Perspectives in Disease Prevention and Health Promotion Progress Toward the 1990 Objectives for Improved Nutrition

In 1985, the Public Health Service (PHS) reviewed progress on the 1990 objectives for the nation (1,2). Although none of the 17 nutrition objectives had been achieved, six appeared to be possibly attainable by 1990; achievement of the others appeared either unlikely or uncertain because of a lack of baseline data and inadequate survey information.

The Food and Drug Administration (FDA) and collaborating federal agencies* recently reported to the Assistant Secretary for Health on progress toward achieving 15 nutrition objectives identified by PHS as having special priority (Table 1). The Association of State and Territorial Public Health Nutrition Directors (ASTPHND) reported at the same time on state activities related to the nutrition objectives. A summary of the reports of these agencies and ASTPHND follows.

Improved Health Status

Since the review in 1985, substantial progress has been made toward achieving nutrition goals, although some objectives are difficult to assess. For example, national trends in iron deficiency anemia in pregnant women and growth retardation in children cannot be assessed because of insufficient data. The 1986 CDC Pediatric Nutrition Surveillance System, which monitors the status of young children from high-risk, low-income families participating in certain publicly supported health programs, found that the prevalence of short stature in this group was 10.4% and that the rate of short stature varied substantially by ethnic groups (3). Surveillance and survey data from the 1970s and the early 1980s indicate that the prevalence of iron deficiency anemia among young children declined during this time span (4). Data from the third National Health and Nutrition Examination Survey (NHANES-III), to be conducted from 1988 to 1994 by the National Center for Health Statistics, CDC, will indicate whether that trend has continued.

Reduced Risk Factors

Progress toward reducing certain risk factors has varied greatly. The 1985 National Health Interview Survey (NHIS) reported that approximately 50% of overweight respondents indicated they were trying to lose weight, with almost half of this group both increasing physical activity and decreasing caloric intake (5). Data from NHANES-III will bee useful further assess trends in the prevalence of overweight during the 1980s. In 1985, the National Heart, Lung, and Blood Institute of the National Institutes of Health launched the National Cholesterol Education Program, a cooperative nationwide education effort to reduce the prevalence of high blood cholesterol. Detailed guidelines for detecting, evaluating, and treating high blood cholesterol in adults have been developed to aid physicians and other health professionals in diagnosing and managing high blood cholesterol.

Accurate estimates of the sodium intake by the U.S. population have been limited by the availability of reliable data on the amount of sodium consumed from processed foods and table salt. The 1982-1984 FDA Total Diet Studies indicate that, excluding salt added at the table, adult sodium intakes are within the Estimated Safe and Adequate Daily Dietary Intakes of the National Academy of Sciences (1100-3300 mg) (6), but that children consume more sodium than the standard recommends for their ages. Further information on sodium consumption will be provided by NHANES-III and the U.S. Department of Agriculture (USDA) Nationwide Food Consumption Survey, which are in progress.

Since 1982, progress in the objective of increasing the proportion of women who breastfeed their babies at time of hospital discharge has slowed (7) and has varied according to geographic regions, education, income levels, and other factors. In 1984, approximately 61% of infants were breastfed at 1 week of age and 28% at 6 months of age. The Health Resources Services Administration has undertaken a special initiative too encourage breastfeeding that includes elements of research, training, and demonstration of effective methods of promoting and supporting breastfeeding.

Improved Services Protection

Public awareness objectives primarily address diet and health relationships. In the 1986 FDA Diet and Health Survey, 83% and 76% of adults were aware that diet plays a role in hypertension and coronary artery disease, respectively, and 65% and 57% of surveyed adults associated sodium and fat with these respective diseases (FDA, unpublished data). In addition, more than half of those surveyed believed that diet may play a role in cancer risk and that changing intakes of certain dietary components may help prevent cancer (2). About 90% of adults were aware that avoiding between-meal sweets can help reduce tooth decay (2). In 1985, more than 70% of adults identifiedd calorie reduction and increased physical activity as the two best ways to reduce body weight (5).

Nutrition labeling, initiated in 1973, is used on 55% of the packaged foods regulated by FDA. Fifty-nine percent have sodium labeling. The publication, Nutrition and Your Health: Dietary Guidelines for Americans (8) offers guidance about healthy eating and has been widely promoted in both the public and private sectors. USDA has revised recipe files for school lunch programs to lower fat, salt, and sugar in school meals (2).

Because data are limited regarding nutrition education and counseling in patient contacts with health professionals, the 1985 NHIS included a question about nutrition education received during routine health consultations. Twenty-nine percent of women and 22% of men reported that eating proper foods was discussed sometimes or often in routine contacts (5).

Progress toward requiring nutrition education in school health curricula has lagged. In 1978, 10 states mandated nutrition as a core content area in school health education; by 1985, only two additional states required nutrition education.

Surveillance-Evaluation System

A comprehensive nutrition surveillance system targeted for 1985--thee National Nutrition Monitoring System (NNMS)--is now in place. The U.S. Department of Health and Human Services and USDA have made several reports to Congress on the NNMS, including a recently updated Operational Plan (9). Survey information about special populations is improving; for example, NHANES-III will oversample blacks and Hispanics to improve data on these populations (2).

ASTPHND Model Objectives

The ASTPHND has developed Model State Nutrition Objectives that relate directly to the 1990 objectives. The model customizes objectives to fit a state's needs and priorities; for example, each state may set specific objectives to reduce blood cholesterol levels in at-risk persons. Recently, ASTPHND ranked a comprehensive national nutrition monitoring system as the highest national priority among the 1990 objectives, and nutrition education in school health education as the highest priority on a state basis. Reported by: Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Service.

Editorial Note

Editorial Note: The experiences of the 1990 objectives suggested additional guidelines for the development of nutrition objectives for the year 2000. For example, the PHS Midcourse Review (2) found that some nutrition objectives were not measurable. For other objectives, a lack of baseline or other data has limited the tracking of progress. Accordingly, future objectives should be both measurable and addressed through surveys or appropriate surveillance systems.

Feasibility is also important in establishing objectives. National objectives predicated solely on improved nutrition may not be feasible for diseases and conditions of complex etiology. One current objective calls for the elimination of growth retardation caused by diet. However , because nutrition is only one factor in growth retardation, it is unlikely that the portion attributable solely to nutritional factors can be separately identified. Technical feasibility is another consideration. One 1990 objective calls for reduction of sodium intake levels as measured by urinary excretion, but national data are not available--and are not likely to be--because sodium excretion measures require specimens of total urinary excretion for a 24-hour period.

Scientifically sound and effective intervention strategies are essential for setting nutrition goals. For example, one objective targets decreases in adult obesity by 1990. However, there are no effective intervention strategies for the attainment of this objective. For obesity and other conditions of complex etiology, nutrition-related behavioral and educational objectives may be necessary.

The development of 1990 objectives has provided useful insights into o the advantages of establishing goals that address national nutrition problems and the challenges of measuring progress toward their achievement. The recently released Surgeon General's Report on Nutritionn and Health (10) emphasizes the importance of diet in preventing widely prevalent chronic diseases. It also emphasizes the need for realistic dietary strategies to reduce health risks and for data to monitor improvements in the nutritional health of the nation. The development off objectives for the year 2000 presents an opportunity to address these important needs.

References

1. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, DC: US Department of Health and Human Services, Public Health Service, 1980.

2. Public Health Service. The 1990 health objectives for the nation: a midcourse review. Washington, DC: US Department of Health and Human Services, Public Health Service, 1986.

3. CDC. Nutritional status of minority children--United States, 1986. MMWR 1987;36:366-9.

4. Yip R, Binkin NJ, Fleshood L, Trowbridge FL. Declining prevalence of anemia among low-income children in the United States. JAMA 1987; 58:1619-23.

5. Stephenson MG, Levy AS, Sass NL, McGarvey WE. 1985 NHIS findings: nutrition knowledge and baseline data for the weight-loss objectives. Public Health Rep 1987;102:61-7.

6. National Research Council. Recommended dietary allowances. 9th ed. Washington, DC: National Academy of Sciences, 1980.

7. Martinez GA, Krieger FW. 1984 milk-feeding patterns in the United States. Pediatrics 1985;76:1004-8.

8. Department of Agriculture, Department of Health and Human Services. Nutrition and your health: dietary guidelines for Americans. 2nd ed. Washington, DC: US Department of Agriculture, US Department of Health and Human Services, 1985.

9. Department of Health and Human Services, Department of Agriculture. Operational plan for the National Nutrition Monitoring System. Washington, DC: US Department of Health and Human Services, US Department of Agriculture, 1987.

10. Department of Health and Human Services. The Surgeon General's report on nutrition and health. Washington, DC: DHHS publication no. (PHS)88-50210. *National Center for Health Statistics, Center for Health Promotion and Education, CDC; Health Resources and Services Administration; and National Institutes of Health.

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