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Nutrition Education . . . . JOHANNA T. DWYER Many factors, including economics, personal lifestyles, trends in the food supply, and psychology, exert powerful influences on what people eat. Consumers do not base food choices largely on their consideration of the right mix of nutrients for optimal health and disease prevention. However, many consumers want and will use health-related nutritional advice that takes all the reasons they eat into account and phrases dietary recommendations in ordinary language at the level of food choice (Dwyer, 1984~. The task for nutrition scientists is to develop such recommenda- tions, especially for those most likely to be at nutritional nsk; to test their utility; and to communicate them to appropriate target groups. Three misconceptions related to nutrition education research and policy limit our ability to make sound recommendations: Scientists know what He most nutritionally vulnerable are eating today. ~ The basic four food guide (described later in this chapter) is the best food guide for the l980s. Diets of the general population are unrelated to diets prescribed for medical or therapeutic purposes. Nutrition scientists can help to dispel these misconceptions by recog- nizing the realities that refute them and making appropriate recommen- dations for action. 150

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NUTRITION EDUCATION 151 EATING PATTERNS OF THE NUTRITIONALLY VULNERABLE Misconception 1: Scientists know what the most nutritionally vulnerable are eating today. In reality, little is known about the current dietary intakes of some nutritionally vulnerable subgroups, especially those who are multiply vulnerable because of several risk characteristics. Swann (1983) has recently reviewed evidence on dietary intakes of the population obtained from the U.S. Department of Agriculture (USDA) Nationwide Food Consumption Survey (NFCS) and the U.S. Department of Health and Human Services (DHHS) Health and Nutrition Examination Surveys (HANES). These surveys provide benchmark data about what the population ate at the time the surveys were conducted. They also provide some helpful nutrition information on subgroups within the pop- ulation, such as the poor. However, these surveys have two limitations. First, because they survey a representative sample of He entire population, it is not possible to sample all the subgroups that may be of particular interest, that is, those that possess a constellation of risk factors believed to confer nutritional vulnerability. Such subgroups include the poor who are ill or who have physical or mental disabilities, the poor who have recently migrated to this country from war-torn countries in Southeast Asia or countries in the Western Hemisphere, illegal migrants, and the mentally ill who are homeless. Current estimates of how many of these persons are under- or maInounshed differ considerably. A second limitation of these surveys is that they are dated; results are several years old, and times have changed. Obtaining timely nutritional information is important, especially for high-nsk groups, when, for ex- ample, changes in social welfare and public assistance programs, espe- cially those involving categorical grants, are being contemplated. Since federal grants of the categorical type are for very specific purposes, such as nutrition, arguments in favor of continuing or discontinuing them should be based in part on the evidence of their effects on nutritional status. Recommendations Several recommendations emerge from this picture of the nutritionally vulnerable. First, existing surveillance efforts should continue. Since 1980, the budget of the National Center for Health Statistics has been cut by 28%, and staff reductions have totaled 12% (Burnham, 1984~. Further cuts in major programs for descriptive statistics on the food consumption and health of the population must be avoided in both USDA and DHHS. It is vital that the federal government continue to collect these descriptive statistics. It is unlikely that surveys conducted by private or voluntary

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152 PERSPECTIVES ON NATION PROMS, POLICY, AD RESEARCH groups could ever be sufficiently large to provide valid samples of the entire population. Nor would statistics derived from such surveys be re- garded as authoritative and plausible by all the various parties and interest groups that are involved in making national nutrition policy. Regardless of what the federal government's role is in health and nutrition intervention programs, the government clearly is responsible for documenting food consumption and health status of the population and characteristics of groups that are especially likely to be adversely affected by nutrition policy. These kinds of data are particularly important if states, localities, and nongovernmental groups will, in the future, assume greater respon- sibility for social intervention programs. A second recommendation is Hat nu~ition-monitonng mechanisms must be developed. These mechanisms could be integrated with the existing nutritional status surveillance systems to increase timeliness, improve co- ordination, and increase target group specificity (e.g., focus on groups that are expected to experience particular nutritional problems). A third recommendation is Nat groups at high nutritional risk should be assessed for the potential effects that any changes in government pro- grams might have. These groups include He so-called "attractive" vul- nerable people, such as pregnant women, infants, and children, as well as He '`unattractive" vulnerable peoplewhose problems are even more profoundsuch as the homeless, the mentally ill, the indigent sick, and refugees. With data available now, it is possible to guess how changes in categorical programs would be likely to affect these groups; if several categorical grant programs were cut simultaneously, the effects would be even more pronounced. With present data, however, it is impossible to make predictions about their ultimate effect on nutritional status. When assessing effects of government program changes on groups at high nutritional nsk, it is important to evaluate more carefully persons who have several characteristics that impart nutritional risk, such as pov- erty~r near poverW~ombined with poor health, poor education, or other disabilities. Many of the legislative changes in the Omnibus Budget Reconciliation Act of 1981 (P.~. 97-35) were crafted without these careful evaluations. This led to sometimes needless disruption and suffering among a number of disadvantaged groups (Nathan and Doolittle, 1983; Palmer and Sawhill, 1984~. One example is the confusion wrought by this law among many disabled and deserving Social Security insurance disability recipients whose payments were terminated and then restored after a con- siderable delay. The end result was few or no monetary savings and great anxiety among this vulnerable population. Federal and state executive agencies also need to be judicious, com- passionate, and aware of how simultaneous changes in several categorical

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NUTRrTION EDUCATION 153 grants (such as Elderly Meals) and entitlement programs (such as Medicare and Social Security) may affect vulnerable populations. It is their re- sponsibility to write regulations that minimize negative effects on these groups. In addition, the academic community, especially community nu- trition researchers, must improve its documentation of the natural history of changes in dietary status and nutritional health of various groups at high nutritional risk as programs change. In spite of major changes in the economy and in categorical programs in recent years (Nathan and Doo- little, 1983; Palmer and Sawhill, 1984), few solid studies reporting the effects of program changes on health and nutritional status have appeared in peer-reviewed journals. These descriptive studies have potential impact on policy and thus are too important to leave to social welfare advocates or their critics to conduct wig the use of indirect measurements of nu- ~itional and health effects. FOOD GUIDANCE SYSTEMS Misconception 2: The basic four food guide was the best food guide in the 1950s, aM it remains so today. The guide recommended specified numbers of servings to be eaten each day from four food groups: fruits and vegetables; meat, pouchy, fish, eggs, and beans; breads, grains, and cereals; and milk and milk products. In reality, over, better food guidance systems exist for Me 1980s. The so-called "basic five" guide, which adds fats, sweets, and alcohol, is a step in the right direction but not quite far enough. There is ample evidence that Americans are not presently obtaining enough of some key nutrients (Pao and Mickle, 19811. And a recent publication demonstrated that the basic four food guide does not adequately assist American consumers in the 1980s with good eating habits (Crocetti and Guthrie,1983~. It is well known that the Recommended Dietary Al- lowances in Heir present form (NRC, 1980) and the Dietary Guidelines for Americana (USDA and DHHS, l9X0) also have limitations for planning family meals or as eating guides (Dwyer, 19811. The pnnciples embodied in the basic four guide, that is, sufficiency, variety, and balance, are still valid. However, food guidance must also address economic issues, moderation, the enormous variety of available foods, current eating habits, and diet-related problems. Severe guides that deal with these issues are available. Nutrition and Your Health: Di- etary Guidlelines for Americans (USDA and DHHS, 1980) was the first attempt to modify the basic four guide by stating some additional principles about nutrient intake and suggesting their applications. Also helpful is a recently released food guidance system that was developed by the USDA

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154 PERSPECTIVES ON NUTRITION PROGRAMS, POLICY, kD RESEARCH for the American Red Cross's nutrition course (American National Red Cross, 19841. It includes a good food guide as well as additional nutrition education materials for age and physiological groups with special needs. Another good food guide is USDA's Ideas for Better Eating (USDA, 19811. Several new publications on diet for consumers may also be avail- able soon from DHHS. The development of a single food guidance system that all public, private, and voluntary groups endorse is probably impossible. However, it may be possible to develop consensus statements on general nutrition principles that could be included in all systems. The National Institutes of Health (NIH) Consensus Conferences on various biomedical issues may offer the forum to develop these statements. For example, one of the NIH Consensus Conferences in 1985 was devoted to obesity and its health risks; conferences on other issues that must be resolved for the develop- ment of food guidance materials should also be held. These conferences have the benefit of being more specific and perhaps more removed from partisan politics and the policymaking process than are such committees as the executive branch's Dietary Guidelines Review Committee. At the very least, such consensus conferences and other forums can supplement and enrich the other policymaking committees. They can be used as a basis for developing special recommendations for specific therapeutic pur- poses. Recommendations Observations of past and present food guidance systems suggest that the most recent ones, for example, the basic four and basic five food guides and USDA's Ideas for Better Eating (1981), should be evaluated with consumer testing. The empirical results of such testing should then be examined and the systems changed accordingly so that nutritional advice fits the dietary actualities of Americans in the 1980s and takes into account public understanding of the scientific issues involved (Funkhauser, 19721. Nutrition education materials should be developed for nutritionally vul- nerable, high-risk groups (e.g., refugees and illegal migrants from Latin America' Haiti, and Southeast Asia). They should be based on the best food guidance systems and results from studies of the groups' character- istics and lifestyles. These materials should be useful adjuncts to food, health, and over assistance programs. Because these persons' lives differ from those of the mainstream population with respect to economic levels, education, health status, and in some cases, culture, special efforts will be needed. Federal involvement is esseniial-because private and local government resources and expertise do not exist to develop such materials.

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NUTRTRON EDUCATION 155 PREVENTIVE AND THERAPEUTIC DIETS Misconception 3: Nutritional recommendations for persons at risk for, or who already super from, a particular disease are unrelated to rec- ommendations for the general population. In reality, the eating patterns, food supply, and diets of the larger society exert important influences on those persons who eat modified diets for preventive or therapeutic reasons. Moreover, therapeutic recommendations are based on usual recommen- dations in most respects. The larger nutritional environment can be sup- portive or destructive to the maintenance of special dietary regimens, such as low-fat, low-protein, or low-calorie diets. Recent research findings suggest a role for diet in the treatment of disease. Some examples include the possible role of low-protein thera- peutic diets in delaying chronic renal failure and hemodialysis (Alvestrand et al., 1982; Barsotti et al., libel; Maschio et al., 1982; Mitch, 1984~; the need for reexernining the recommended restriction of simple carbo- hydrates and emphasis on complex carbohydrates in diabetic diets (Ienkins et al., 1982; Kolata, 1983~; and He possible role of low-fat diets in preventing colon and breast cancers (Hernandez, 19841. Investigators are testing such hypotheses with metabolic studies in hu- mans (Hernandez, 1984; Mitch, 1984), and NIH has recently launched two feasibility studies for large-scale clinical trials involving high-risk patients or patients who are already suffering from cancer of the breast or early end-stage renal disease. The ease with which patients adhere to special diets in these trials will vary, depending on how the food supply and food habits change. For example, if low-fat products become more widely available to consumers, patients in the lipid-lowering and breast cancer trials will find it easier to eat diets very low in fat without making extraordinary efforts to do so. In addition, with regard to experimental design, dietary changes in the larger population may alter the number of subjects needed to detect true differences between those on usual diets and those on experimental diets, if such differences do exist. Recommendations One recommendation regarding nutritionally vulnerable people is that descriptive research is needed on the diets and diet-related beliefs of persons who are at risk for a disease or who have been prescribed diets for chronic degenerative diseases requiring therapeutic dietary alterations. What these persons actually believe or do about diet is not well known (Dwyer, 1983; McNutt, 19X01. It is important to describe the eating habits

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156 PERSPECTIVES ON NUTRITION PROGRESS, POLICY, AD RESEARCH of these persons in order to develop nutrition education efforts to help them. A second recommendation is to develop authoritative guidelines to clarify for the public the differences between preventively oriented diets for those at risk of disease and therapeutic diets for those already afflicted by disease. Consumers are often unaware of He differences, and without consulting their physicians, they may mistakenly embark on extremely modified diets of their own devising. The elderly and Nose at high risk for cancer are groups especially likely to do so. CONCLUSIONS Federal support for biomedical research, including nutrition research, has been relatively strong over the past decade (Dickson, 19841. Advances in fundamental knowledge have been considerable, and it is important that such support continue. Modest support for nutrition education research is needed, as are funds for maintaining and expanding descriptive research- based on nutritional and health statistics- Cat will better monitor nutri- tionally vulnerable high-risk groups. These applied research efforts should result in nutrition policy that is more sound and in the application of nutrition science to the daily lives of Americans. REFERENCES Alves~and, A., M. Ahlberg, P. Furst, and J. Bergstrom. 1982. Clinical results of long-term treatment with a low protein diet and a new amino acid preparation in patients with chronic ~ uremia. Clin. Nephrol. 19:67-73. American National Red Cross. 1984. Better Eating for Better Health. American National Red Cross, Washington, D.C. Barsotti, G., A. Guidicci, F. Ciardella, and S. Giovanetti. 1981. Effects on renal function of a low nitrogen diet supplemented with essential amino acids and ketoanalogues and of hemo- dialysis and free protein supply in patients with chronic renal failure. Nephron 27:113-117. Burnham, D. 1984. Staff cuts for statistical agencies are studied. New York Times, Friday, November 23, p. A24. Crocetti, A. F., and H. A. Guthrie. 1983. Eating Behavior and Associated Nutrient Quality of Diets. Anarem Systems Research Corporation, New York. Dickson, D. 1984. Pp. 11-56 in the New Politics of Science. Pantheon Books, New York. Dwyer, J. T. 1981. Consumer needs for the translation of the recommended dietary allowances. Pp. 237-257 in the Beltsville Agricultural Research Symposium Proceedings. U.S. Department of Agriculture, Washington, D.C. Dwyer, J. T. 1983. Dietary recommendations and policy implications: The U.S. experience. Pp. 315-355 in J. Weininger and G. Briggs, eds. Nutrition Update, Vol. 1. John Wiley and Sons, New York. Dwyer, J. T. 1984. The optimal diet: An impossible dream? National Forum (Phi Kappa Phi) Winter: 10- 14.

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NUTRITION EDUCATION 157 Funkhauser, G. R. 1972. Public understanding of science: The data we have. Presented at the Workshop on the Goals and Methods of Assessing the Public's Understanding of Science. Materials Research Laboratory, Pennsylvania State University, University Park, Pa. Hernandez, T. B. 1984. Fat and Breast Cancer: Summary of Literature Review of Epidemiologic and Metabolic Studies in Humans. JWL International Corporation, Annandale, Va. Jenkins, D. J. A., R. H. Taylor, and T. M. S. Wolever. 1982. The diabetic diet, dietary carbohydrate and differences in digestibility. Diabetologia 23:477. Kolata, G. 1983. Dietary dogma disproved. Science 220:487488. Maschio, G., L. Oldrizzi, and N. Tessitore. 1982. Effects of dietary protein and phosphorus restriction on the progression of early renal failure. Kidney Int. 22:371-376. McNutt, K. 1980. Dietary advice to the public. Nutr. Rev. 19:570-578. Mitch, W. E. 1984. The influence of the diet on the progression of renal insufficiency. Annul Rev. Med. 35:249-264. Nathan, D., and E. Doolittle. 1983. The Consequences of Cuts. Princeton University Press, Princeton, N.~. NRC (National Research Council). 1980. Recommended Dietary Allowances, 9th ed. A Report of the Food and Nutntion Board, Assembly of Life Sciences. National Academy of Sciences, Washington, D.C. Palmer, J., and I. Sawhill. 1984. The Reagan Record. Urban Institute, Washington, D.C. Pao, E. M., and S. J. Mickle. 1981. Problem nutrients in the United States. Food Technol. 35:69-79. Swann, P. S. 1983. Food consumption by individuals in the United States: Two major surveys. Annul Rev. Nutr. 3:413432. USDA (U.S. Department of Agriculture). 1981. Ideas for Better Eating: Menus and Recipes to Make Use of the Dietary Guidelines. U.S. Government Printing Office, Washington, D.C. USDA and DHHS (U.S. Department of Agriculture and U.S. Department of Health and Human Services3. 1980. Nutrition and Your Health: Dietary Guidelines for Americans. HG232. U.S. Government Printing Office, Washington, D.C. 20 pp.