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The Role of Nutrition Research in Policy and Program Planning JEAN-PERRE HABICHT Perceived needs motivate policies and programs. As these are imple- mented, additional perceptions about needs result in new and changed policies and programs. Scientific research can improve this process by helping to define needs and by encouraging He development of effective, efficient, and equitable policies and programs to meet them Nutntionists measure nutrient needs according to the National Research Council's Recommended Daily Allowances (RDAs) and Recommended Energy Intakes (REIs) (NRC, 1980~. These measures are used to estimate inadequate intakes in populations. However, those scientists who set the RDAs and REls gave insufficient consideration to the potential harm of safety margins that are too generous, and nutritionists who use the RDAs to interpret intake data from population surveys pay insufficient heed to the safety margins, which are variously inflated for various nutrients. Reported results, ~en, may show erroneously high inadequate intakes of some nutrients and distorted ranking of nutrients of public health concern. The Research Council's Food and Nutrition Board, which is responsible for sewing He RDAs, is examining this use of the RDAs for assessing the prevalence of nutritional problems (NRC, in press). Another issue that needs scientific attention is whether nutritional prob- lems affect a few persons or many, which would determine the policies and programs that are required. Clinical occurrences are not necessarily public health concerns amenable to public health and other nonclinical interventions that are appropriate only when a significant portion of a population is affected. Of course, consideration is given not merely to the 144

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ROLE OF NEUTRON ~SE~CH IN POLICY AD PROM PINING 145 number of persons afflicted but also to where those persons are clustered either geographically or within particular groups. The identification of such clusters depends on adequate nutrition surveillance. At the level of the total population, the United States is in the forefront in developing nutritional monitoring mechanisms. These systems, in which large national probability samples are surveyed, demonstrate that nutri- tional deficiencies in the United States today are relatively uncommon. (See paper by Woteki and colleagues in the first section of this volume.) In those rare instances in which classical nutritional deficiencies are iden- tified, they affect low numbers of the general population. Some high-risk groups, however, are simply not picked up by our current surveillance system: the elderly, Me homeless, runaway children, migrant laborers, and vagrant, psychologically debilitated persons. In short, all those without a residence or who do not respond to voluntary surveys are not sampled by current surveillance systems. To provide these unsampled persons with a safety net that goes beyond simply providing food, they must be identified, their nutritional needs understood, and appropriate strategies developed to meet their needs. Present surveillance systems are inadequate for this purpose. Large na- tional probability samples, an essential component of any national nutrition surveillance system, will not reveal prevalent nutritional problemseven if such problems are clustered. Nor will local probability sample surveys do much better. Therefore, a new, different kind of mechanism that can ascertain He needs of He few who are physiologically undernourished must be developed. Although there are few persons who suffer observable ill effects from malnutrition, many persons do not eat well, according to what Americans consider to be a suitable diet (Physician Task Force on Hunger in America, 1985~. For Amencans, a minimum suitable diet, in contrast to a physim logically adequate one, not only prevents overt malnutrition but also is psychologically and culturally acceptable, even if it is more expensive than a physiologically adequate but less acceptable diet. This attitude is, in fact, embodied in the policy underlying He U.S. Department of Ag- riculture's thrifty food plan (Code of Federal Regulations, 19821. It is therefore inappropriate to use only measures of physiological adequacy to determine whether persons have enough to eat. Nutritionists must re- define suitable diet, based on physiology, economics, and food likes and preferences. The classical nutritional deficiencies and unsuitable diets that typically concern nutritionists are not responsible for the nutrition-related illnesses that affect most Amencans. For example, the major nutrition-related cause of death among teenagers and young adults in the United States today is

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146 PERSPECTfVES ON NUTRITION PROGRESS, POLICY, ED BESEECH alcoholism. Although the solutions to alcoholism may be unfamiliar to nutritionists, the problem needs their concern and research. Another ex- ample: dental caries is a nutritionally caused heady problem with the highest incidence in the United States, although it is not a classic life- threatening deficiency clisease. And, in contrast to what many people believe, the most feasible approach to preventing dental caries is not simply to curtail sugar intake but to increase food resistance by the use of fluoride (Horowitz, 1980~. Furthermore, the feasibility of increasing fluoride intake by means of water and salt fluoridation is proven and under way, whereas no intervention that decreases sugar intake has been shown to be feasible on a large scale. Nutritionists could help decrease the incidence of dental caries by more forcefully supporting these findings in public education and policy formulation. Most deans and disabilities in the United States are caused by yet other diseases in which nutrition has either an etiologic, contributory, or ex- acerbating influence: atherosclerosis, stroke, diabetes, cancer, and osteo- porosis. For these diseases, knowledge about Be nutritional contribution is less well defined, and effective preventive interventions by nutritionists and others are still tentative. In spite of incomplete knowledge about nutrition and chronic diseases, enough is known or strongly suspected so that a prudent and informed person will select a diet different from the typical American diet. Such a diet, however, may not fulfill] the RDAs (NRC, 19801. For example, lowering of recommended total fat and salt intakes for disease prevention is almost incompatible with American palates and pocketbooks if the diet must also fulfill all the RDAs. If one also wants to consume a diet win fewer potential carcinogens and more protective factors against cancer, attaining the RDAs is jeopardized even more. One solution to this problem is for scientists to add these considerations to the physiological ones of the past when they set guidelines for a healthy diet. These considerations include concern for persons who wish to choose their own diets wisely, for dietetic counseling, for institutional food procurement, for food and nutrition policy, and for nutritional surveillance. Such an action requires an authoritative group, such as the Research Council's Food and Nutrition Board (which, in fact, now envisages this initiative), to look beyond the biochemical and clinical aspects of nutrition and to incorporate findings from epidemiology, economics, psychology, and other sciences in these new recommendations.

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ROLE OF NUTRITION RESEARCH IN POLICY ED PROM PINING 147 REFERENCES Code of Federal Regulations. 1982. Section 271. Title 7, Agriculture; Chapter II, Food and Nutrition Service; Subchapter C, Food S=np and Food Distribution Program; Part 271, General Inflation and Definitions. Office of the Federal Register, Washington, D.C. Horowitz, H. S. 1980. Theme 1 The prevention of oral disease. Established methods of prevention. Br. Dent. J. 149:311-318. NRC (National Research Council). 1980. Recommended Dietary Allowances, 9th ed. A report of the Food and Nutrition Board, Assembly of Life Sciences. National Academy of Sciences, Washington, D.C. NRC (National Research Council). In press. Nutnent Adequacy: Assessment Using Food Con- sumption Surveys. A report of a committee of the Food and Nutrition Board, Commission on Life Sciences. National Academy Press, Washington, D.C. Physician Task Force on Hunger in America. 1985. Hunger in America. The Growing Epidemic. Harvard University School of Public Health, Boston, Mass. 147 pp.