Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 150
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
OCR for page 151
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
OCR for page 152
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 people—whose problems are even more
profound—such 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
OCR for page 153
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
OCR for page 154
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.
OCR for page 155
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
OCR for page 156
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.
OCR for page 157
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.
Representative terms from entire chapter:
nutrition education
