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new solutions1
Food Policy 24 (1999) 135–144 www.elsevier.com/locate/foodpol
Diet and health: new problems/new solutions1 Laina M. Busha,*, Richard A. Williamsb a
Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy, Room 432E, 200 Independence Avenue, SW, Washington, DC 20201, USA b Food and Drug Administration, Center for Food Safety and Applied Nutrition, Division of Market Studies, HFS-726, 200 C Street, SW, Washington, DC 20204, USA
Abstract Our premise is that the US government has an established role in both tracking diet related diseases and in prevention of these diseases. As such, we note that the four major causes of morbidity and mortality associated with diet are heart disease, cancer, cerebrovascular disease and diabetes. The trends for these are generally toward decreasing incidence with the exception of diabetes, undoubtedly due in some part to US policies on nutrition. However, the trend for overweight, which is closely related with those illnesses, and for diabetes is increasing. We also note that there are socioeconomic concerns with overweight and the other illnesses that are negatively correlated with income and positively correlated with minority status. Also, children are increasingly becoming a concern due to the increasing incidence of overweight among children. The US government’s role has been primarily in regulations addressing labeling and food fortification and developing dietary guidance. In terms of getting people to eat a healthier diet there are three avenues: (1) relying on individual choice between groups of foods; (2) relying on individual choice within groups of foods; or (3) presenting consumers with better food choices by encouraging manufacturers to reformulate foods. We argue that the latter has been neglected as a policy tool in the US arena and that we should be both tracking these foods and formulating policy to encourage positive development of these foods. We raise some possibilities for further study as to how and whether US policy can or should encourage such markets. 1999 Published by Elsevier Science Ltd. All rights reserved.
* Corresponding author. Tel.: ⫹ 1-202-690-6102; fax: ⫹ 1-202-690-6167. 1 Disclaimer: The views presented in this paper represent those of the authors only. They do not reflect the policies of either the Department of Health and Human Services, the Food and Drug Administration, or the Department of Agriculture. 0306-9192/99/$ - see front matter Published by 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 9 1 9 2 ( 9 9 ) 0 0 0 1 8 - 4
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Introduction A healthful diet provides sustenance and nourishment for growth, development, health and well-being. It is well documented that good nutrition can substantially contribute to preventing illness and premature death. In fact, diet is a contributing factor in overweight and four of the 10 leading causes of death in the United States: heart disease, some cancers, cerebrovascular disease, and diabetes mellitus. A number of Federal agencies are charged with tracking and developing policies to influence trends in illnesses and the dietary factors that partially give rise to them. This paper addresses two components of Federal mandates associated with diet/disease relationships: tracking trends in morbidity and mortality related to diet and how Federal agencies may positively influence these trends. All data on morbidity and mortality trends are from the Centers for Disease Control and Prevention report Health, United States (National Center for Health Statistics, 1998).
Health trends Overweight From examination of the most recent health data, the most significant trend among US citizens is an increasing prevalence of overweight, defined as Body Mass Index greater than or equal to 27.8 kg/m2 for men and greater than or equal to 27.3 kg/m2 for women. This trend is disturbing for several reasons, not the least of which is that overweight is a correlate and, in some instances, a cause of the four illnesses mentioned above. Specifically, overweight is considered a risk indicator for cerebrovascular disease and some forms of cancer and is a direct contributor to the risk of contracting diabetes or heart disease through its effect on blood lipids. Overweight is also associated with gall bladder disease, osteoarthritis, sleep disorders, and psychological stress. Even without the contribution to mortality, overweight gives rise to the same costs as some kinds of morbidity in terms of reduced physical activity and enjoyment of life as, for example, people recovering from heart attacks. Over one-third of the population, 36.6% in 1988–1994 are now overweight as compared to 25.7% in 1976–1980, an increase of over 40%, keeping the definition of overweight constant. However, the distribution of overweight people is skewed in certain socioeconomic subgroups. First, overweight continues to be more of a problem for women than for men. In addition, both income and race/ethnicity are significant predictors of overweight. Among the adult population, overweight prevalence is highest among black, non-Hispanic females (53.3% in 1988–1994). Prevalence among Mexican-origin females is also extremely high, increasing from 39% to 50% during this same time period. These two socioeconomic subgroups, besides having a quality of life adversely affected by being overweight, are among the highest risk subgroups for diet-related morbidity and mortality. For instance, African American females are in the highest risk group for diabetes. Overweight is lowest among white, non-Hispanic males (33.7% in the same time period). However, the rate of
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being overweight among all adult males increased to a greater extent than among women during these time periods. The problem of overweight is not limited to adults only. Especially alarming from a public health perspective is the prevalence of overweight among children and adolescents. Because dietary and physical activity habits are typically formed before adolescence, it is of particular concern that the prevalence of overweight adolescents more than doubled from 1976–1980 to 1988–1994. Prevalence among teen males increased 134% and among teen females, 75%. Again, socioeconomic disparities persist in some race and ethnic groups. When data on overweight is examined in its totality (without regard to sex, race, or ethnicity), the higher the income of the family, the less likely the occurrence of overweight among adolescents. Prevalence of overweight is 17% among poor adolescents (defined as family income below the Federal poverty level), as compared to 13% for near poor (family incomes between 100 and 199% of the poverty level) and 9% for middle/high income families (family incomes at 200% or more of the poverty level). Although socioeconomic disparities exist when examining overweight overall, this trend is driven solely by non-Hispanic white adolescents. The association does not hold in other racial/ethnic groups where cultural attitudes appear to cause higher rates of adolescent overweight in the wealthier households. Heart disease Although age-adjusted death rates have declined significantly, the leading cause of death in the United States is still heart disease for all adult racial/ethnic groups. In 1996, diseases of the heart caused 733,361 deaths, about 32% of all deaths. Ageadjusted death rates related to heart disease declined almost 26% from 1985 to 1996 with men improving more than women. Again, socioeconomic status and racial/ethnic disparities are significant. Thus, death rates are negatively correlated with income in every category of sex, race, and ethnic groups. In addition, heart disease death rates are also higher among African Americans than among whites. Cerebrovascular disease Cerebrovascular disease, including stroke, is the third leading cause of death in the United States. Although death rates from cerebrovascular disease have been declining, almost 19% from 1985 to 1996, African Americans are still more likely to suffer from cerebrovascular disease than the general population. Although all cerebrovascular disease rates are declining, males, particularly African American males, continue to have higher rates than women. Heart disease and stroke share many risk factors, including hypertension and high serum cholesterol. Overweight, already described, is also a risk factor for heart disease. Prevalence of hypertension among adults declined from 39% in 1976–1980 to 23% in 1988–1994. Men are more likely to have high blood pressure than women (25% of men, 21% of women). Although men from high income families are less likely to be hypertensive than men from middle, near poor, or poor families, the
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difference is not highly significant. However, the between the prevalence of hypertension among women and income appears to be stronger. Women from high-income families are very likely to be less hypertensive than women from middle, near poor, or poor families. Hypertension is more prevalent among African Americans than among whites, although African Americans are less likely to have high blood cholesterol than whites. Mean serum cholesterol levels have declined almost 5% from 1976–1980 to 1988– 1994. High blood cholesterol prevalence has declined more than 30% from 1976– 1980 to 1988–1994, exceeding the Healthy People 2000 goals for both men and women (National Center for Health Statistics, 1997). This may be due, in part, to the National Cholesterol Program activities that are aimed at educating public health professionals and the public about the importance of cholesterol as a risk factor. Cancer The best scientific evidence thus far indicates that as many as one-third of all cancer deaths are attributable to dietary factors. The link between colorectal cancer and dietary risk factors, such as overweight, high fat diets, and diets low in fiber, fruits, and vegetables has been well established. Diet is also believed to be a factor in other cancers, such as female breast cancer, but the evidence is not conclusive. Cancer remains the second leading cause of death in the United States, accounting for 539,533 deaths in 1996—an increase of almost 30% since 1980. However, there is good news. After several years of increasing cancer death rates, from 1990 to 1996, age-adjusted death rates from cancers decreased on average 0.5% per year. From 1985 to 1996, cancer death rates declined by 5%, exceeding the Healthy People 2000 goals for all cancers and particularly in the case of colorectal cancer. Although the causes of cancer death varied by race/ethnicity, the top four sites associated with death from cancer in all racial and ethnic groups were: lung, female breast, prostate, and colon/rectum. African Americans had the highest cancer incidence and mortality rates and the lowest survival rates. Diabetes mellitus There are essentially three types of diabetes mellitus: Type I, formerly called insulin-dependent or juvenile diabetes; Type II, formerly called non-insulin dependent, or adult-onset diabetes; and gestational diabetes. Of the three, Type II diabetes, which is affected by diet, is the most common form of diabetes, especially in minorities and the elderly. Approximately 95% of all persons diagnosed with diabetes are Type II. Overall, diabetes mellitus is the seventh leading cause of death in the United States, with 61,767 deaths in 1996. These deaths are primarily due to cerebrovascular disease. As is the case with overweight, prevalence of diabetes is increasing at alarming rates. The age-adjusted death rate, for all persons, has increased from 9.7 per 100,000 in 1985 to 13.6 in 1996. Men are more likely to die with diabetes than women (14.9 age-adjusted death rate for men, 12.5 for women) and racial/ethnic disparities again
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exist. According to the age-adjusted death rates in 1996, African Americans were more likely to die from diabetes than any other racial/ethnic group (28.8 for African Americans, 12.0 for whites).
Federal role in dietary management Federal involvement in policies that affect the diets of Americans has been well established for decades and includes both monitoring American’s diets and trying to improve those diets. Activities designed to improve diets include provision of information to guide consumers into making choices for a healthful diet, creating and enforcing measures for consumers to use to evaluate individual foods by use of food labels, requiring or allowing food supplementation with vitamins and minerals, and restricting misleading claims. Federal involvement in dietary policies fall under authorities granted under the Food, Drug, and Cosmetic Act, the Nutrition Labeling and Education Act, and others. Federal information campaigns include such activities as the Food Guide Pyramid. The Food Guide Pyramid serves as the cornerstone of Federal nutrition policy and reflects the Dietary Guidelines for Americans which recommend that consumers eat a variety of foods; maintain a healthy weight; choose a diet that is plentiful in grain products, fruits and vegetables; moderate in salt, sodium, and sugars; and low in fat, saturated fat, and cholesterol; and that alcoholic beverages be consumed in moderation, if at all. Another example of Federal action is the requirements set forth in the Nutrition Labeling and Education Act and the many regulations that implement it. These regulations include those requiring disclosure of nutrients in the Nutrition Facts Panel, serving size declarations, and definitions of nutrient content claims and health claims. These implementing regulations apparently have had some acceptance in that 75% of all US consumers use the food label, although it is not clear precisely how it has impacted diets. The Federal government tracks intake of both macro and some micro nutrients in the diet through surveys, such as the market-based survey, Continuing Survey of Food Intakes by Individuals, and National Household and Nutrition Examination Survey. We observe from this data that, in fact, some changes are being made in the diets of Americans (less fat and saturated fat consumption, more vegetables), although not all of the changes recommended. The average fat and saturated fat intake, expressed as a percentage of calories, has decreased and the proportion of the population who meets the average daily goals of the Dietary Guidelines for fat and saturated fat has increased. However, the vast majority still do not meet the guidelines. According to a review of the Healthy People 2000 goals, approximately one-third of the population consume less than 30% of calories from fat and less than 10% of calories from saturated fat, even though the average number of servings of fruits, vegetables, and grains has increased since the beginning of the decade. Also, the total caloric consumption has increased on average. Thus, although the amount of calories from fat and saturated fat has declined, the absolute amount of calories has actually increased. Although the availability of reduced fat processed foods has
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increased, people appear to have increased their caloric consumption and thus, their consumption of fat. Clearly, as shown earlier in the paper, some groups are still at very high risk for diet related diseases and overweight. It may be that improvements are needed both in what we monitor and how we influence policy to change diets further. There are three possible ways in which diets can be improved although they are not mutually exclusive: 1. People switch from a less healthy food in one grocery category to a more healthy food in another category. That is, rather than eating cake or candy for dessert, they eat fruit. There is evidence from various studies, such as Putler and Frazao (1991) discussed later, that shows that cross-category switching does occur, although people do not always end up improving their diets. 2. People choose healthier foods within an existing grocery category of foods. For example, people switching from a regular cheddar cheese to a low fat cheddar cheese. 3. Manufacturers create healthier foods within a grocery category. In this case, manufacturers increase the availability and taste within a category of foods so that the proportion of food within a grocery category increases toward more healthy foods. Note that each of these classes of policies reflects the fact that for people to eat healthier diets, they must have healthier foods. If eating a balanced diet was the only problem, nutrition labels would not be needed as consumers could simply select foods randomly from the major Food Guide Pyramid categories and diets would be optimal. Thus, this analysis presumes that a diet in which consumers choose foods randomly from within Food Guide Pyramid categories, while although technically balanced, can be improved by more careful selection of particular foods within those categories. In a random selection, macro and micro nutrient intake would tend toward the mean of the existing distribution of foods within those categories, which we presume is not necessarily optimal. It is likely, however, that that is not sufficient and that improving diets is a combination of both balancing the diet and choosing foods for a healthier diet from within Food Guide Pyramid categories. The Federal government has, by allowing for and authorizing health and nutrient content claims, as well as requiring labeling of macro and micro nutrients, implicitly adopted the position that individual foods count and that some foods within product categories are more helpful in creating healthy diets than others. We know that the prevalence of people using nutrition labels is about 75%. We also know the percent of the market making health or nutrient content claims. However, we do not know how much, as a percent of energy, these foods are replacing similar foods that are not making such claims. Nor do we know who is using claims. Further, we do not know the extent to which claims are leading to an overall healthier diet. The discussion that follows will explore the possibility of an intervention for each method of causing a diet change.
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Change food categories There is some evidence that these types of substitutions have occurred. A study by Putler and Frazao (1991) showed changes in women’s diets over time away from red meats. However, in this case, they showed that these changes did not necessarily lead to healthier diets. For people to change the food categories they eat, they must overcome the cultural eating patterns that they learned in childhood. Further, even if people make such substitutions, it is questionable as to whether or not their diets are improved. For example, if one tries to compare the diet implications of increasing the price or safety of seafood, such that there is a shift in quantity demanded relative to other protein sources (e.g., red meat), analysis of nutritional improvements resulting from such shifts proves to be intractable because of the difficulty accounting for both consumer preparation and other, offsetting shifts. Preparation methods (i.e. broiled, steamed, baked, fried or breaded) affect the macro and micro nutrient content of these foods. In addition, the substitution of one high protein food for another often engenders substitutions of accompanying dishes, such as hush puppies for baked potatoes. Thus, as a policy tool, this method of influencing diets seems to have considerable problems. Thus, making permanent dietary changes across entire food categories in the general population would most likely require massive public expenditures in nutrition education resulting in a very small return. Choose better foods within categories Interventions to affect a substitution of foods within grocery categories assume that it is possible to convince consumers that, from a fixed distribution of foods, they should begin choosing healthier foods. This can be achieved through either changes in manufactured food choices, such as no fat cheese instead of full fat cheese, or through adoption of different preparation methods, such as broiling instead of frying. The difficulty for an intervention to effect such a change is that people usually place taste and price above other food selection criteria including nutrition. In order to change diets, this type of change assumes people will now make previously rejected changes based on government supplied or any other information. Without changes in either consumer taste preferences or the ability to create healthier foods that taste better, nutritional programs aimed at getting consumers to change food choices within a category are unlikely to have a significant impact. Just as with the last type of policy mentioned, this would require massive expenditures in nutrition education programs with very little return. Create healthier foods within categories Interventions to create healthier foods within categories can happen in two ways: manufacturers can reformulate foods within existing Federal food composition/processing guidelines or they can reformulate as a result of Federal fortification requirements.
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Reformulating foods for market share and to increase consumer options Manufacturers can, for example, create better tasting products with fewer calories, lower total fat or simply better combinations of fat (e.g., lower saturated fat and transfatty acids), lower sodium, etc. Since the implementation of NLEA, many manufacturers have indeed reformulated their products. This type of reformulation can take into account taste, nutrition, convenience, price, and any other important factor that affects consumer choices. In addition to packaged foods that manufacturers reformulate to gain market share, restaurateurs could create more nutritious foods through a change in preparation methods, menu selections, or portion sizes. However, the incentive for restaurants to do this is small unless consumers demand it. Consumers must be educated to demand more nutritious choices. Of course, this must also be in the context of an overall proper diet including portion sizes. Reformulation for Federal fortification requirements Required reformulation is illustrated by the recent FDA rule requiring folate enrichment of bread products. The Federal government either mandates reformulation or allows fortification for certain food products. To the extent that it is difficult to change consumer diets through the first two types of policy interventions, this type of policy may surface as an attractive intervention that should be explored, although it will not address problems with macronutrients or energy. As mentioned earlier, although the Federal government does track macro and micronutrient intakes, they are generally not tracked relative to the macro and micronutrient content of individual foods within food categories. Because of the implicit adoption by the Federal government of the policy that individual foods matter, it is incumbent upon us to track the creation of more nutritious foods and their effect upon overall diets. Examining the three possible ways to change diets through better individual food selection, the most unexamined category appears to be the third one, reformulation either through mandatory fortification or through total product reformulation. One primary attraction of such a policy is that, from a consumer’s point of view, the change in food selected could be relatively costless, economically or culturally. If this is so, it is worth exploring how this type of intervention can facilitate the creation of such markets. However, there may be legitimate reasons for objecting to such a policy. For example, some groups have expressed concerns about whether or not consumers should be encouraged to eat ‘manufactured foods’, foods that are not ‘natural’. These concerns usually incorrectly cite manufactured foods as somehow being nutritionally inferior to ‘fresh’ or ‘natural’ foods. As discussed in FDA’s final rule on the definition of the term ‘healthy’, data on canned and frozen formulated fruits and vegetables, for example, shows that this simply is not true. In addition, breeding and hybridization of fruits, vegetables and animals is over a century old. In a sense, all food products are now ‘manufactured.’ This does not imply that some manufactured foods may ultimately be shown to have problems, only that lumping them all in a category as being superior to ‘natural’ foods is incorrect. Finally, there is some legitimate concern that Federal policies do not override consumer choice. For example, recent consideration of taxing offending macro nutrients such as dietary fat is probably not appropriate.
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More study is necessary before making recommendations. However, assuming that policy changes made to encourage reformulation is a sound direction for Federal policy, the factors that would be necessary to implement such a policy are discussed below. 1. First, it would be necessary to track the creation of new, more nutritious foods, their content, who eats them, and how it affects their diet. We know that there are about 12,000 new products offered each year and we know something about the claims made on those products. However, we do not know the nutrient composition of these foods. By tracking these foods, we may be able to determine which policies help or hinder their creation or, more generally, if in fact they do make a positive difference on the diets of Americans. 2. Second, it would be necessary to continue to educate the public to use food labels to purchase healthier foods and construct healthier diets. This increases demand for these foods and facilitates creation of these markets. 3. Third, it would be necessary to continue to use metrics that consumers can use to judge the relative nutritional content of foods. Creating metrics is a major component of the Nutrition Labeling and Education Act and its implementing regulations. We have observed that these metrics force competition along those labeled attributes. There are other examples of improving markets by the use of new metrics, such as requiring airlines to report percentage of on-time arrivals. 4. Lastly, it would be necessary to continue to create rules to prevent adverse consequences of competition for new products or to remove rules that impede helpful competition. Existing rules that need to be examined include food standards, fortification policies, and policies on claims. These rules should be examined to determine if they impede the goal of improving diets. For example, FDA recently determined that its standards for certain low fat dairy products conflicted with the goals of the Dietary Guidelines. Those standards were subsequently eliminated and now those dairy products must comply with the nutrient content claims requirements promulgated under NLEA. Other potentially similar situations must be carefully examined.
Conclusion Virtually all of the diet-related diseases examined, except diabetes, are declining in terms of age-adjusted death rates. However, possibly due to an increased intake of calories, there has been a marked increase in overweight in all groups and a very large increase in some socioeconomic and racial/ethnic subgroups. Similarly, the increasing prevalence of diabetes mellitus is also of public health concern. The Federal government maintains a long standing interest in these effects and both tracks them and tries to exert a positive influence on them. Using more policies to encourage creation of reformulated more nutritious foods may be a promising avenue to change the trend towards being overweight, diabetic, and at risk for other diet-related illnesses.
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References Derby, B.M., Fein, S.K., 1995. Meeting the NLEA Education Challenge: A consumer research perspective. In: Shapiro, R. (Ed.), Nutrition Labeling Handbook. Marcel Dekker, New York, pp. 315–353. National Center for Health Statistics, 1997. Healthy People 2000 Review 1997. Public Health Service, U.S. Department of Health and Human Services, Hyattsville, Maryland. National Center for Health Statistics, 1998. Health, United States, 1998 with Socioeconomic Status and Health Chartbook. Public Health Service, U.S. Department of Health and Human Services, Hyattsville, Maryland. Putler, D., Frazao, E., 1991. Diet/health concerns about fat intake. Food Review 14 (1), 16–20.
Diet and health: new problems/new solutions1 Laina M. Busha,*, Richard A. Williamsb a
Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy, Room 432E, 200 Independence Avenue, SW, Washington, DC 20201, USA b Food and Drug Administration, Center for Food Safety and Applied Nutrition, Division of Market Studies, HFS-726, 200 C Street, SW, Washington, DC 20204, USA
Abstract Our premise is that the US government has an established role in both tracking diet related diseases and in prevention of these diseases. As such, we note that the four major causes of morbidity and mortality associated with diet are heart disease, cancer, cerebrovascular disease and diabetes. The trends for these are generally toward decreasing incidence with the exception of diabetes, undoubtedly due in some part to US policies on nutrition. However, the trend for overweight, which is closely related with those illnesses, and for diabetes is increasing. We also note that there are socioeconomic concerns with overweight and the other illnesses that are negatively correlated with income and positively correlated with minority status. Also, children are increasingly becoming a concern due to the increasing incidence of overweight among children. The US government’s role has been primarily in regulations addressing labeling and food fortification and developing dietary guidance. In terms of getting people to eat a healthier diet there are three avenues: (1) relying on individual choice between groups of foods; (2) relying on individual choice within groups of foods; or (3) presenting consumers with better food choices by encouraging manufacturers to reformulate foods. We argue that the latter has been neglected as a policy tool in the US arena and that we should be both tracking these foods and formulating policy to encourage positive development of these foods. We raise some possibilities for further study as to how and whether US policy can or should encourage such markets. 1999 Published by Elsevier Science Ltd. All rights reserved.
* Corresponding author. Tel.: ⫹ 1-202-690-6102; fax: ⫹ 1-202-690-6167. 1 Disclaimer: The views presented in this paper represent those of the authors only. They do not reflect the policies of either the Department of Health and Human Services, the Food and Drug Administration, or the Department of Agriculture. 0306-9192/99/$ - see front matter Published by 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 3 0 6 - 9 1 9 2 ( 9 9 ) 0 0 0 1 8 - 4
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Introduction A healthful diet provides sustenance and nourishment for growth, development, health and well-being. It is well documented that good nutrition can substantially contribute to preventing illness and premature death. In fact, diet is a contributing factor in overweight and four of the 10 leading causes of death in the United States: heart disease, some cancers, cerebrovascular disease, and diabetes mellitus. A number of Federal agencies are charged with tracking and developing policies to influence trends in illnesses and the dietary factors that partially give rise to them. This paper addresses two components of Federal mandates associated with diet/disease relationships: tracking trends in morbidity and mortality related to diet and how Federal agencies may positively influence these trends. All data on morbidity and mortality trends are from the Centers for Disease Control and Prevention report Health, United States (National Center for Health Statistics, 1998).
Health trends Overweight From examination of the most recent health data, the most significant trend among US citizens is an increasing prevalence of overweight, defined as Body Mass Index greater than or equal to 27.8 kg/m2 for men and greater than or equal to 27.3 kg/m2 for women. This trend is disturbing for several reasons, not the least of which is that overweight is a correlate and, in some instances, a cause of the four illnesses mentioned above. Specifically, overweight is considered a risk indicator for cerebrovascular disease and some forms of cancer and is a direct contributor to the risk of contracting diabetes or heart disease through its effect on blood lipids. Overweight is also associated with gall bladder disease, osteoarthritis, sleep disorders, and psychological stress. Even without the contribution to mortality, overweight gives rise to the same costs as some kinds of morbidity in terms of reduced physical activity and enjoyment of life as, for example, people recovering from heart attacks. Over one-third of the population, 36.6% in 1988–1994 are now overweight as compared to 25.7% in 1976–1980, an increase of over 40%, keeping the definition of overweight constant. However, the distribution of overweight people is skewed in certain socioeconomic subgroups. First, overweight continues to be more of a problem for women than for men. In addition, both income and race/ethnicity are significant predictors of overweight. Among the adult population, overweight prevalence is highest among black, non-Hispanic females (53.3% in 1988–1994). Prevalence among Mexican-origin females is also extremely high, increasing from 39% to 50% during this same time period. These two socioeconomic subgroups, besides having a quality of life adversely affected by being overweight, are among the highest risk subgroups for diet-related morbidity and mortality. For instance, African American females are in the highest risk group for diabetes. Overweight is lowest among white, non-Hispanic males (33.7% in the same time period). However, the rate of
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being overweight among all adult males increased to a greater extent than among women during these time periods. The problem of overweight is not limited to adults only. Especially alarming from a public health perspective is the prevalence of overweight among children and adolescents. Because dietary and physical activity habits are typically formed before adolescence, it is of particular concern that the prevalence of overweight adolescents more than doubled from 1976–1980 to 1988–1994. Prevalence among teen males increased 134% and among teen females, 75%. Again, socioeconomic disparities persist in some race and ethnic groups. When data on overweight is examined in its totality (without regard to sex, race, or ethnicity), the higher the income of the family, the less likely the occurrence of overweight among adolescents. Prevalence of overweight is 17% among poor adolescents (defined as family income below the Federal poverty level), as compared to 13% for near poor (family incomes between 100 and 199% of the poverty level) and 9% for middle/high income families (family incomes at 200% or more of the poverty level). Although socioeconomic disparities exist when examining overweight overall, this trend is driven solely by non-Hispanic white adolescents. The association does not hold in other racial/ethnic groups where cultural attitudes appear to cause higher rates of adolescent overweight in the wealthier households. Heart disease Although age-adjusted death rates have declined significantly, the leading cause of death in the United States is still heart disease for all adult racial/ethnic groups. In 1996, diseases of the heart caused 733,361 deaths, about 32% of all deaths. Ageadjusted death rates related to heart disease declined almost 26% from 1985 to 1996 with men improving more than women. Again, socioeconomic status and racial/ethnic disparities are significant. Thus, death rates are negatively correlated with income in every category of sex, race, and ethnic groups. In addition, heart disease death rates are also higher among African Americans than among whites. Cerebrovascular disease Cerebrovascular disease, including stroke, is the third leading cause of death in the United States. Although death rates from cerebrovascular disease have been declining, almost 19% from 1985 to 1996, African Americans are still more likely to suffer from cerebrovascular disease than the general population. Although all cerebrovascular disease rates are declining, males, particularly African American males, continue to have higher rates than women. Heart disease and stroke share many risk factors, including hypertension and high serum cholesterol. Overweight, already described, is also a risk factor for heart disease. Prevalence of hypertension among adults declined from 39% in 1976–1980 to 23% in 1988–1994. Men are more likely to have high blood pressure than women (25% of men, 21% of women). Although men from high income families are less likely to be hypertensive than men from middle, near poor, or poor families, the
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difference is not highly significant. However, the between the prevalence of hypertension among women and income appears to be stronger. Women from high-income families are very likely to be less hypertensive than women from middle, near poor, or poor families. Hypertension is more prevalent among African Americans than among whites, although African Americans are less likely to have high blood cholesterol than whites. Mean serum cholesterol levels have declined almost 5% from 1976–1980 to 1988– 1994. High blood cholesterol prevalence has declined more than 30% from 1976– 1980 to 1988–1994, exceeding the Healthy People 2000 goals for both men and women (National Center for Health Statistics, 1997). This may be due, in part, to the National Cholesterol Program activities that are aimed at educating public health professionals and the public about the importance of cholesterol as a risk factor. Cancer The best scientific evidence thus far indicates that as many as one-third of all cancer deaths are attributable to dietary factors. The link between colorectal cancer and dietary risk factors, such as overweight, high fat diets, and diets low in fiber, fruits, and vegetables has been well established. Diet is also believed to be a factor in other cancers, such as female breast cancer, but the evidence is not conclusive. Cancer remains the second leading cause of death in the United States, accounting for 539,533 deaths in 1996—an increase of almost 30% since 1980. However, there is good news. After several years of increasing cancer death rates, from 1990 to 1996, age-adjusted death rates from cancers decreased on average 0.5% per year. From 1985 to 1996, cancer death rates declined by 5%, exceeding the Healthy People 2000 goals for all cancers and particularly in the case of colorectal cancer. Although the causes of cancer death varied by race/ethnicity, the top four sites associated with death from cancer in all racial and ethnic groups were: lung, female breast, prostate, and colon/rectum. African Americans had the highest cancer incidence and mortality rates and the lowest survival rates. Diabetes mellitus There are essentially three types of diabetes mellitus: Type I, formerly called insulin-dependent or juvenile diabetes; Type II, formerly called non-insulin dependent, or adult-onset diabetes; and gestational diabetes. Of the three, Type II diabetes, which is affected by diet, is the most common form of diabetes, especially in minorities and the elderly. Approximately 95% of all persons diagnosed with diabetes are Type II. Overall, diabetes mellitus is the seventh leading cause of death in the United States, with 61,767 deaths in 1996. These deaths are primarily due to cerebrovascular disease. As is the case with overweight, prevalence of diabetes is increasing at alarming rates. The age-adjusted death rate, for all persons, has increased from 9.7 per 100,000 in 1985 to 13.6 in 1996. Men are more likely to die with diabetes than women (14.9 age-adjusted death rate for men, 12.5 for women) and racial/ethnic disparities again
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exist. According to the age-adjusted death rates in 1996, African Americans were more likely to die from diabetes than any other racial/ethnic group (28.8 for African Americans, 12.0 for whites).
Federal role in dietary management Federal involvement in policies that affect the diets of Americans has been well established for decades and includes both monitoring American’s diets and trying to improve those diets. Activities designed to improve diets include provision of information to guide consumers into making choices for a healthful diet, creating and enforcing measures for consumers to use to evaluate individual foods by use of food labels, requiring or allowing food supplementation with vitamins and minerals, and restricting misleading claims. Federal involvement in dietary policies fall under authorities granted under the Food, Drug, and Cosmetic Act, the Nutrition Labeling and Education Act, and others. Federal information campaigns include such activities as the Food Guide Pyramid. The Food Guide Pyramid serves as the cornerstone of Federal nutrition policy and reflects the Dietary Guidelines for Americans which recommend that consumers eat a variety of foods; maintain a healthy weight; choose a diet that is plentiful in grain products, fruits and vegetables; moderate in salt, sodium, and sugars; and low in fat, saturated fat, and cholesterol; and that alcoholic beverages be consumed in moderation, if at all. Another example of Federal action is the requirements set forth in the Nutrition Labeling and Education Act and the many regulations that implement it. These regulations include those requiring disclosure of nutrients in the Nutrition Facts Panel, serving size declarations, and definitions of nutrient content claims and health claims. These implementing regulations apparently have had some acceptance in that 75% of all US consumers use the food label, although it is not clear precisely how it has impacted diets. The Federal government tracks intake of both macro and some micro nutrients in the diet through surveys, such as the market-based survey, Continuing Survey of Food Intakes by Individuals, and National Household and Nutrition Examination Survey. We observe from this data that, in fact, some changes are being made in the diets of Americans (less fat and saturated fat consumption, more vegetables), although not all of the changes recommended. The average fat and saturated fat intake, expressed as a percentage of calories, has decreased and the proportion of the population who meets the average daily goals of the Dietary Guidelines for fat and saturated fat has increased. However, the vast majority still do not meet the guidelines. According to a review of the Healthy People 2000 goals, approximately one-third of the population consume less than 30% of calories from fat and less than 10% of calories from saturated fat, even though the average number of servings of fruits, vegetables, and grains has increased since the beginning of the decade. Also, the total caloric consumption has increased on average. Thus, although the amount of calories from fat and saturated fat has declined, the absolute amount of calories has actually increased. Although the availability of reduced fat processed foods has
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increased, people appear to have increased their caloric consumption and thus, their consumption of fat. Clearly, as shown earlier in the paper, some groups are still at very high risk for diet related diseases and overweight. It may be that improvements are needed both in what we monitor and how we influence policy to change diets further. There are three possible ways in which diets can be improved although they are not mutually exclusive: 1. People switch from a less healthy food in one grocery category to a more healthy food in another category. That is, rather than eating cake or candy for dessert, they eat fruit. There is evidence from various studies, such as Putler and Frazao (1991) discussed later, that shows that cross-category switching does occur, although people do not always end up improving their diets. 2. People choose healthier foods within an existing grocery category of foods. For example, people switching from a regular cheddar cheese to a low fat cheddar cheese. 3. Manufacturers create healthier foods within a grocery category. In this case, manufacturers increase the availability and taste within a category of foods so that the proportion of food within a grocery category increases toward more healthy foods. Note that each of these classes of policies reflects the fact that for people to eat healthier diets, they must have healthier foods. If eating a balanced diet was the only problem, nutrition labels would not be needed as consumers could simply select foods randomly from the major Food Guide Pyramid categories and diets would be optimal. Thus, this analysis presumes that a diet in which consumers choose foods randomly from within Food Guide Pyramid categories, while although technically balanced, can be improved by more careful selection of particular foods within those categories. In a random selection, macro and micro nutrient intake would tend toward the mean of the existing distribution of foods within those categories, which we presume is not necessarily optimal. It is likely, however, that that is not sufficient and that improving diets is a combination of both balancing the diet and choosing foods for a healthier diet from within Food Guide Pyramid categories. The Federal government has, by allowing for and authorizing health and nutrient content claims, as well as requiring labeling of macro and micro nutrients, implicitly adopted the position that individual foods count and that some foods within product categories are more helpful in creating healthy diets than others. We know that the prevalence of people using nutrition labels is about 75%. We also know the percent of the market making health or nutrient content claims. However, we do not know how much, as a percent of energy, these foods are replacing similar foods that are not making such claims. Nor do we know who is using claims. Further, we do not know the extent to which claims are leading to an overall healthier diet. The discussion that follows will explore the possibility of an intervention for each method of causing a diet change.
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Change food categories There is some evidence that these types of substitutions have occurred. A study by Putler and Frazao (1991) showed changes in women’s diets over time away from red meats. However, in this case, they showed that these changes did not necessarily lead to healthier diets. For people to change the food categories they eat, they must overcome the cultural eating patterns that they learned in childhood. Further, even if people make such substitutions, it is questionable as to whether or not their diets are improved. For example, if one tries to compare the diet implications of increasing the price or safety of seafood, such that there is a shift in quantity demanded relative to other protein sources (e.g., red meat), analysis of nutritional improvements resulting from such shifts proves to be intractable because of the difficulty accounting for both consumer preparation and other, offsetting shifts. Preparation methods (i.e. broiled, steamed, baked, fried or breaded) affect the macro and micro nutrient content of these foods. In addition, the substitution of one high protein food for another often engenders substitutions of accompanying dishes, such as hush puppies for baked potatoes. Thus, as a policy tool, this method of influencing diets seems to have considerable problems. Thus, making permanent dietary changes across entire food categories in the general population would most likely require massive public expenditures in nutrition education resulting in a very small return. Choose better foods within categories Interventions to affect a substitution of foods within grocery categories assume that it is possible to convince consumers that, from a fixed distribution of foods, they should begin choosing healthier foods. This can be achieved through either changes in manufactured food choices, such as no fat cheese instead of full fat cheese, or through adoption of different preparation methods, such as broiling instead of frying. The difficulty for an intervention to effect such a change is that people usually place taste and price above other food selection criteria including nutrition. In order to change diets, this type of change assumes people will now make previously rejected changes based on government supplied or any other information. Without changes in either consumer taste preferences or the ability to create healthier foods that taste better, nutritional programs aimed at getting consumers to change food choices within a category are unlikely to have a significant impact. Just as with the last type of policy mentioned, this would require massive expenditures in nutrition education programs with very little return. Create healthier foods within categories Interventions to create healthier foods within categories can happen in two ways: manufacturers can reformulate foods within existing Federal food composition/processing guidelines or they can reformulate as a result of Federal fortification requirements.
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Reformulating foods for market share and to increase consumer options Manufacturers can, for example, create better tasting products with fewer calories, lower total fat or simply better combinations of fat (e.g., lower saturated fat and transfatty acids), lower sodium, etc. Since the implementation of NLEA, many manufacturers have indeed reformulated their products. This type of reformulation can take into account taste, nutrition, convenience, price, and any other important factor that affects consumer choices. In addition to packaged foods that manufacturers reformulate to gain market share, restaurateurs could create more nutritious foods through a change in preparation methods, menu selections, or portion sizes. However, the incentive for restaurants to do this is small unless consumers demand it. Consumers must be educated to demand more nutritious choices. Of course, this must also be in the context of an overall proper diet including portion sizes. Reformulation for Federal fortification requirements Required reformulation is illustrated by the recent FDA rule requiring folate enrichment of bread products. The Federal government either mandates reformulation or allows fortification for certain food products. To the extent that it is difficult to change consumer diets through the first two types of policy interventions, this type of policy may surface as an attractive intervention that should be explored, although it will not address problems with macronutrients or energy. As mentioned earlier, although the Federal government does track macro and micronutrient intakes, they are generally not tracked relative to the macro and micronutrient content of individual foods within food categories. Because of the implicit adoption by the Federal government of the policy that individual foods matter, it is incumbent upon us to track the creation of more nutritious foods and their effect upon overall diets. Examining the three possible ways to change diets through better individual food selection, the most unexamined category appears to be the third one, reformulation either through mandatory fortification or through total product reformulation. One primary attraction of such a policy is that, from a consumer’s point of view, the change in food selected could be relatively costless, economically or culturally. If this is so, it is worth exploring how this type of intervention can facilitate the creation of such markets. However, there may be legitimate reasons for objecting to such a policy. For example, some groups have expressed concerns about whether or not consumers should be encouraged to eat ‘manufactured foods’, foods that are not ‘natural’. These concerns usually incorrectly cite manufactured foods as somehow being nutritionally inferior to ‘fresh’ or ‘natural’ foods. As discussed in FDA’s final rule on the definition of the term ‘healthy’, data on canned and frozen formulated fruits and vegetables, for example, shows that this simply is not true. In addition, breeding and hybridization of fruits, vegetables and animals is over a century old. In a sense, all food products are now ‘manufactured.’ This does not imply that some manufactured foods may ultimately be shown to have problems, only that lumping them all in a category as being superior to ‘natural’ foods is incorrect. Finally, there is some legitimate concern that Federal policies do not override consumer choice. For example, recent consideration of taxing offending macro nutrients such as dietary fat is probably not appropriate.
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More study is necessary before making recommendations. However, assuming that policy changes made to encourage reformulation is a sound direction for Federal policy, the factors that would be necessary to implement such a policy are discussed below. 1. First, it would be necessary to track the creation of new, more nutritious foods, their content, who eats them, and how it affects their diet. We know that there are about 12,000 new products offered each year and we know something about the claims made on those products. However, we do not know the nutrient composition of these foods. By tracking these foods, we may be able to determine which policies help or hinder their creation or, more generally, if in fact they do make a positive difference on the diets of Americans. 2. Second, it would be necessary to continue to educate the public to use food labels to purchase healthier foods and construct healthier diets. This increases demand for these foods and facilitates creation of these markets. 3. Third, it would be necessary to continue to use metrics that consumers can use to judge the relative nutritional content of foods. Creating metrics is a major component of the Nutrition Labeling and Education Act and its implementing regulations. We have observed that these metrics force competition along those labeled attributes. There are other examples of improving markets by the use of new metrics, such as requiring airlines to report percentage of on-time arrivals. 4. Lastly, it would be necessary to continue to create rules to prevent adverse consequences of competition for new products or to remove rules that impede helpful competition. Existing rules that need to be examined include food standards, fortification policies, and policies on claims. These rules should be examined to determine if they impede the goal of improving diets. For example, FDA recently determined that its standards for certain low fat dairy products conflicted with the goals of the Dietary Guidelines. Those standards were subsequently eliminated and now those dairy products must comply with the nutrient content claims requirements promulgated under NLEA. Other potentially similar situations must be carefully examined.
Conclusion Virtually all of the diet-related diseases examined, except diabetes, are declining in terms of age-adjusted death rates. However, possibly due to an increased intake of calories, there has been a marked increase in overweight in all groups and a very large increase in some socioeconomic and racial/ethnic subgroups. Similarly, the increasing prevalence of diabetes mellitus is also of public health concern. The Federal government maintains a long standing interest in these effects and both tracks them and tries to exert a positive influence on them. Using more policies to encourage creation of reformulated more nutritious foods may be a promising avenue to change the trend towards being overweight, diabetic, and at risk for other diet-related illnesses.
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References Derby, B.M., Fein, S.K., 1995. Meeting the NLEA Education Challenge: A consumer research perspective. In: Shapiro, R. (Ed.), Nutrition Labeling Handbook. Marcel Dekker, New York, pp. 315–353. National Center for Health Statistics, 1997. Healthy People 2000 Review 1997. Public Health Service, U.S. Department of Health and Human Services, Hyattsville, Maryland. National Center for Health Statistics, 1998. Health, United States, 1998 with Socioeconomic Status and Health Chartbook. Public Health Service, U.S. Department of Health and Human Services, Hyattsville, Maryland. Putler, D., Frazao, E., 1991. Diet/health concerns about fat intake. Food Review 14 (1), 16–20.