Health. 3. Nutrition. 4. Risk Factors. QU 145 I593i] RA784.I57 1991 363.8'0973-dc20 DNLM/DLC for Library of Congress Copyright (31991 by the National Academy of Sciences 91-7471 CIP No part of this book may be reproduced by any mechanical, photographic, or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted, or otherwise copied for public or private use, without written permission from the publisher, except for the purposes of official use by the U.S. government. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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COMMITTEE ON DIETARY GUIDELINES IMPLEMENTATION EDWARD N. BRANDT, IR. (Chairman), Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma NORMAN M. KAPLAN (Vice Chairman), University of Texas South- western Medical Center, Dallas, Texas STANLEY ARONSON, Brown University, Providence, Rhode Island LORELEI DiSOGRA, Nutrition and Cancer Prevention Program, California Public Health Foundation, Sacramento, California JANICE M. DODDS, School of Public Health, University of North Carolina, Chapel Hill, North Carolina CHARLES DWYER, Graduate School of Education, University of Pennsylvania, Philadelphia, Pennsylvania JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital, Boston, Massachusetts JOHN W. FARQUHAR, Center for Research in Disease Prevention, Stanford University School of Medicine, Palo Alto, California JOAN D. GUSSOW, Department of Nutrition Education, Teachers College, Columbia University, New York, New York D. MARK HEGSTED, New England Regional Primate Center, Harvard Medical School, Southborough, Massachusetts H. O. KUNKEL, College of Agriculture and Life Sciences, Texas A&M University, College Station, Texas LESTER LAVE, Graduate School of Industrial Administration, Carnegie-Mellon University, Pittsburgh, Pennsylvania BERNARD I. LISKA, Department of Food Science, Purdue Univer- sity, West Lafayette, Indiana BEATRICE MARKS, Ketchum Public Relations, New York, New York ODONNA MATHEWS, Giant Food, Inc., Landover, Maryland RICHARD E. PETTY, Department of Psychology, Ohio State University, Columbus, Ohio BONITA WYSE, College of Family Life, Utah State University, Logan, Utah Committee on Diet and Health Liaison Members HENRY BLACKBURN, School of Public Health, University of Min- nesota, Minneapolis, Minnesota DONALD B. McCORMICK, Department of Biochemistry, Emory University School of Medicine, Atlanta, Georgia ANTHONY B. MILLER, Department of Preventive Medicine & Bio- statistics, University of Toronto, Toronto, Ontario, Canada . . .

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Staff PAUL R. THOMAS, Project Director (from January 1990; formerly Program Officer) LENORA MORAGNE, Project Director (to December 1989) FRANCES M. PETER, Editor (to August 1990) MARIAN M. F. MILLSTONE, Research Assistant (to July 1990) GERALDINE KENNEDO, Senior Secretary (from April 1990) MARION RAMSEY ROBERTS, Senior Secretary (from Jarruary to December 1989) IV

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FOOD AND NUTRITION BOARD M. R. C. GREENWOOD (Chair), Office of Graduate Studies, Univer- sity of California, Davis, California DONALD B. MCCORMICK (Vice Chair), Department of Biochemis try, Emory University School of Medicine, Atlanta, Georgia EDWIN L. BIERMAN, Division of Metabolism, Endocrinology, and Nutrition, University of Washington School of Medicine, Seattle, Washington EDWARD I. CALABRESE, Environmental Health Program, Div sion of Public Health, University of Massachusetts, Amherst, Massachusetts JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital, Boston, Massachusetts JOHN W. ERDMAN, JR., Division of Nutritional Sciences, Univer sity of Illinois, Urbana, Illinois CUTBERTO GARZA, Division of Nutritional Sciences, Cornell University, Ithaca, New York DeWITT S. GOODMAN, Institute of Human Nutrition, Columbia University, New York, New York RICHARD I. HAVEL, Cardiovascular Research Institute, University of California School of Medicine, San Francisco, California JANET C. KING, Department of Nutritional Sciences, University of California, Berkeley, California JOHN E. KINSELLA, School of Agriculture and Environmental Sciences, University of California, Davis, California LAURENCE N. KOLONEL, Cancer Center of Hawaii, University of Hawaii, Honolulu, Hawaii WALTER MERTZ, Human Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture, Beltsville, Maryland MALDEN C. NESHEIM, Office of the Provost, Cornell University, Ithaca, New York JOHN LISTON (Ex Officio), College of Ocean and Fishery Sciences, University of Washington, Seattle, Washington ARNO G. MOTULSKY (Ex Officio), Center for Inherited Diseases, University of Washington, Seattle, Washington ROY M. PITKIN (Ex Officio), Department of Obstetrics and Gyne cology, School of Medicine, University of California, Los Angeles, California v

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Staff CATHERINE E. WOTEKI, Director (from April 1990) ALVIN G. LAZEN, Interim Director (from September 1989 to April 1990) SUSHMA PALMER, Director (to August 1989; consultant to commit- tee from September 1989 to February 1990) FRANCES M. PETER, Deputy Director (to August 1990) SHIRLEY ASH, Financial Specialist UTE S. HAYMAN, Administrative Assistant Vl

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Preface In late 1987, the Henry J. Kaiser Family Foundation and the National Cancer Institute commissioned the National Academy of Sciences to develop a comprehensive plan to implement the scientific consensus that has emerged on dietary guidelines as a means to improve the health of Americans and to assess the possible consequences of implementing the plan. A committee was formed in the Institute of Medicine's Food and Nutrition Board (FNB) to accomplish the project's two major goals: · propose detailed strategies and options for the implementation of dietary guidelines by government agencies at all levels; by profession- als in the nutrition, medical, and allied health fields; by educational institutions and those who provide nutrition information to the pub- lic; and by certain segments of the private sector, including institutions concerned with mass feeding; and · to the extent possible, examine the potential benefits and costs of implementing dietary guidelines. This report is closely related to an earlier report of the FNB en- titled Diet and Health: Implications for Reducing Chronic Disease Risk (NRC, 1989~. That report provided a comprehensive review of the relationships of dietary patterns and nutrient intake to the risk of diet-related chronic diseases that affect Americans; it included nine recommendations for maintaining health. In the present report, the Committee on Dietary Guidelines Implementation proposes a series of strategies and actions to put those recommendations into action. . . V11

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. . . V111 PREFACE However, the strategies and actions are sufficiently general to be applied as well to several sets of dietary recommendations developed during the 1980s. The intended audience for this report is the many people who share some responsibility for implementing dietary recommendations in the United States. Examples of implementors include public- and private-sector policymakers, supermarket managers, restaurant owners, food writers, the entire nutrition community, and deans of schools of higher education. FORMATION OF COMMITTEE AND COMMITTEE PROCEDURES The 17-member interdisciplinary Committee on Dietary Guidelines Implementation was appointed in early 1988. In addition, there were three liaison members from the Committee on Diet and Health and from the FNB. Collectively, the membership provided expertise in nutrition science and education, dietetics, epidemiology, preventive medicine, public health, public policy, food production, food retailing, food marketing, food safety, community nutrition intervention strat- egies, social and behavioral psychology, public relations, medicine, medical science administration, and cost-benefit analysis. In prepar- ing this report, the committee drew on its own considerable resources as well as the diverse experiences of agencies, organizations, consultants, and other experts working to improve eating habits in the United States. The committee met 10 times during the course of the study. Early in its work, it obtained and reviewed many materials, including de- scriptions of efforts to promote more healthful eating patterns and influence consumer behavior. In addition, a public meeting was convened in July 1988 as a forum for representatives of the food industry, pro- fessional societies, voluntary organizations, advocacy groups, and interested consumers. The committee also held several workshops to obtain more detailed information from individuals whose experiences in implementing guidelines on diet and health were believed to be particularly important. Four task forces composed of committee members were established to develop implementation strategies and actions for specific broad sectors of society: (1) the public sector (legislative and executive branches of governments); (2) the private sector (areas as diverse as segments of the food industry to the work site); (3) health-care professionals (including nutritionists, physicians, and nurses, both as practitioners and as members of associations); and (4) public education (defined

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PREFACE IX broadly to include the many settings in which learning occurs). In developing recommendations for consideration by the full commit- tee, each task force studied what had been done and what was currently being undertaken to implement dietary recommendations in these sectors. Important incentives, constraints, and barriers to implementation for these societal sectors were also identified. As a result of information-gathering efforts and activities within the task forces, the committee was able to define its approach to the task, to learn what has and has not worked in changing dietary hab- its, and to identify gaps in the knowledge base. The committee then developed strategies and actions for implementation by specific sectors of society as well as three broad strategies for implementation based largely on the commonalities identified among the four sectors. In response to the second part of its charge, the committee attempted to make some assessments of the costs and benefits to the United States of implementing the committee's recommendations; it was unsuccessful in these efforts because of the paucity of data. Although different parts of this report were drafted by different groups, it represents the consensus of the entire committee rather than the views of individual members or task forces. As is to be expected in any committee endeavor, not every member may agree with every specific point. However, all members agree that the statements represent the consensus view. This report contains nine chapters. Chapter 1 provides a summary of the entire report and the committee's principal strategies for implementing dietary recommendations. The product of the deliberations of the task forces and a presentation of background and assessments of critical elements of the study appear in Chapters 2 through 8. In Chapter 9, the committee identifies the research needed to develop more successful implementation initiatives. SCOPE AND LIMITATIONS OF REPORT In a public policy report such as this, it is important to make clear its scope and limitations. This report does not provide a blueprint for carrying out a coordinated, national effort to improve dietary patterns in the United States. Our charge was simply too broad (one sympathetic, anonymous reviewer described it as "Herculean" in scope), our size too small, and our time too short to develop very specific recommendations for the behavior of large, diverse, and complex so- cietal sectors. In addition, it was difficult to reach agreement among all participants on basic elements of a national nutrition policy and how its activities should be coordinated and prioritized. In retrospect, the extreme difficulty of our task should not have been surprising. Our

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x PREFACE committee simply reflected the larger society in holding many differ- ent views about what should be done to improve dietary patterns in this country and how it should be done. Because the biomedical and social science literature provide few data on which to base specific recommendations, opinion and professional judgment prevail, inevi- tably producing conflict. Our recommendations are therefore general by design and default. To the extent that they call for changing existing programs and practices, implementation will be uncomfortable or difficult, will take consider- able time, and in many cases will require new and redirected financial resources. For example, our recommendations for mass media cam- paigns to enhance public awareness of dietary recommendations and for the expansion of nutrition education at all levels may seem im- practical at a time of high budget deficits when funding for such initiatives will be difficult to obtain. We have tried to make our recommendations practical and attainable with an eye toward the realities of the contemporary political, economic, and social environ- ments, but our primary consideration in selecting them was that they are likely, in our judgment, to improve American diets. Each recommendation of this committee has implications which, depending on one's perspective, can be perceived as desirable or undesirable. For example, our recommendation that guidelines be developed for book publishers to enable them to provide consistent and authoritative information on dietary recommendations might be applauded by some and interpreted by others as a recommendation for a censorship board. This disagreement illustrates the fact that our political and social leanings and biases affect how we view rec- ommendations to encourage or push us to behave in certain ways. Recommendations which may be considered by some to be protective or in the interests of public health may be seen by others as paternalistic, intrusive, and a violation of rights or infringing on civil liberties, freedom of choice, and free enterprise. We believe that our recom- mendations are detailed enough to provide adequate direction for implementing dietary recommendations, yet general enough so as to encourage public debate in deciding how to carry them out. Rather than laying out a very specific plan for implementation, this report provides reasonably detailed recommendations that in the committee's judgment should be the basis of efforts to improve the diet and health of Americans. Many recommendations have specified or obvious outcomes so that progress in achieving them can be mea- sured. The best index indicating that the committee's recommendations have been reached will be evidence from surveys (e.g., the Nation- wide Food Consumption Survey and the National Health and Nutri

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PREFACE Xl lion Examination Survey) of populationwide dietary changes to meet dietary recommendations. A public policy report in which recommendations are made less on the basis of experimental data and more on considered professional judgment will receive extensive review and criticism. This we welcome. Having largely met the challenge of achieving scientific consensus on the composition and components of healthy diets, it is now time to face the even greater challenge of encouraging and enabling people to eat better. To the extent that this report leads to greater efforts to face and meet that challenge through discussion, debate, new initiatives, and extensions of important initiatives already in progress, the com- mittee considers its efforts a success. ACKNOWLEDGMENTS The committee thanks the many individuals and organizations who contributed to this report by providing important information and by serving as consultants, advisers, informal reviewers, and presenters at workshops. They include Emerita N. Alcantara, National Dairy Council; American Dietetic Association; American Health Foundation; American Heart Association; American Society for Clinical Nutrition; Elaine Bratic Arkin, Health Communication; Ronald Baker, C & B Feedyards; Stephen Balsam, Food and Nutrition Service (FNS), U.S. Department of Agriculture (USDA); Amy Barr, McCall magazine; Clement Bezold, Institute for Alternative Futures; Susan T. Borra, Food Marketing Institute (FMI); Marilyn Burkart, National League for Nursing; Marion Burros, New York Times; C. Wayne Callaway, George Washington University; Charles l. Carey, National Food Processors Association; Carol Carlson, ARA Services; Linda Cleveland, Human Nutrition Information Service (HNIS), USDA; Victor Cohn, The Washington Post; Gerald F. Combs, Agricultural Research Service, USDA; Frances Cronin, HNIS, USDA; Callie Crossley, ABC News; Patricia Daniels, ENS, USDA; Eileen DeLeeuw, Utah State University; Arnold E. Denton, Campbell Soup Company; Robert Dorfman, Emeritus Professor of Economics, Harvard University; Adam Drewnowski, University of Michigan; Mary Egan, Egg Nutrition Center; Chet England, Burger King Corporation; Carol Fletcher, Grocery Manufacturers of America, Inc.; Florida Department of Health and Rehabilitative Services; Allan L. Forbes, Food and Drug Administration (FDA), U.S. Department of Health and Human Services (DHHS); John Francis, National Live Stock and Meat Board; Ardyth H. Gillespie, Cornell University; Mary T. Goodwin, Montgomery County (Maryland) Department of Health; Dottie Griffith, Dallas Morning News; Joan Guberman, American Col

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. . X11 PREFACE lege Health Association; Timothy M. Hammonds, FMI; James T. Heimbach, HNIS, USDA; Elisabet Helsing, World Health Organiza- tion; Thomas A. Hodgson, National Center for Health Statistics, DHHS; Hilarie Holing, American Meat Institute; Michael Jacobson, Center for Science in the Public Interest; Marsha D. Kelly, National Council of State Boards of Nursing, Inc.; Chor-San Khoo, Campbell Soup Company; John LaRosa, George Washington University; Bryan R. Luce, Battelle Human Affairs Research Centers; Barbara Luke, Board on Agriculture, National Research Council; l. Michael McGinnis, Office of Disease Prevention and Health Promotion (ODPHP), DHHS; Elaine McLaughlin, United Fresh Fruit and Vegetable Association; Linda D. Meyers, ODPHP, DHHS; Nancy Milio, University of North Carolina at Chapel Hill; Kathryn Montgomery, University of California at Los Angeles; Marion Nestle, New York University; New York State De- partment of Corrections; William D. Novelli, Porter/Novelli; Grace L. Ostenso, U.S. House of Representatives, Committee on Science, Space and Technology; Lynn Parker, Food Research and Action Center; Betty B. Peterkin, HNIS, USDA (retired); Donna V. Porter, Congressional Research Service; Claire Regan, National Restaurant Association; lames Rotherham, U.S. House of Representatives, Committee on Agriculture; Sarah Setton, The Sugar Association, Inc.; Becky Smith, Association for the Advancement of Health Education; Elwood W. Speckman, National Dairy Council; Marilyn G. Stephenson, FDA, DHHS; Tennessee Child Nutrition Program; George W. Tressel, National Science Foun- dation; Nancy l. Tucker, Produce Marketing Association, Inc.; U.S. Department of Defense; Michael I. Wargo, U.S. General Accounting Office; Susan Welsh, HNIS, USDA; Michael White, National Heart, Lung, and Blood Institute of the National Institutes of Health; and Donna M. Woolcott, University of Guelph. Our thanks go as well to those anonymous individuals who formally reviewed the penultimate draft of this report and provided extremely helpful comments and suggestions. Of course, the committee assumes full responsibility for the contents of this report and the opinions expressed in it. Completion of this report would not have been possible without the efforts of the Food and Nutrition Board staff, particularly Paul R. Thomas, as well as Catherine E. Woteki, Sushma Palmer, Frances Peter, and Lenora Moragne; research assistance by Marian M.F. Millstone; administrative assistance from Geraldine Kennedo, Marion Ramsey Roberts, and Dionis Gaines; and copy editing by Michael K. Hayes and Wallace K. Waterfall. The committee also expresses its thanks and appreciation to the members of the FNB who gave their time and expertise to the review of this manuscript. Special recognition and thanks are also due to Sarah Samuels and Alvin Tarlov of the Kaiser

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PREFACE Family Foundation and to Luise Light and Suzanne Haynes of the National Cancer Institute for their encouragement and support. Finally, the committee would like to thank the staff of the National Academy Press, particularly Sally Stanfield, Richard E. Morris, and Scott F. Lubeck, for their assistance in publishing this report. Special acknowledgment is due to Samuel 0. Thier and Enriqueta C. Bond of the Institute of Medicine as well as Alvin G. Lazen and John E. Burris of the Commission on Life Sciences for their expert advice, oversight, and constant encouragement throughout the course of this study. EDWARD N. BRANDT, JR. Chairman Committee on Dietary Guidelines Implementation REFERENCE NRC (National Research Council). 1989. Diet and Health: Implications for Reducing Chronic Disease Risk. Report of the Committee on Diet and Health, Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. 749 pp.

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Contents 1 Summary 2 Introduction 3 Determinants of Food Choice and Prospects for Modifying Food Attitudes and Behavior 4 interpretation and Application of the Recommendations in the Diet and Health Report Public Sector: Strategies and Actions for Implementation 6 Private Sector: Strategies and Actions for Implementation 7 Health-Care Professionals: Strategies and Actions for implementation Education of the Public: Strategies and Actions for implementation xv 1 18 33 84 112 140 168 184

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XVI 9 Directions for Research Appendix A: Dietary Recommendations Appendix B: Summary of Committee's Major Recommendations Acronyms index CONTENTS 210 215 218 227 229