14
Diet Modification and Food Policy Strategies: What Works?

Thomas A. Pearson and Rajesh V. Patel

Introduction

The list of potential nutritional causes of chronic diseases is a long one. It includes not only fat and cholesterol, but also a diet characterized by excess calories, high protein, high sodium, low potassium or calcium, low fiber, heavy alcohol, deficient antioxidant vitamins, and a host of less well defined dietary constituents. While no dietary recommendation can totally ignore these additional macroand micronutrients, the focus of this discussion is on reduction of total dietary fat, saturated fat, and cholesterol1; strategies for achieving that reduction; and the relevance and potential for implementation of those strategies in the New Independent States (NIS).

Two types of international comparisons have particular relevance for the consideration of proposed changes in population-wide nutrition for the NIS. First, as shown in Table 14-1, international comparisons indicate strong, direct, and consistent correlations between consumption of dietary fat, especially saturated fat, and cholesterol and a host of chronic diseases, including coronary artery disease (Kesteloot and Joosens, 1992). As is the case with tobacco and excess alcohol consumption, these data point out an opportunity to affect several conditions with the modification of a single macronutrient. A second set of informative international comparisons includes the correlation between changes in national consumption of fat from animal and vegetable sources and changes in cardiovascular disease mortality over the past quarter-century. Those countries which have demonstrated declining mortality rates from cardiovascular disease have been characterized by a declining per capita consumption of fat from animal



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--> 14 Diet Modification and Food Policy Strategies: What Works? Thomas A. Pearson and Rajesh V. Patel Introduction The list of potential nutritional causes of chronic diseases is a long one. It includes not only fat and cholesterol, but also a diet characterized by excess calories, high protein, high sodium, low potassium or calcium, low fiber, heavy alcohol, deficient antioxidant vitamins, and a host of less well defined dietary constituents. While no dietary recommendation can totally ignore these additional macroand micronutrients, the focus of this discussion is on reduction of total dietary fat, saturated fat, and cholesterol1; strategies for achieving that reduction; and the relevance and potential for implementation of those strategies in the New Independent States (NIS). Two types of international comparisons have particular relevance for the consideration of proposed changes in population-wide nutrition for the NIS. First, as shown in Table 14-1, international comparisons indicate strong, direct, and consistent correlations between consumption of dietary fat, especially saturated fat, and cholesterol and a host of chronic diseases, including coronary artery disease (Kesteloot and Joosens, 1992). As is the case with tobacco and excess alcohol consumption, these data point out an opportunity to affect several conditions with the modification of a single macronutrient. A second set of informative international comparisons includes the correlation between changes in national consumption of fat from animal and vegetable sources and changes in cardiovascular disease mortality over the past quarter-century. Those countries which have demonstrated declining mortality rates from cardiovascular disease have been characterized by a declining per capita consumption of fat from animal

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--> TABLE 14-1 Correlation Coefficients Between Mortality (1984-1987) and Nutritional Data (1979-1981), Standardized for Energy Intake, for Average of Males and Females from 36 Countries Cause of Death Total Fat Animal Fat Vegetable Fat Cereals Coronary disease 0.23 0.46* -0.40* -0.38* Lung cancer 0.43* 0.54* -0.15 -0.38* Colon cancer 0.58* 0.63* -0.02 -0.63* Breast cancer 0.76* 0.76* 0.09 -0.82* * p < 0.05 SOURCE: Epstein (1989). Reprinted with permission of Oxford University Press. sources in particular. On the other hand, those countries which have demonstrated an increase in cardiovascular mortality rates have shown trends of increasing animal and total fat consumption (Epstein, 1989). Taken together, these comparisons provide a comprehensive picture of the potential ability to reduce cardiovascular disease rates through reductions in dietary saturated fat and cholesterol, acknowledging the simultaneous contributions of other factors in the overall disease trends. Additional information on the scientific rationale for the lowering of total dietary fat, saturated fat, and cholesterol is available in the literature (Carleton et al., 1991). Based on this scientific evidence, a variety of U.S. national research and policy organizations have recommended reducing total dietary fat to less than 30 percent of calories, saturated fat to less than 10 percent of calories, and cholesterol to less than 300 milligrams per day (mg/day) for the entire U.S. Population.2 Additional reductions in saturated fat and cholesterol are recommended for persons with such conditions as hypercholesterolemia, obesity, and coronary disease (Carleton et al., 1991). It is emphasized that these dietary changes should be part of a comprehensive program to improve lifestyles in general, including smoking cessation and increased physical activity. Evidence from within the NIS suggests that saturated fat may likewise be a worthy target for intervention in the region. Comparison of the nutrient intake of middle-aged men in the United States and the Soviet Union in the Lipid Research Clinics Prevalence Study showed, if anything, that saturated fat consumption was higher among Soviet than among U.S. men (U.S.-U.S.S.R. Steering Committee for Problem Area I, 1984). Until 1990, per capita consumption of meat, eggs, and whole-fat dairy products increased annually in the Soviet Union, contributing to the 36 percent of calories from fat in the Russian diet in 1990 (see Popkin et al.,

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--> in this volume). Recent changes in the economic situation in the NIS may have altered these trends in consumption, but the opportunity to affect chronic disease rates through modification of dietary fat and cholesterol consumption still remains. The next section reviews various strategies for reducing consumption of total fat, saturated fat, and cholesterol that have been used in Western countries and have potential applicability to the NIS. The final section presents conclusions. Strategies to Reduce Consumption of Total Fat, Saturated Fat, and Cholesterol Overview There is abundant evidence from many Western nations that consumption of fat, especially from animal sources, can be markedly altered on a nationwide basis (Epstein, 1989). The United States provides a useful case study (Stephen and Wald, 1990). Table 14-2 shows that total dietary fat consumption has fallen modestly in the United States since 1940, while the proportion of total fat as saturated fat from meat and dairy products has fallen markedly, being replaced with polyunsaturated fats from vegetable sources. Given relatively infrequent use of cholesterol-lowering medications (Wysowski et al., 1990), the substantial reductions (15 milligrams per deciliter [mg/dl] or more) in mean serum cholesterol levels among the entire U.S. population between 1960 and 1991 have generally been attributed to dietary changes (Johnson et al., 1993), thereby linking population-wide dietary change with declines in cardiovascular disease. Parenthetically, these improvements in serum cholesterol levels have been achieved despite a progressive rise in obesity in the United States, suggesting that the likely explanation for the population-wide changes in serum cholesterol is the TABLE 14-2 Estimates of Consumption of Total Fat, Saturated Fat, and Polyunsaturated Fat in the United States Between 1940 and 1985     % of Calories Year Total Fat Saturated Fat Polyunsaturated Fat Polyunsaturated/ Saturated 1940-1949 37.6 15.3 2.5 0.16 1950-1959 40.5 16.6 4.3 0.26 1960-1969 39.9 15.8 3.7 0.24 1970-1979 37.8 13.8 5.1 0.37 1980-1985 37.5 11.8 5.4 0.46   SOURCE: Popkin et al. (in this volume).

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--> Figure 14-1 Major elements in the food chain that determine eating patterns on a population-wide basis. SOURCE: Carleton and Lasater (1994). Reproduced with permission. Copyright American Heart Association. cholesterol and saturated fat content of the foods consumed, rather than the caloric balance. Elements in the food chain that determine the population's eating patterns are logical targets for strategies aimed at reducing consumption of fat and cholesterol (Carleton and Lasater, 1994). Figure 14-1 shows the major elements of the food chain. Evidence on the ability to influence the manufacture, distribution, purchase, preparation, and consumption of foods is discussed in this chapter, using data from studies in Western countries, especially the United States. Opportunities for intervention to alter the diet in the NIS are discussed relative to several constituencies with which a successful intervention must interact. As listed in Table 14-3, these constituencies include governmental bodies; the food industry; local institutions, such as worksites and schools; and health-related groups, including voluntary organizations, such as heart foundations and cancer societies, and health professionals. One important point to emphasize is that dietary change in many Western countries, certainly in the United States, cannot be attributed solely to any one organization or group. Dietary recommendations to reduce fat and cholesterol in the United States have often been released by voluntary and professional organizations, such as the American Heart Association, the American Cancer Society, and the American Diabetic Association, well in advance of governmental recommendations, which have frequently been constrained by political issues involving

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--> TABLE 14-3 Organizations and Potential Programs for Sponsorship to Change the Food Chain   Organizations   Governments Food Industry Health-related Groups Programs National Local Manufacturing Distributing Retail Local Institutions Voluntary Organizations Professional Dietary recommendations x           x x Food subsidies x               Production quotas x   x           Taxation x x             Alternative production     x   x       Advertising/promotion     x x x       Food labeling x   x x x   x x Mass media campaign x x         x   Local media campaign   x         x x Worksite programs   x       x x   School programs   x       x x   Health screenings x x       x x x Nutrition surveillance x           x x

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--> special-interest groups. Several different types of organizations might sponsor the same type of program. For example, a mass media campaign could be undertaken by the national government, local government, or a voluntary health organization such as a heart foundation. Each type of program is discussed here under the organization(s) most likely, but not solely capable of, sponsoring such an initiative. The remainder of this chapter, then, reviews the roles of governmental organizations, the food industry, local institutions, and health-related groups in interventions to achieve dietary change. The Role Of Governmental Organizations Dietary Recommendations A logical starting point in designing strategies to achieve dietary change is to identify nutritional goals for the population, such as those recommended by several scientific and governmental bodies in the United States (National Research Council, 1989; U.S. Department of Agriculture and U.S. Department of Health and Human Services, 1995). Criteria for the establishment of recommended daily allowances (RDA) have been established, and generally apply to the populations of the NIS (Food and Nutrition Board and Institute of Medicine, 1994). Nutrition policymakers in the NIS could identify goals related to consumption of total fat, saturated fat, and cholesterol, based on their populations' needs, as the basis for population-wide intervention and monitoring.3 The present period of evolution in the economies of these countries represents a propitious time to develop population-wide dietary goals and national nutrition policies. The Cost and Availability of Food Cost is an important consideration in the selection of foods (Terry et al., 1991). Even in the United States, where a relatively small proportion of household income is spent on food, increased cost may be a major barrier to certain dietary changes (Ammerman et al., 1991). However, contrary to the popular notion, recent data suggest that low-fat, low-cholesterol diets, as currently consumed in the United States, do not necessarily cost more, but may actually cost less, representing an incentive rather than a barrier to dietary change (Shaul et al., 1996). The costs of low-fat, low-cholesterol alternatives in the NIS are not known. Yet according to the Russian Longitudinal Monitoring Study (Allen and Howson, 1994; see also Popkin et al., in this volume), between 52 and 60 percent of household income in Russia is spent on food. Thus the low cost of foods such as grains and breads should promote their consumption, rather than that of the more costly dairy products and meats. The large proportion of income spent on food suggests that the Russian population may have particularly high price elasticities with regard to low- versus high-fat foods. Economic instability and this

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--> TABLE 14-4 Producer Subsidies (%) for Selected Commodities in Selected Countries, 1978-1981   Low-Fat Foods High-Fat Foods Country Wheat Coarse Grains Poultry Dairy Beef/ Veal Pork United States 17.2 13.1 6.3 48.2 9.5 6.2 Canada 17.6 13.3 25.7 66.5 13.1 14.5 European Community 28.1 27.9 16.4 68.8 52.7 21.7 Australia 3.4 2.9 2.5 20.8 4.0 2.7 Nordic Europe 56.6 54.7 43.4 70.8 61.6 23.5 Mediterranean Europe 10.7 14.8 19.4 68.4 17.6 16.7   SOURCE: Jones and Ralph (1992). Reprinted with permission of Oxford University Press. high price elasticity may account for the drop in meat and egg consumption observed between 1990 and 1992 in Russia (see Popkin et al., in this volume). In market economies, production of food by the agricultural sector and by food manufacturers has been dictated largely by consumer demand, unless manipulated by subsidies or production quotas. Where production is manipulated, national agricultural policy and national nutrition policies may not always agree (Jones and Ralph, 1992). In the former Soviet Union, root crops (e.g., potatoes), vegetables, and grains form an important part of the traditional diet. However, quotas and subsidies of high-fat foods, meat, and dairy products in the past spurred the production of these foods and made them available to the population at reduced cost (see Popkin et al., in this volume). A similar situation appears to have occurred in other European economies, as shown in Table 14-4. The price supports for dairy products and beef are especially high in the European Community and Nordic Europe, relative to supports for poultry, while the United States and Australia support dairy and beef prices and production to a lesser extent (Jones and Ralph, 1992). In Hungary during the period 1960-1985, prices of fats, meats, alcohol, and cigarettes were kept low, while prices of fruits and vegetables were less protected (Poulter, 1993). While the demand for low-fat and low-cholesterol foods can be manipulated, persistently low costs for high-fat foods are an obvious inducement for their consumption. The removal of subsidies and production quotas for high-fat foods in the NIS may in part eliminate economic factors that prevent costs and consumption from reverting back to their 1960s levels (see Popkin et al., in this volume). Conversely, subsidies and production quotas for grain, fruits, and vegetables may be needed in some of the NIS countries whose consumption of these healthful alternatives is low (Allen and Howson, 1994).

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--> The Role of the Food Industry Production of Low-Fat, Low-Cholesterol Alternatives The food industry can take a creative role in promoting population-wide dietary change through the development, production, distribution, and promotion of products low in saturated fat and cholesterol. In a market economy, the key motivation to do this is the profitability of such products. An example is the demand for nonfat or low-fat milk in the United States, where an increasing proportion of the market has been taken over by these products despite continued marketing of full-fat milk by the dairy industry. Thus, governmental, voluntary, and health-related organizations may have an important role in creating demand for new food products low in saturated fat and cholesterol to motivate the food industry to produce and market such products. The market created for low-fat foods may also spur the food industry to develop foods with a taste and texture similar to those of foods high in saturated fat and cholesterol. Investments by several U.S. companies in the development of fat substitutes illustrate the likelihood of private-sector initiative if the chance of profitability is perceived as high. Advertising The perceived effectiveness of advertising of food products in various media, including television, radio, print, and billboards, is demonstrated by the multi-billion dollar effort it represents in the United States. Clear and factual advertising provides an opportunity to convey considerable nutritional information to the consumer. In general, successful advertising campaigns identify increased benefits (e.g., health, cost, taste) to the consumer and require only a brief effort to process the information (Russo and Leclerc, 1991). This means nutrition information must be highly visible and actively promoted (Kendall and Spicer, 1993). It should be noted also that advertising programs emphasizing the healthful aspects of food have been successful in boosting sales, but the effects have been transient and limited to the period of the active campaign (Levy et al., 1985: Levy and Stokes, 1987). At the same time, commercial efforts to market foods high in fat and cholesterol may serve as a barrier to health promotion. Particular concern has been expressed in the United States regarding the advertising of high-fat foods to children. Foods requested by children correlate with the frequency with which those foods appear on television, and the number of hours children spend viewing television therefore correlates with their requests for specific food items and the purchase of those items by their parents (Taras et al., 1989). The advertising of products high in fat and cholesterol may require regulation as advertising develops within the food industry of the NIS.

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--> Food Labeling in Grocery Stores Until recently, in accordance with a recommendation of the U.S. Surgeon General, the food industry voluntarily provided information on food packages giving the total fat, saturated fat, and cholesterol content of the foods contained therein (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 1995). Approximately 55 percent of food packages carried such labeling (Kessler, 1989). However, misleading information, variable formats, and unsubstantiated health claims led the Director of the U.S. Food and Drug Administration to increase the regulation of the information presented (Kessler, 1989). New nutrition labeling provides an opportunity to show clearly a food's identity, ingredients, nutritional content, and portion size, including the amount of total fat, saturated fat, and cholesterol. The new requirements should prevent customers from being misled with regard to foods high in cholesterol and fat. Accurate food labels can also have a positive effect on food purchasing behavior, sensitizing at least a portion of consumers to the fat and cholesterol content of foods and allowing them to regulate their intake of cholesterol-raising nutrients. In one study, approximately 42 to 45 percent of U.S. consumers reported looking at food labels when shopping; doing so was most common among those concerned about nutrition and those requiring special diets (Schucker et al., 1992). A shelf-labeling or package-labeling program can provide useful support to an individual who is attempting to change his or her diet (Mullis et al., 1987). In the NIS, however, the benefits of food labeling may be limited by the number of alternatives available, the level of awareness among the population about the need to reduce dietary fat and cholesterol, and food costs. The Role of Local Institutions Worksites/Military Organizations Employers may wish to provide health promotion programs for their employees in order to improve worker productivity and reduce health care expenditures. At least 48 published reports have examined the health benefits and cost savings of a variety of health promotion/disease prevention interventions in the workplace, with generally positive results (Pelletier, 1991, 1993). Worksites and the military provide opportunities for several nutritional interventions (American Dietetic Association, 1986). These include improved food services (low-fat/low-cholesterol food choices), screening programs to identify nutritional problems, and intervention programs (e.g., classes, counseling) for individual workers. In a 1989 survey of 1,358 U.S. worksites, healthful food choices were provided at 59.3 percent of the worksites with cafeterias and 33.7 percent of those with vending machines (Fielding and Piserchia, 1989), 29.5 percent had some type of

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--> health risk assessment, 16.8 percent conducted nutrition education activities, and 14.7 percent offered weight control programs. Generally, larger worksites (750+ employees) were more likely to have health promotion programs (Fielding and Piserchia, 1989). Several well-designed studies have included worksite weight control programs that illustrate some potential strategies for altering employees' nutritional behavior. The Pennsylvania County Health Improvement Program, conducted among 12 small industries located in rural north-central Pennsylvania, established a county-wide risk factor reduction program (Brownell et al., 1984). After a program was introduced in a company, a ''heart-health committee" was established, composed of both labor and management personnel. The committee would then survey employee interests and risk factors and organize subcommittees to address the prevalent risk factors. The subcommittees would devise programs for reducing those risk factors that would be most appealing to employees. A total of 58 programs were established for the 4,200 workers involved in the study. The study found that weight loss competitions generated good recruitment, with immediate weight loss averaging more than 5 kilograms during the competition (although there was poor maintenance of that loss following the program—a recognized problem of most such efforts), and very low attrition (0.5 percent). Team competitions were more successful than individual competitions (Brownell et al., 1984: Felix et al., 1984). Financial incentives implemented through payroll deductions decreased attrition further to 6 percent in one program and to 21 percent in another (Stunkard et al., 1989). The Minnesota Heart Health Program combined on-site classes that emphasized behavior change with an incentive plan that involved financial commitment by the employer and the employees who participated in the program. Their weight loss program was characterized by high recruitment, low drop-out rates, and a reasonable short-term weight loss of approximately 7 pounds per participant (Jeffery et al., 1989). Finally, a study in a Cincinnati worksite included worksite screening for plasma lipids, a visit with the nutritionist, a group session every 3 months, and monthly follow-up telephone calls. At the end of a year, the men had reduced their mean dietary cholesterol intake from 444 mg/day to 304 mg/day, and their dietary fat intake had fallen from 38 to 31 percent of calories (Baer, 1993). While employee wellness programs have been successful in Western settings, the extent to which worksites in the NIS are prepared to embark on such programs is unknown. Schools/Other Educational Institutions Like worksites, educational institutions provide opportunities to both educate young people about healthy eating habits and provide healthy choices in their meal programs. A number of large, well-designed and -executed programs

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--> have demonstrated the effectiveness of school-based coronary risk reduction programs in several countries and ethnic groups (Stone et al.. 1989). Most involve the randomization of a number of schools to either no intervention or a program of cardiovascular health education supported by environmental changes conducive to the desired behavioral change. The following are examples of such programs: The North Karelia Youth Project studied 13 year olds (n = 904) with direct, indirect, and no interventions in each of two schools (Puska et al., 1985a,b). Among the children participating in the intervention, the ratio of polyunsaturated to saturated fat in the diet increased from 0.13 to 0.60 after 2 years. The Oslo Youth Study, which included 1,010 children in grades 5-7, saw a reduction in the use of butter and an increase in low-fat milk consumption after 1.5 years of intervention (Tell and Vellar, 1987). The "Know Your Body" study included 1,105 children in the fourth grade; a 5-year follow-up showed reduced consumption of dietary total fat (Walter et al., 1988). A similar program (the SEGEV Program) was undertaken in Israel in 16 Arab and Israeli schools; changes in nutritional habits were observed after 2 years of intervention (Tamir et al., 1988). The Heart Smart Program sought to change the entire school health environment in kindergarten through grade 6 with a health curriculum, a school lunch program, developmental programs for teachers and other school workers, and programs that could be taken home to adults (Downey et al., 1987; Butcher et al., 1988). Changes in eating behaviors among both adults and children were observed. The Minnesota Home Team Program included 15 classroom sessions for 2,250 third graders and a 5-week home-based course with parental involvement (Perry et al., 1989). Participation rates were high, and consumption of total and saturated fat fell relative to control schools, with some recidivism after one year. At least two of the above studies (Downey et al., 1987; Perry et al., 1989) illustrate the ability of school-based programs to affect the eating behaviors of parents and emphasize the importance of children taking such educational experiences home with them. School cafeteria programs also provide an opportunity to alter the eating behaviors of large numbers of children and young adults. Providing low-cholesterol, low-fat choices and identifying them as such are rather simple initial steps (Mayer et al., 1986; Zifferblatt et al., 1980). The resulting effect on the intake of total fat, saturated fat, cholesterol, and sodium among young people can be marked. In one study of boarding schools in which all meals were controlled, consumption of total and saturated fat was reduced by 9.3 and 21.8 percent,

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--> respectively, and there was good acceptance of the changes in the foods offered (Ellison et al., 1989). Thus it would appear that school-based programs in the NIS could have considerable long-term benefit in changing eating behaviors. Health education programs, with or without food service providing low-fat choices, may also have more rapid short-term effects if they include components targeting family-wide behavior. Such programs might be advocated by national or local governments or voluntary health organizations. The Role of Health-Related Groups Voluntary Health Organizations Organizations within national governments, local governments, and voluntary health organizations have used the mass media, including television, radio, newspapers and other print materials, posters, and billboards, to promote more healthful dietary behaviors. One example in the United States is the use of media in the National Cholesterol Education Program, directed by the National Heart, Lung, and Blood Institute, but involving a large array of voluntary organizations involved with disease prevention and health promotion (Bellicha and McGrath, 1990). In general, this program has sought to (1) give high blood cholesterol greater prominence on the public health agenda as a health concern, (2) improve and maintain awareness of the benefit of lowering high levels of blood cholesterol, (3) influence public perceptions of the causes of and means for reducing high blood cholesterol, (4) reinforce positive attitudes and behaviors as regards reducing high blood cholesterol, and (5) demonstrate skills for therapy maintenance (Bellicha and McGrath, 1990). Additional media-based programs, such as Project LEAN, have taken even more aggressive approaches (Samuels, 1993). Several community intervention programs have examined the ability of mass media to influence population-wide eating behaviors. The Stanford Three-Community Study was a two-year intervention in which a mass media campaign was conducted in two California communities, with a third community serving as a control (Farquhar et al., 1977). Dietary cholesterol was reduced 23 to 34 percent and saturated fat consumption 25 to 30 percent, both reductions being higher than in the control community (Fortmann et al., 1981). Media campaigns in the NIS could serve an important role in increasing awareness that certain dietary behaviors are a major cause of heart disease, demonstrating the benefits of lowering dietary fat and cholesterol as a way to prevent heart disease, reinforcing positive attitudes and behaviors toward eating low-fat foods, and demonstrating skills in the purchase and preparation of these healthful alternatives (Bellicha and McGrath, 1990). While it is unclear who might sponsor such a program in the NIS, such initiatives might be undertaken by the national government, voluntary health organizations, or even the media them-

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--> selves. Such efforts may be needed to counterbalance the advertising of products deleterious to heart health. In addition to the above large-scale efforts, voluntary health organizations such as the American Heart Association have often provided valuable health education materials in the form of posters, brochures, booklets, and the like. Such local-level media campaigns have the advantage of tailoring the message to the local population, including persons of different ethnic or language backgrounds. One such example is a low-fat milk campaign targeted at Spanish-speaking mothers of young children in New York City (Wechsler and Wernick, 1992). Instead of television and other expensive mass media, flyers, posters, local presentations, local radio, and supermarket programs were used. Similarly, rural populations may have different media channels that can be used effectively, such as newsletters, local newspapers, and church bulletins. The successful role played by nongovernmental health organizations in a number of nations suggests that the formation of such an organization in the NIS could be a useful step in heart health promotion. Health Professionals Endorsement and Advocacy The endorsement, if not the leadership, of the health professional community is essential to any national or local campaign to change nutritional behavior. Many programs described in the literature, such as the Minnesota Heart Health Program, have used health professionals to endorse and support interventions (Farquhar et al., 1990). The Minnesota Heart Health Program is a 13-year research project designed to reduce morbidity and mortality from coronary heart disease among whole communities in the upper midwestern United States. The program was easily able to recruit instructors such as dietitians, nutritionists, exercise instructors, and other health care workers. It held many classes and programs to educate and promote risk factor reduction (Murray et al., 1990). After a year of intervention, patients participating in a personalized risk factor screening education program showed a significant reduction in serum cholesterol, an increase in physical activity, a decrease in resting heart rate, and a decrease in systolic blood pressure as compared with a control group. The intervention group also displayed an increase in the selection of low-fat and low-sodium foods in local restaurants, as well as increases in the reading of food labels and the making of considered food purchasing decisions. Physicians and other health care professionals continue to be respected sources of health information. Health professionals can integrate dietary behavior change into routine counseling of patients. Such efforts can include the use of local forms of print media (e.g., brochures and pamphlets) as discussed above. In one project, adult patients in primary-care practices received, by mail, nutrition messages tailored by a computer to the patient's dietary intake, psychosocial

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--> factors, and willingness to change (Campbell et al., 1994). The group that received these tailored messages reduced total fat consumption by 23 percent. versus 9 percent for those receiving a nontailored message and only 3 percent for the control group. A number of strategies have been developed to assist primary care providers in becoming more effective in changing their patients' dietary behaviors (Ammerman et al., 1994). The extent to which health professionals in the NIS are supportive of or participate in preventive cardiology practices is not known. Nonetheless, professional education programs in the NIS could enhance the awareness, knowledge, attitudes, and intervention skills of physicians, nurses, nutritionists, and other health professionals with regard to total dietary fat, saturated fat, and cholesterol as causes of the current epidemic of coronary disease. Their active endorsement of any program would promote its success (Farquhar et al., 1990). Screening Screening for serum cholesterol and blood pressure, either as part of health care programs or through mass screenings at health fairs, is obviously part of a strategy to identify those at high risk of coronary disease because of these factors so they can be targeted for intensive interventions. At the same time, recommending such screening to health care practitioners and the public for widespread implementation is also an effective means of enhancing awareness of these risk factors among the general public (Carleton et al., 1991). In the Minnesota Heart Health Program, for example, a random sample of adults was offered a risk factor screening and education program that included a blood cholesterol screening (Murray et al., 1986). At the end of a year, those who had participated in the screening had significantly lower blood cholesterol levels than a randomly selected comparison group that was not screened. They were also more likely to select low-fat and low-cholesterol meals at local restaurants. These results illustrate the potential role of mass screening as part of a strategy to reach the general population, as well as those at high risk. A major issue, however, is whether the health care systems in the NIS could afford such a screening initiative. Unfortunately, many persons at highest risk are least likely to present themselves for screening. There is also concern about the effects of screening among those found to have desirable serum cholesterol levels. Although the U.S. goal is to reduce the dietary consumption of fat and cholesterol population-wide, one study demonstrated that persons with normal cholesterol levels had a reduced inclination to change their diet when told their cholesterol levels were normal (Kinlay and Heller, 1990). Clearly, this finding demonstrates the need to provide appropriate counseling for all persons screened for blood cholesterol, regardless of cholesterol level. Community Health Interventions There has been some recent concern about the effectiveness of community interventions in changing behaviors and risk factor levels (Luepker et al., 1994). However, there is reason for optimism that popula-

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--> tion-wide nutrition interventions and other community-wide risk factor programs might be especially effective in the NIS. Certainly, such a program has been successful in neighboring Finland (Puska et al., 1985b; see also Puska, in this volume). It is difficult to demonstrate the effectiveness of community interventions in the United States in part because of long-term secular changes affecting the whole population in knowledge, attitudes, behaviors, risk factors, and even death rates related to cardiovascular disease (Winkleby, 1994). Thus it is difficult to identify any additional positive effects of interventions designed to address these factors. As a result, community-wide interventions have been proposed for populations, including subgroups in the United States, among whom risk factors and deleterious health behaviors are still highly prevalent (Winkleby, 1994). Such appears to be the case in most of Eastern Europe, including the NIS. Considerable recent experience with community-wide interventions suggests the need to have realistic expectations of these programs (Mittelmark et al., 1993). However, within this context, the NIS might benefit from one or more such efforts to modify high levels of dietary fat and cholesterol. Many of the strategies already discussed, such as media campaigns, worksite programs, school-based interventions, and health professional initiatives, might be combined in such interventions. Conclusions The populations of the NIS appear to consume saturated fat and cholesterol at levels similar to those previously prevalent in the United States, which has successfully reduced consumption of these macronutrients on a population-wide basis over the past 30 years or so. If there is no evidence of widespread undernutrition, the interventions available to governments, food producers, institutions, and health organizations may be similar to those tried singly or as a comprehensive program in the United States or other Western countries. Several points deserve emphasis in this connection. First, the interventions selected should take into account the organization of the community targeted, as well as the resources available. Second, the use of several different interventions, sponsored by several different organizations, may be the most effective approach to the social marketing of dietary change. Third, there is a great need for population-wide surveillance (Carleton and Lasater, 1994), as well as specific evaluation programs, so that intervention programs can evolve as needs and resources change. Finally, while cultural factors, social organization, economic resources, the lack of private and voluntary organizations, and a dearth of population-wide data may limit the generalizability of programs proven successful in the United States and other Western countries, those programs can serve as a starting point for programs unique and appropriate to the NIS.

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--> Wysowski, D.K., D.L. Kennedy, and T.P. Gross 1990 Prescribed use of cholesterol-lowering drugs in the United States, 1978 through 1988. Journal of the American Medical Association 263:2185-2188. Zifferblatt, S.M., C.S. Wilbur, and J.L. Pinsky 1980 Changing cafeteria eating habits. Journal of the American Dietetic Association 76: 15-20. Notes 1.   Most evidence supports the notion that these dietary constituents adversely affect serum lipids and lipoprotein levels (Grundy and Denke, 1990; Kris-Etherton et al., 1988). However, additional mechanisms have also been proposed, since dietary saturated fat and cholesterol correlate with coronary disease incidence even after adjustment for serum cholesterol levels (Shekelle et al., 1981). Two mechanisms proposed have been the effect of dietary saturated fat on blood pressure (Puska et al., 1983) and the ability of high-fat diets to increase blood-clotting factors (Hornstra, 1990; Marckmann et al., 1993). 2.   These organizations include the National Academy of Sciences/National Research Council (National Research Council, 1989), the U.S. Surgeon General (U.S. Department of Health and Human Services, 1988), the U.S. Department of Agriculture (U.S. Department of Agriculture and U.S. Department of Health and Human Services, 1995), the American Heart Association, and the National Cholesterol Education Program (Carleton et al., 1991). 3.   The present discussion of strategies assumes that both quantitative dietary changes (i.e., reduction in calories, fat, and cholesterol) and qualitative dietary changes (i.e., replacement with alternative foodstuffs that do not increase coronary risk) are needed.