• Experts estimate that unhealthful eating and physical inactivity are responsible for more than 300,000 premature deaths each year in the United States. Only tobacco use causes more preventable deaths in the country.[5,16]

• Today, 55 percent of U.S. adults 20 or older are overweight or obese.[6] Ten percent to 15 percent of young people 6 to 17 years old are overweight. The percentage of young people who are overweight has more than doubled during the past 30 years.[5].

• Obesity in the U.S. population increased from 12 percent in 1991 to 18 percent in 1998. Although obesity increased across all states, regions and demographic groups, the highest increases occurred among 18- to 29-year-olds, people with some college education and people of Hispanic ethnicity.[17]

• While the average daily intake of fruits and vegetables consumed by Americans -- and the proportion of the population meeting the dietary guidelines for fruits and vegetables has risen -- only 35 percent of the population meets the goal of eating five servings of fruits and vegetable a day.[19].

• Intake of total fat, saturated fat, cholesterol and sodium remains above recommended levels, while calcium intake and iron intake remain below recommended levels for many population groups.[7,19]

• A new set of dietary guidelines from the American Heart Association recommends tailoring nutritional advice to the individual based on his or her risk of heart disease and stroke.[13]

• The AHA guidelines recommend eating certain kinds of food rather than counting calories; specifically more plant-based foods and adding two servings a week of fish -- particularly those high in omega-3 fatty acids such as salmon and tuna -- to a diet already rich in fruits, vegetables, legumes, whole grains, low-fat dairy products, fish, lean meat and poultry.[13]

Interview #1:

'Reducing Chronic Disease Risk through Nutrition'

Karen Glanz, PhD, MPH, is a professor at the Cancer Research Center of Hawaii, University of Hawaii, and on the graduate faculty of the Department of Food Science and Nutrition. Her research focuses on advancing the understanding of individuals’ and communities’ behaviors for cancer prevention and control as well as developing and evaluating interventions to reduce cancer incidence, morbidity and mortality. She has applied these interests in several areas, including nutrition. Dr. Glanz has a master’s degree in public health and a doctorate in health behavior and health education, both from University of Michigan.

Q: Why is nutrition so important?

A: Except for tobacco use, nutrition probably has the most important influence on overall health and reducing disease, illness and death. Diet is associated with many of the major chronic diseases such as heart disease, stroke and diabetes; several types of cancer; and obesity, which is a risk factor for those diseases but also is considered a disease by some people. Nutrition also is important to growth and development at every stage of life.

Q: In what ways does diet affect the management of chronic diseases?

A: Changing one’s diet is the least risky method of managing a lot of chronic diseases and related risk factors like hypertension and high blood cholesterol. It also is a lot less expensive than most pharmacologic types of treatment. For instance, a person who has high blood pressure and is also overweight and not eating a healthy diet often can bring his or her blood pressure under control through dietary changes, without taking medicine. On the other hand, if a person is on medication, a healthier diet may reduce the amount of medication needed.

Q: How widespread is the problem of poor nutrition?

A: It’s hard to quantify because nutrition is multi-dimensional. If you take a behavior like cigarette smoking or physical inactivity, even though they are complicated behaviors, you can quantify them on a scale of "not at all" to "a lot." Nutrition has many qualitative dimensions. You need to look at whether people are eating fruits and vegetables, how high their fat intake is, whether they are eating too many calories or whether they are getting enough calcium. The measures that are easiest to report on are weight and obesity. In the United States, about half the adults are either overweight or obese.

Q: Are the diets of people in this country becoming worse?

A: For every step forward, we take one step backward. More healthful foods, such as fat-modified foods, are available than in the past, but there also is a trend toward eating more rich, high-calorie, high-sugar, high-fat foods. One important dimension of the problem in the United States is that portion sizes are becoming larger. For example, a bagel nowadays is about twice the size of what it was 10 or 15 years ago.

Q: What aspects of diet do we need to change for the population overall?

A: It’s typically thought that if we can get people to eat more fruits and vegetables, people will not eat as much of the unhealthy foods. That approach is generally agreed on by people coming from different disease perspectives. The other approach is to reduce the overall quantity of food individuals consume to bring it closer to the amount of energy they expend.

Q: What factors influence people’s food choices?

A: I collaborated on a recent research project that looked at 3,000 people’s relative ratings of taste, cost, convenience, nutrition and weight control [9]. Across the board, taste came out at the top. Cost was the second most important influence. Certain clusters of people said nutrition and weight control were more important, but overall, taste was ranked the most important. Part of the take-home message from this finding is that if people want to eat tasty foods and we want them to eat healthy foods, then we have to find ways to make nutritious foods more tasty.

Q: What are the barriers to nutritious eating?

A: Limitations on people’s time is certainly one. Access to and availability of healthful food choices is another barrier for some people -- if they’re on the road, at work or in a part of the country where fresh foods aren’t available.

As a society, we tend to be much more rushed with less time for food preparation, and there are more options for take-away foods. These foods are often higher in fat, salt and calories than the homemade equivalents. Although they need not be less healthy, they often are.

Q: Under what circumstances are people most successful at improving their eating habits?

A: People who have a real driving reason to change are most successful; for instance, if they have just been diagnosed with high cholesterol. In this situation, a message from a doctor, such as, "If your blood pressure doesn’t go down, we’ll put you on medication," or "You’re diabetic and you’re going to lose your eyesight if we don’t get this under control," can be very motivating.

Sometimes people are motivated by other factors, such as friends’ health problems, not feeling well and the positive feelings they might get by improving their diet for a little while. It’s not easy to suggest one motivator for all people, but these are some examples that "hit the mark" for some.

Interview #2:

'Promoting Improved Nutrition: What Works Well?'

Alice Ammerman, DrPH, RD, is associate professor of nutrition in the Schools of Public Health and Medicine, University of North Carolina at Chapel Hill. Her research includes diet and physical activity behavior as it relates to preventing chronic diseases, particularly in minority, low-literacy, and underserved populations. Some of her research has involved church-based nutrition and physical activity interventions and computer-based and computer-tailored nutrition interventions. Dr. Ammerman received her master’s degree and doctorate in public health from the University of North Carolina at Chapel Hill.

Q: Are the messages about nutrition’s role in people living longer and healthier lives getting through to the general public?

A: Sometimes I’m surprised how many people know the basics. People have generally gotten the message about eating fewer fats, more fruits and vegetables and less salt. The much more difficult piece for people is knowing how to apply the knowledge -- knowing what to buy, how to read the labels and how to put together a meal that reflects the recommendations. Even harder is getting people to make changes and stick with them on a long-term basis. People need to understand that there is no magic bullet approach of one food or one change that will extend their lives.

Q: What are some of the larger national programs to improve America’s nutritional status?

A: There have been some good efforts by federal agencies to simplify the information about diet and health. The Dietary Guidelines for Americans [24] are updated every five years and have become more recognized and endorsed over time. Another big step forward has been the Food Guide Pyramid.[22] The pyramid does a good job of showing relative proportions of different foods, but it also conveys the need for variety in a person’s diet. The 5 A Day for Better Health campaign [18] focuses in on the pyramid’s second tier -- fruits and vegetables. It’s a nice example of a very positive alliance between the nutrition and agriculture community and the food industry. It stems from research that’s been growing over time to show that some elements of fruits and vegetables do seem to be protective in terms of chronic diseases, although exactly what elements are not fully known yet.

Q: Is there any evidence that these information campaigns have had any effect on people’s health?

A: There has definitely been a trend toward decreased fat intake since the mid-1960s, when there was a recognition of the association between fat and heart disease. For example, whole milk consumption has gone down and low-fat milk consumption has gone up. Data also show modest increases in fruit and vegetable consumption since the 5 A Day campaign was launched. At the same time, there is a lot of concern about people becoming more sedentary. It’s possible that people are consuming fewer calories and gaining weight because they are less physically active.

Q: Are some populations not being reached through these types of national campaigns?

A: With any campaign, there is a concern about whether people of lower literacy or those who have fewer communication resources are being left out. Use of the Internet and some other intervention strategies depend on access to computers. More and more health communication is being transmitted through the Internet, though, because it offers a means to reach a lot of people. This brings up very real concern about whether the whole population is being reached.

Q: How do the national campaigns reach more diverse populations?

A: Interventions that make an effort to be culturally sensitive seem to have more positive outcomes, and people have worked hard to adapt the information to local cultures. For example, lots of different groups have developed culture-specific Food Guide Pyramids.[23]

Q: Has listing nutritional content and "daily values" on packaged-food labels had any impact on people’s food choices?

A: A lot of time and effort went into designing packaged-food labels, and they do represent an attempt to make things as understandable as possible. That being said, I am not sure that the average shopper can make a lot of sense of the information on the labels, although we are getting closer. In addition, manufacturers can label foods with a line that says "Heart healthy" or "This food prevents cancer," but there’s been a lot of abuse of this, which has now been pretty well curtailed by the Food and Drug Administration. There’s still a lot of work to be done with regulation of the supplement industry, too.

Q: What kind of interventions work best in promoting healthful eating?

A: Self-monitoring and goal-setting work well, as do identifying the positive aspects of a person’s diet, food-related activities such as taste-testing or meal preparation and providing social support. Dietary assessments are also important. A counselor should start by trying to find out what the person is eating and what are the person’s attitudes and barriers to change. You have a much better chance of directing your intervention efforts if you have an idea of where someone starts. Although it takes time to do an assessment, it makes nutrition counseling more efficient and effective. You don’t spend time telling a person about how he or she should be drinking skim milk and then you find out that the person is lactose intolerant and doesn’t drink milk at all.

Q: Are new tools or approaches being used?

A: There is a lot going on in this area, such as computerized tailoring. This involves developing personalized messages, usually in print but sometimes through the Internet, that are very specific to a person’s situation and characteristics. It’s somewhat like direct marketing mail taken to a much higher level in terms of value and complexity. Computerized tailoring has shown some success, although there has not been enough research to say conclusively that this works. People seem to remember tailored messages more. Some studies have shown that people receiving tailored messages make more changes than do others in group intervention situations where the information is not tailored.

Q: What further steps need to be taken to promote healthful eating?

A: We are heading toward much greater emphasis on environmental-level and policy changes. Over the years, we have tried a lot of approaches to help individuals make good decisions and alter their behavior, but there is a limit to how much we can accomplish when the environment is screaming french fries and hamburgers. In some ways, this is parallel to tobacco, but there are greater challenges with food. I think there will be more interest in policy changes related to school lunches, marketing of certain foods to children, availability of food, or subsidizing healthful foods. [8,20]

Environment, Parents Can Influence Kids’ Eating Patterns:

Eating patterns established in childhood and adolescence are important in the development of nutrition habits throughout a person’s life, but kids often don’t eat as healthfully as they should. Fewer than one in five children eat the recommended five servings per day of fruits and vegetables, and more than 60 percent of young people consume more fat than recommended.[5] Unhealthful eating behaviors in the younger years are associated with greater risk of chronic disease in adulthood, increased obesity and lower academic achievement and cognitive development.[15]

Many people’s eating patterns begin to disintegrate in the childhood years, say experts. Leslie Lytle, PhD, RD, associate professor in the Division of Epidemiology at the University of Minnesota School of Public Health, and colleagues recently completed a study that tracked dietary changes in a cohort of Minnesota students as they progressed from third to fifth to eighth grade.[15] In each grade, the students were asked to recall what and how much they had consumed during the previous 24 hours.

In the study, fruit and vegetable consumption fell dramatically between the third and eighth grades. By the eighth grade, only 37 percent reported eating fruits and only 42 percent reported eating vegetables. In addition, the proportion of the students who drank soft drinks nearly tripled between the third and eighth grades, while the proportion who drank milk and fruit juice dropped. Moreover, in the third grade, 99 percent of the students said they ate breakfast, but by the eighth grade only 85 percent said they did.

Lytle attributes the changes in children’s eating patterns to social, parental and developmental factors.

"I think the environment, particularly the school environment, is an incredibly large part of it," she says. "We know that as kids move from elementary to middle school their choices of foods expand tremendously. Many schools have soft drink machines and different snack items available."

Lytle also notes that when their children reach adolescence, many parents shift their emphasis -- from topics like drinking milk and brushing their teeth to not smoking and whom to hang out with -- and nutrition goes by the wayside. Moreover, peer pressure and "normal developmental changes" in the early adolescent years affect food choices.

"It becomes cool to say ‘I’m going to skip breakfast or I’m going to have a Coke for lunch.’ They have more autonomy and more control. They can walk to a convenience store by themselves, and some have more of their own spending money," says Lytle.

So what’s the solution? Lytle suggests that focusing on the social environment, as well as the individual, could go a long way toward improving children’s eating patterns.[21] For example, taking a closer look at whether soft drink machines should be present in schools or selling low-cost, healthy foods in school vending machines and at à la carte snack bars could make a difference.

"Parents also are key, both as role models and in encouraging improvements in school nutrition policies," Lytle asserts.

Tailoring Nutrition Messages to Meet the Need:

The use of computers to personalize sales material is standard practice in the marketing field, but in the past decade this approach has also been tapped to promote change in health behavior, including nutrition. Computer-tailored approaches allow experts to design and deliver highly individualized health messages that address each person’s unique situation.[14]

Marci Campbell, MPH, PhD, a leader in developing and evaluating computer-tailored health interventions, explains that the idea melds concepts used in marketing and individual counseling.

"We know from the marketing field that the more you know about a person, the more you can make the message personally relevant and the more the person will pay attention to the message," says Campbell, who is assistant professor of nutrition in the School of Public Health at the University of North Carolina-Chapel Hill. "We also know from the individual counseling arena that the more you individualize the patient encounter, the more likely you are to address the person’s specific needs."

Most computer-tailored health messages have been delivered in printed newsletter formats. Health educators create such materials by first gathering information about the population that they are trying to reach. They then undertake formative research to develop a variety of messages that are appropriate to individuals within the population, explains David Farrell, MPH, health educator and president of People Designs, a North Carolina firm that creates computer-tailored health promotion materials.

Farrell and Campbell agree that as the field advances, computer-tailored materials are becoming increasingly sophisticated, in terms of both what factors influence behavior change and the media used.

"It used to be that researchers looked at people’s willingness, barriers and key motivation to change," Farrell notes. "Now we are looking at cultural factors and all sorts of other psychosocial influences."

In addition, experts are moving toward disseminating computer-tailored messages via the Internet and the use of tailored audio and video messages.

Campbell cites research evidence showing that when it comes to nutrition messages, "tailoring is better than not tailoring." In a recent research review, she and colleagues concluded that, compared to traditional materials, computer-tailored nutrition education is more likely to be read, remembered and seen as personally relevant. Computer-tailored education also appears to have a greater impact on motivating people to change their diets and particularly their fat intake. [14]

However, Campbell says, the jury is still out on how well computer-tailored nutrition messages stack up against other state-of-the-art interventions such as telephone counseling, which employs person-to-person interaction, and how much tailoring is really needed.

Doctors Need More Nutrition Training, Experts Say:

More than 90 percent of the American public views doctors as valuable sources of information about food and nutrition,[1] yet most physicians are not prepared to counsel their patients about nutrition. This lack of "nutrition literacy" exists in large part because the topic is not well-addressed by medical schools and residency training programs, experts say.[11]

Results of a survey of 128 accredited U.S. medical schools show that only 26 percent of schools required a nutrition course during the 1997-98 academic year. Moreover, about two-thirds (64 percent) of medical students believe that the time devoted to nutrition in medical school is inadequate.[2]

"Nutrition has never been taught very well to physicians, yet the top 10 causes of death in the United States are related in one way or another to nutrition and dietary habits. Atherosclerosis, cancer, diabetes, stroke and coronary artery disease all have dietary lifestyle factors associated with them," says Douglas C. Heimburger, MD, MS, FACP, professor in the Departments of Nutrition Sciences and Medicine at the University of Alabama at Birmingham and founding director of the Intersociety Professional Nutrition Education Consortium.

"The public has a sustained interest in nutrition, and people figure that their physicians should be informed about nutrition. Quite often, they are appalled to find out that their physicians are not," Heimburger explains.

For well over a decade, Heimburger and others have advocated more physician training in nutrition, with the primary aim of enlarging the pool of certified "physician nutrition specialists" -- doctors with special training in nutrition. A PNS typically works in academic settings, where he or she teaches, conducts research and sometimes provides patient care. A PNS is usually an internist, pediatrician, family practice physician or surgeon who has completed a fellowship in clinical nutrition and may have training in gastroenterology or endocrinology.[12]

IPNEC, an interdisciplinary organization established with National Institutes of Health funding in 1997, has set out to resolve this issue by bringing together stakeholders in physician nutrition education. One of IPNEC’s long-term goals is to ensure that every U.S. medical school faculty includes a PNS who can champion the teaching of nutrition and can serve as a role model for physicians-in-training.

With representation from groups such as the American Society for Clinical Nutrition and the American Dietetic Association, the consortium is working to delineate the role of the PNS, establish standards for PNS training and create a unified PNS certification mechanism.

IPNEC also philosophically supports efforts to shift medical care more toward prevention, Heimburger adds. "One of the things we hope to do is to move modern medicine toward more of a preventive orientation and away from a search-and-destroy, treat-after-it’s-already-occurred orientation. That’s really an uphill battle."

Steps to the Collaborative Reduction of Health Behavior Risks:

Successfully reducing health behavior risks such as smoking, physical inactivity, obesity and alcohol and substance abuse is a process that may be best achieved through the collaborative engagement of providers and patients. These simple steps, drawn from research on the collaborative management of chronic illness, provide one framework for providers and patients to work together to help patients improve their chances of staying healthy.

1) Ask: Providers provide a context for helping patients reduce health risks by asking patients about their lives and the regular activities in which they engage. Asking about health-threatening and health-promoting behaviors helps providers and patients establish a common starting point in addressing potential health risks.

2) Advise: Based on the information patients share with them, providers can help patients recognize how and why specific behaviors may threaten their health and advise them about steps that can be taken to change health-threatening behaviors.

3) Arrange: Armed with knowledge about programs and services that are appropriate to patients’ needs, priorities and preferences, providers can play a key role in helping patients reduce health risks through referrals to appropriate sources of supplementary health behavior change intervention and support.

4) Assist: Providers can help catalyze successful behavior change by targeting their assistance and interventions to patients’ specific circumstances. Arranging regular telephone contacts by office staff, for example, may help one patient’s efforts to change a lifelong habit, while another patient may do best with face-to-face visits with a provider that occur at less frequent intervals.

5) Anticipate: Successfully reducing health behavior risks involves a lifelong process of behavior change and monitoring. A critical step in this process is anticipating points at which re-evaluation of behavior change efforts and subsequent course corrections may be necessary. Planned follow-up by providers is one way to help ensure that needed course corrections take place.

The Research:

1. American Dietetic Association. (2000). Nutrition and You: Trends 2000. Chicago, IL.

2. American Medical Association, Council on Medical Education. (1999). Nutritional and Dietetic Education for Medical Students (CME Report 1-I-99). Chicago, IL.

3. Brug J, Campbell M, van Assema P. (1999). The application and impact of computer-generated personalized nutrition education: A review of the literature. Patient Education Counseling, 36(2):145-56.

4. Campbell MK, DeVellis BM, Strecher VJ, Ammerman AS, et al. (1994). Improving dietary behavior: The effectiveness of tailored messages in primary care settings. American Journal of Public Health, 84(5):783-7.

5. Centers for Disease Control and Prevention. (2000). Physical activity and good nutrition: Essential elements for good health. Atlanta, GA. Available at http://www.cdc.gov/nccdphp/dnpa/dnpaaag.htm; accessed 9/5/00.

6. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults. (1998). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: Executive summary. American Journal of Clinical Nutrition, 68:899-917.

7. Federation of American Societies for Experimental Biology, Life Sciences Research Office. (1995). Third Report on Nutrition Monitoring in the United States: Executive Summary. Washington, DC: U.S. Government Printing Office.

8. Glanz K. (1999). Progress in dietary behavior change. American Journal of Health Promotion, 14(2):112-7.

9. Glanz K, Basil M, Maibach E, Goldberg J, Snyder D. (1998). Why Americans eat what they do: Taste, nutrition, cost, convenience, and weight control concerns as influences on food consumption. Journal of the American Dietetic Association, 98(10):1118-26.

10. Glanz K, Lankenau B, Foerster S, Temple S, Mulls R, et al. (1995). Environmental and policy approaches to cardiovascular disease prevention through nutrition: Opportunities for state and local action. Health Education Quarterly, 22(4):512-27.

11. Heimburger D, Intersociety Professional Nutrition Education Consortium. (2000). Physician-nutrition-specialist track: If we build it, will they come? American Journal of Clinical Nutrition, 71:1048-53.

12. Intersociety Professional Nutrition Education Consortium. (1998). Bringing physician nutrition specialists into the mainstream: Rationale for the Intersociety Professional Nutrition Education Consortium. American Journal of Clinical Nutrition, 68:894-8.

13. Krauss RM, Eckel RH, Howard B, Appel LJ, et al. (2000). AHA Dietary Guidelines: Revision 2000: A Statement for Healthcare Professionals From the Nutrition Committee of the American Heart. Circulation 102:2296-311. Available on the web at http://circ.ahajournals.org/cgi/content/full/4304635102.

14. Lutz SF, Ammerman AS, Atwood JR, Campbell MK, et al. (1999). Innovative newsletter interventions improve fruit and vegetable consumption in healthy adults. Journal of the American Dietetic Association, 99(6):705-9.

15. Lytle LA, Seifert S, Greenstein J, McGovern P. (2000). How do children’s eating patterns and food choices change over time? Results from a cohort study. American Journal of Health Promotion, 14(4):222-8.

16. McGinnis JM, Foege WH. (1993). Actual causes of death in the United States. The Journal of the American Medical Association, 270(18):2207-12.

17. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, et al. (1999). The spread of the obesity epidemic in the United States, 1991-1998. The Journal of the American Medical Association, 282(16):1519-22.

18. National Cancer Institute. (1995). Time to Take Five: Eat 5 Fruits and Vegetables a Day. Bethesda, MD.

19. National Center for Health Statistics. (1999). Healthy People 2000 Review, 1998-99. Hyattsville, MD.

20. Nestle M. (1998). Toward more healthful dietary patterns -- A matter of policy. Public Health Reports, 113:420-3.

21. Neumark-Sztainer D, Story M, Perry C, Casey MA. (1999). Factors influencing food choices of adolescents: Findings from focus-group discussions with adolescents. Journal of the American Dietetic Association, 99(8):929-937.

22. U.S. Department of Agriculture, Center for Nutrition Policy and Promotion. (1996). The Food Guide Pyramid. Home and Garden Bulletin No. 232. Available at http://www.usda.gov/cnpp/pyrabklt.pdf; accessed 9/21/00.

23. U.S. Department of Agriculture, Food and Nutrition Information Center. (2000). Food Guide Pyramid. Ethnic/Cultural Food Guide Pyramids. Available at http://www.nal.usda.gov/fnic/etext/000023.html; accessed 11/8/00.

24. U.S. Department of Agriculture, U.S. Department of Health and Human Services. (2000). Nutrition and Your Health: Dietary Guidelines for Americans. Available at http://www.usda.gov/cnpp/DietGd.pdf, accessed 11/7/00.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research, Academy of Psychosomatic Medicine, American Academy of Nursing, Association for Applied Psychophysiology and Biofeedback, American College of Neuropsychopharmacology, American Psychiatric Association, American Psychological Association, American Psychological Association-Division 38, American Psychological Society, American Psychosomatic Society, American Sociological Association, American Society of Psychiatric Oncology, College on Problems of Drug Dependence, Institute for the Advancement of Social Work Research, International Psycho-Oncology Society, International Society for Traumatic Stress Studies, Society of Behavioral Medicine, Society for Developmental and Behavioral Pediatrics, Society for Public Health Education, Society for Research on Nicotine and Tobacco.

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic, and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For Information Contact:
Ira R. Allen
Director of Public Affairs
Center for the Advancement of Health
2000 Florida Ave., NW, Suite 210
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p. 202.387.2829 / f. 202.387-2857
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