SPECIAL ARTICLE

Improving America' s Diet and Health: From Recommendations to Action

PAUL R. THOMAS

Food and Nutrition Board, Institute of Medicine, National Academy of Sciences, Washington, DC 20418

"It is time to accelerate efforts to improve America' s diet and health."

This is the calI to action of a new report issued by the Food and Nutrition Board of the Institute of Medicine, National Academy of Sciences. The report, titled lm­proving America's Diet and Health: From Recommen­dations to Action (1), lays out strategies and actions to implement the scientific consensus that has emerged on the use of dietary guidelines as a means to improve health. These recommendations are not directed to individuals but to the sectors of society that bear special responsi­bilities for encouraging and enabling people to eat better. This report has important implications-and provides extensive support-for the activities of nutrition profes­sionals.

lmproving America's Diet and Health proceeds from the understanding that broad agreement now exists on the overall nature of dietary modifications that can re­duce the risk of diet-related chronic diseases. While there is admittedly more to be learned about optimal eating patterns, the main challenge now is to assist an entire population to eat in a manner that will improve its chances for a healthier life.

Already, much progress is being made to meet this challenge. For example, many federal and state programs exist to implement dietary recommendations, the private sector is producing and promoting food products that

This study was supported by the Henry J. Kaiser Family Foundation (Grant No. 87-4338) and the National Cancer Institute (Contract No. N01-CN-85072).

Copies of the report are available for $29.95 (plus $3.00 postage/han­dling on prepaid orders) from National Academy Press, 2101 Consti­tution Avenue, NW, Washington, DC 20418; 1-800-624-6242.

Members of the Committee on Dietary Guidelines Implementation are Edward N. Brandt, Jr. (Chair), Norman M. Kaplan (Vice-chair), Stanley Aronson, Lorelei DiSogra, Janice M. Dodds, Charles Dwyer, Johanna T. Dwyer, John W. Farquhar, Joan D. Gussow, D. Mark Hegsted, H.O. Kunkel, Lester Lave, Bernard J. Liska, Beatrice Marks, Odonna Mathews, Richard E. Petty, and Bonita Wyse. Liaison meJ11-bers are Henry Blackburn, Donald B. McCormick, and Anthony B. Miller. Paul R. Thomas is Study Director. 0022-3182/91/2303-0128$03.00/0 © 1991 SOCIETY FOR NUTRITION EDUCATION

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help people meet various recommendations, and there is an increasing recognition by health-care professionals of the links between diet and the risk of many chronic degenerative diseases. Yet these efforts, although com­mendable, have been fragmented, not necessarily con­sistent, and thus insufficient to promote large-scale di­etary modification. There remains a clear need for comprehensive and coordinated actions to improve America' s diet and health. This report represents the first major attempt to develop such actions for the United States. Both Canada (2) and Australia (3) have already issued reports on implementing their dietary recom­mendations.

BACKGROUND

This report is the product of a three-year effort by 20 experts in diverse fields-from nutrition education and dietetics to medicine, social psychology, economics, and public relations-organized as the Committee on Dietary Guidelines Implementation. Many outside individuals and organizations supplied information to the committee.

The committee determined that effective impie men­tation of the dietary recommendations requires the fol­lowing broad initiatives:

• enhancing awareness, understanding, and accept­ance of the dietary recommendations;

• creating legislative, regulatory, commercial, and ed­ucational environments supportive of the recom­mendations; and

• improving the availability of foods and meals that facilitate implementation of the recommendations.

Both individual and societal actions are needed to en­courage and enable Americans to alter their food con­sumption practices in more healthful directions. Indi­viduals are responsible for seeking out and using information to improve their personal eating habits. So­ciety has the responsibility of facilitating the adoption of better diets by increasing the availability and accessi­bility of health-promoting foods and by using its consid-

J. of Nutr. Educ. Vol. 23, No. 3

erable resources to make such foods economical, ap­pealing, and easily identifiable (e.g., through improved nutrition labeling and nutrition education). Society also has an obligation to ensure that food choices over which individual consumers rarely have control (e. g., meals served in institutional cafeterias or at various social events) are, whenever possible, sufficiently varied so that those who wish to eat in accordance with the principles of dietary recommendations are able to do so.

In the course of its work, the committee examined determinants of food choice, current American eating patterns, consumer attitudes and beliefs about food and nutrition, and the special needs of the poor and disad­vantaged. It also reviewed current theory and practice in promoting healthy behaviors. A major section of the report is devoted to these issues.

The committee also generated a wide range of strat­egies for modifying eating behavior. To the extent pos­sible, each strategy was examined in terms of criteria (e. g., public acceptability, affordability, political feasi­bility) that served as the basis for selecting interventions and actions that the committee judged most likely to be successful. The committee concluded that its recom­mended strategies and actions could not be put in any order of priority because they are diverse and their im­plementation would involve different societal sectors.

M uch of the committee' s work was do ne by four task forces, each focusing on a specifie societal sector: public, private, health-care professions, and public education (from formaI schooling to public relations and advertis­ing). These groupings were an effective mechanism for identifying the main interventions that have been at­tempted, for recommending those that might be under­taken, and for identif)lÏng opportunities and barriers to implementation. A large section of the report describes in detail the recommendations developed for each of these sectors (see Table 1).

PRINCIPAL COMMITTEE RECOMMENDATIONS

After deciding upon recommendations to individual so­cietal sectors, the committee developed three overall strategies that it believes should form the basis for fur­thering the implementation of dietary recommendations throughout American society.

Governments and health-care professionals must be­come more active as policymakers, role models, and agenda setters in implementing dietary recommenda­tions. Governments from the federal to locallevels have many opportunities to encourage, empower, and enable more people to improve their diets. The opportunities come largely from their control over the spending of public funds and by their ability to set public policy (e.g., enact legislation and revise laws and standards) and to

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Table 1. Recommendations to various sectors of society to implement dietary recommendations (DR).

Recommendations to Governments • Establish a coordinating mechanism at the federallevel to

implement DR and encourage action by federal and state legislative bodies.

• Alter food assistance, food safety, and nutrition programs, as weil as farm subsidy, tariff, and trade programs.

• Change laws, regulations, and agency practices that affect the foods choices of consumers (food labeling, standards of identity, grading standards, etc.).

• Improve government feeding facilities and enable them to serve as models to private food services.

• Develop a comprehensive nutrition research, monitoring, and evaluation plan.

Recommendations to the Priva te Sector • Promote DR and motivate consumers to use them through

improved food labels, point-of-purchase information, etc. • Continue to increase the availability of a wide variety of

health-promoting, appealing foods.

Recommendations to Hea/th Professiona/s • Raise the level of knowledge about food, nutrition, and

dietlhealth relationships through formai schooling and con­tinuing education programs.

• Provide nutrition information during interactions with clients and patients, and serve as role models and leaders in implementation.

• Intensify research on understanding relationships between food, nutrition, and health and how to promote more ef­fectively the consumption of healthful diets.

Recommendations for Education of the Public • Ensure that consistent educational messages about DR

reach the public by convening meetings among national groups and by developing panels to develop guidelines and to review materials.

• Incorporate principles, concepts, and skills training that support DR into ail levels of schooling from kindergarten through college.

• Ensure that children in child-care programs receive nutri­tious meals served in supportive environments.

• Enhance opportunities for consumers to increase their knowledge and skills to meet DR through the development of a continually updatable foods data bank and a manual containing strategies to influence food providers.

• Establish educational and training systems for designing, implementing, and maintaining community-based inter­ventions to improve dietary patterns.

• Enlist the mass media to help motivate and equip con­sumers to make health-promoting dietary choices.

bring public attention and interest to issues they deem important. The federal government, for example, is re­viewing or revising its policies on food labeling, standards of identity and grading of food, and the distribution of surplus food commodities as a result of knowledge and concerns about di et and health. Greater interest and action by governments in promoting healthy lifestyles is likely to further improve dietary patterns in the United States-particularly if its top leaders become involved and if governments participate in implementation efforts developed by other societal sectors.

130 Thomas /DIET & HEALTH

Health professionals, viewed by the public as credible authorities on health and disease, have many opportu­nities to encourage and instruct people on how to im­prove their dietary habits and other health-related be­haviors. Working alone and collectively, they should apply their knowledge of diet and disease connections to im­prove their own diets and the diets of their clients. Health­care professionals can also create or encourage initiatives to improve dietary patterns in their communities. Fi­nally, they should contribute to the development oflocal, state, and national food policies and to the establishment of social environments that encourage healthy eating.

Improve the nutrition knowledge of the public and in­crease the opportunities to practice good nutrition. If individuals are to be encouraged to take responsibility for adopting and maintaining healthy behaviors, they need information (to identify problem behaviors and how to improve them), motivation (to make the changes), and supportive environments (to maintain the changes).

Because attitudes toward food are formed to a great extent during childhood, incorporating the principles of food, nutrition, and health into child-care settings and preschool, elementary school, and secondary school ed­ucation-and providing children with health-promoting meals in those settings--offers major opportunities to encourage the development ofhealthful eating patterns. In addition, institutions of higher learning should make available to students a course in nutrition or a health course that includes nutrition as a major component. If health professionals are to help the public to eat better, they need adequate training about the role of diet in disease prevention and treatment and the practical ap­plications of dietary recommendations at their educa­tional institutions and in continuing education programs. Schools that train chefs and cooks should also place an emphasis on dietary recommendations and how they can be incorporated in the preparation of nutritious and health-promoting meals.

In addition to formaI schooling, many other oppor­tunities exist to inform consumers about diet and disease connections and how to develop healthy food habits. Worksites provide important opportunities for health and nutrition education. Many food retailers and food-service establishments can provide point-of-purchase informa­tion and literature to their customers.

Television, radio, popular magazines, and other media exert powerful influences on people's lives. Organized campaigns to disseminate, explain, and promote dietary recommendations through a variety of media offer great potential for improving eating patterns. Emphasis must be placed on modifying entertainment programs so that both participants and plots support good eating habits. Successful media campaigns will have to be coordinated with community-based health promotion efforts.

Local communities can be a powerful force that shapes

the lifestyles and health behaviors of their residents. Therefore, community-based interventions have enor­mous potential for improving dietary patterns. Interven­tions include the development of nutrition education programs at such places as worksites, schools, places of worship, and city or county health departments, as weIl as the provision of information on diet and health at these sites and in local supermarkets, restaurants, government offices, offices of health professionals, and many other locations. Communities could establish nutrition and health committees to generate and coordinate local ac­tivities.

Increase the availability of health-promoting food. The U. S. food supply is abundant in variety and high in qual­ity. As technology permits and as marketing opportu­nities are identified, the private sector has been modi­fying many traditional products to make them more nutritionally desirable.

Yet successful implementation of dietary recommen­dations requires that consumers have greater access to health-promoting foods on those occasions when they are unable or unwilling to prepare it. Those who provide and prepare food in hospitals, at worksite cafeterias, at airlines, and in vending machines should examine their policies and practices to determine how they can conform to the principles of dietary recommendations. The same applies to food services and food programs administered by Federal, state, and local governments, including gov­ernment cafeterias and the School Lunch Program. Res­taurants, cafeterias, and fast-food outlets have special responsibilities to promote better eating by providing foods and meals, prepared in attractive and tasty ways, that help people to meet dietary recommendations.

Other important points. Initiatives to implement dietary recommendations should be linked with other health­promoting practices whenever possible. Various personal behaviors (e. g., refraining from smoking and engaging in regular exercise) and other factors (e.g., access to health-care services and the state of the environment) are also strongly linked to risks of disease and should not be neglected in health promotion programs by an over­emphasis on diet.

Because the food system and public responses to new dietary patterns change slowly, a realistic time frame for implementation will be measured in years and perhaps decades. A long-term commitment to implementation by promoting incremental changes is required to ensure success.

IMPLICATIONS FOR NUTRITION PROFESSIONALS

Professional nutritionists, acting individually and through

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their professional societies and associations, are key play­ers and natural leaders in almost aIl efforts to improve dietary patterns in this country.

• In their educational role, they teach a wide variety of audiences, including other health professionals such as doctors and nurses, and provide patients with dietary assessments, counseling, and resources.

• By following dietary recommendations themselves, nutritionists serve as highly credible role models. In this modeling role, they can provide dietary information and advice based in part on their personal experiences.

• As organizers, they can initiate or contribute to community programs to improve nutritional status.

• In their advisory role, nutritionists can help gov­ernment officiaIs promulgate desirable regulations and guidelines pertaining to food, nutrition, and health pol­icy.

• As investigators, they gain new insights into the causal relationships between diet, genetic factors, and disease and learn more about the factors that govern behavior change and how to mobilize communities to promote healthy behaviors. Because financial and human resources for implementing dietary recommendations are limited, continued research is essential to establish a

June 1991 131

better base for designing effective and efficient strategies and for assessing their costs and benefits.

M uch remains to be done to improve America' s diet and health. The authors of Improving America's Diet and Health hope that this report will provide implementors with useful ideas, information, resources, and insights for accomplishing that task. Success will require un­precedented levels of collaboration among the many en­tities involved in providing nutrition information, edu­cation, and food to the public.

Ifs time to move ahead with renewed vigor and en­thusiasm.

REFERENCES

1 Institute of Medicine. Improving America's diet and health: From recommendations to action. Committee on Dietary Guidelines Im­plementation, Food and Nutrition Board. Washington, D.C.: Na­tional Academv Press, 1991.

2 Comll1unicatiOl~s/Implell1entation COll1mÎttee. Action towards healthy eating . .. : Canada's gUidelinesfor healthy eating and recommended strategies for implementation. Ottawa: Health and Welfare Canada, 1990.

3 Subcoll1ll1ittee on Nutrition Education, National Health and Medical Research Council. Implementing the dietary guidelines for Austral­ians. Canberra: Australian Government Publishing Service, 1989.

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