Health Objectives for the Nation Progress Toward Achieving the 1990 National Health Objectives for Improved Nutrition

Seventeen of the 1990 health objectives for the nation (1) addressed improved nutrition for persons in the United States; the Public Health Service gave special priority to 15 of these objectives (2). Progress was made toward achieving six of the objectives; the others either were not achieved or data were insufficient to assess progress. This report summarizes the status of efforts to achieve the 15 priority objectives through June 1990. OBJECTIVES PARTIALLY MET By 1990, growth retardation of infants and children caused by inadequate diets should have been eliminated in the United States as a public health problem.

Data from CDC\'s Pediatric Nutrition Surveillance System (3) provided information on the nutritional status of infants and children in families with low income served by the Supplemental Food Program for Women, Infants, and Children (WIC Program) and other public-health services. In 1988, the prevalence of low height-for-age ranged from 6% to 16% for different age and ethnic groups (representing an excess over the 5% of otherwise healthy children who are statistically likely to be in this population). From 1980 through 1988, substantial changes in height-for-age occurred only among Asian children, reflecting the beneficial impact of nutrition and health services provided to Southeast Asian immigrants. By 1990, 50 percent of the overweight population should have adopted weight loss regimens, combining an appropriate balance of diet and physical activity.

In 1985, among persons aged greater than or equal to 18 years who were classified as overweight (i.e., greater than or equal to 120% of desirable weight, based on self-reported weight and height), approximately 64% of women and 48% of men reported they were trying to lose weight. Approximately 30% of overweight men and 25% of overweight women reported they had adopted weight-loss regimens that combined exercise and diet restriction (4). By 1990, the mean serum cholesterol level in the adult population aged 18 to 74 should be at or below 200 mg/dl.

Mean serum cholesterol levels in men and women aged 20-74 years decreased from 217 and 223 mg/dL, respectively, in 1960-1962 to 211 and 215 mg/dL, respectively, in 1976-1980 (5). Preliminary data from Minnesota (6) and other areas suggest this declining trend was sustained during the 1980s. In addition, data collected in various diet and health knowledge surveys during the 1980s indicated that increasing proportions of the population recognized that high blood cholesterol was a risk factor for heart disease, knew that dietary factors were related to heart disease, reported using label information to avoid or limit fat and cholesterol, and reported being on a blood cholesterol-lowering diet. By 1990, the proportion of the population which is able to identify the principal dietary factors known or strongly suspected to be related to disease, should exceed 75 percent for each of the following diseases: heart disease, high blood pressure, dental caries, and cancer.

The Food and Drug Administration's (FDA) Health and Diet Survey in 1988 indicated that more than 75% of U.S. residents were aware of a relation between diet and hypertension and between diet and heart disease (7). The survey also demonstrated increasing public awareness of the relation between specific dietary components and other diseases. By 1990, the labels of all packaged foods should contain useful calorie and nutrient information to enable consumers to select diets that promote and protect good health. Similar information should be displayed where nonpackaged foods are obtained or purchased.

In 1988, approximately 60% of packaged, processed foods regulated by the FDA had nutrition labeling, an increase from 42% in 1978 (8). The Nutrition Labeling and Education Act of 1990 required nutrition labeling on most products regulated by the FDA, including fresh fruits, vegetables, and fish. In addition, the U.S. Department of Agriculture (USDA) has proposed nutrition labeling for the products it regulates. Accordingly, this objective should be achieved by the mid-1990s. Before 1990, a comprehensive National nutrition status monitoring system should have the capability for detecting nutritional problems in special population groups, as well as for obtaining baseline data for decisions on National nutrition policies.

By the early 1980s, a National Nutrition Monitoring System had been implemented that sampled population groups at presumed increased risk for malnutrition, including persons with low incomes, pregnant women, older adults, and ethnic minorities. However, data had not been collected on the nutritional status of persons in hospitals, nursing homes, and institutions for the developmentally disabled; physically, mentally, and developmentally disabled persons in community settings; children in day care facilities; Native Americans on reservations; persons in correctional institutions; and homeless persons. OBJECTIVES NOT MET OR DATA INSUFFICIENT TO ASSESS PROGRESS By 1990, the proportion of pregnant women with iron deficiency anemia (as estimated by hemoglobin concentrations early in pregnancy) should be reduced to 3.5 percent.

The most consistent available data were based on CDC's Pregnancy Nutrition Surveillance System (PNSS) and reflected the status of low-income women enrolled in the WIC Program in approximately 15 states. Using CDC's most recent criteria for anemia in pregnancy (9), there was no overall reduction in this problem from 1980 through 1988. By 1990, the prevalence of significant overweight (120 percent of ``desired'' weight) among the U.S. adult population should be decreased to 10 percent of men and 17 percent of women, without nutritional impairment.

Using a definition of obesity based on body mass index, two surveys (the Second National Health and Nutrition Examination Survey (NHANES II) in 1976-1980 and Hispanic HANES in 1982-1984) indicated the prevalence of obesity among persons aged 20-74 years to be approximately 24% among men and 27% among women. These prevalence estimates were virtually unchanged from the early 1960s. Based on the most recent data available, the prevalence of overweight was lowest among non-Hispanic white women (25%) and highest among non-Hispanic black women (44%). In general, the prevalence of overweight among women was inversely related to socioeconomic status. Among men, the prevalence of overweight was lowest among non-Hispanic whites (24%) and highest among Mexican Americans (30%). By 1990, the average daily salt* ingestion (as measured by excretion) by adults should be reduced at least to the 3 to 6 gram range.

Data were not available from large-scale surveys to estimate sodium ingestion as measured by excretion. However, data from the USDA\'s Continuing Survey of Food Intakes by Individuals indicated that in 1985 mean (1-day) dietary intakes of sodium from food (excluding salt added at the table) were approximately 2.5 g for women aged 19-50 years and 3.6 g for men aged 19-50 years (10,11). By 1990, the proportion of women who breastfeed their babies at hospital discharge should be increased to 75 percent and 35 percent at six months of age.

Although the prevalence of breastfeeding increased in the early to mid-1980s, it has remained level or declined in more recent years. Among low-income women included in the PNSS, the percentage of children in different ethnic groups who were ever breastfed increased from approximately 15%-34% in 1980 to approximately 30%-50% in 1984-1985. The proportion of breastfed children has been greatest among white, Hispanic, and American Indian women, and lower among Asian and black women. By 1990, 70 percent of adults should be able to identify the major foods which are: low in fat content, low in sodium content, high in calories, good sources of fiber.

Although reading of nutrient content on food labels was reported as substantial by consumers, progress toward this objective could not be assessed definitively. A population-based survey in 1990 indicated that 79% of consumers read labels before purchasing a food product for the first time; 83% reported that labels influenced their purchasing and that they closely examined sodium, fat, caloric, cholesterol, and sugar content. By 1990, 90 percent of adults should understand that to lose weight people must either consume foods that contain fewer calories or increase physical activity--or both.

Although awareness of these relations was high, data were inadequate to determine whether this objective had been achieved. In 1985, 74% of the population greater than 18 years of age believed that eating fewer calories was one of the two best ways to lose weight; 73% believed that increasing physical activity was one of the two best ways. By 1985, the proportion of employee and school cafeteria managers who are aware of, and actively promoting, USDA/DHHS dietary guidelines should be greater than 50 percent.

Progress on this objective could not be assessed definitively. In 1988, the USDA revised recipe files for school lunch programs for consistency with the Dietary Guidelines for Americans and distributed these files to every school that participated in the school lunch program. In addition, the American School Food Service Association and its members actively supported and promoted the guidelines. By 1990, all States should include nutrition education as part of required comprehensive school health education at elementary and secondary levels.

In 1985, 12 states mandated nutrition as a core content area in school health education, compared with 10 states in 1978. By 1990, virtually all routine health contacts with health professionals should include some element of nutrition education and nutrition counseling.

Data are inadequate to assess progress toward this broad objective. A similar, but more specific, objective is included in the nutrition objectives for the year 2000.

Reported by: Office of Disease Prevention and Health Promotion. Food and Drug Administration. Div of Nutrition, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note:

Although the nutrition objectives were only partially achieved by 1990, many of the problems are of continuing public health concern and have been targeted in the nutrition objectives for the year 2000. These objectives address iron deficiency anemia, growth retardation, overweight, sodium, breastfeeding, nutrition labeling, use of dietary guidelines in school lunch programs, and nutrition education and counseling.

In the decade since formulation of the 1990 national health objectives, there have been substantial increases in public and professional awareness regarding the effect of nutrition on health. In particular, attention has focused on nutritional inadequacies among poor and homeless persons and nutritional excesses reflected by obesity and elevated cholesterol. Efforts such as the National Cholesterol Education Program have further heightened awareness of nutritional issues.

The nutrition objectives for the year 2000 reflect this heightened awareness, especially regarding nutrition-related factors that affect risks for chronic disease. The reduction of obesity and dietary fat intake are special priorities. The National Academy of Sciences recently emphasized three strategies to further implement dietary recommendations (12): 1) increasing the role of government and health-care professionals in developing nutrition policy and agendas; 2) improving nutrition knowledge and practice among the public; and 3) increasing availability of foods that conform to dietary recommendations.

Implementation of these strategies will require coordinated efforts directed toward particular populations at increased nutritional risk and include effective communication of nutrition messages. In addition, consumers will require improved access to affordable and convenient food choices that are both healthy and appetizing. These changes will entail cooperative efforts between the public and private sectors toward the common goals of improved nutrition and health.

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, 1980:143-54.

2. US Department of Health and Human Services, Public Health Service. Implementation plans for attaining the objectives for the nation. Public Health Rep 1983;Sept-Oct(suppl).

3. Trowbridge FL, Wong FL, Byers TE, Serdula MK. Methodological issues in nutrition surveillance: the CDC experience. J Nutr 1990;120:1512-8.

4. NCHS. Health promotion and disease prevention: United States, 1985. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1988; DHHS publication no. (PHS)88-1591.

5. NCHS/National Heart, Lung, and Blood Institute. Trends in serum cholesterol levels among US adults aged 20 to 74 years. JAMA 1987;253:937-42.

6. Burke GL, Sprafka JM, Folsom AR, Luepker RV, Norsted SW, Blackburn H. Trends in CHD mortality, morbidity, and risk factor levels from 1960 to 1986: the Minnesota Heart Survey. Int J Epidemiol 1989;18(suppl 1):S-73-81.

7. Levy AL, Ostrov N, Guthrie T, Heimbach JT. Recent trends in beliefs about diet/disease relationships: results of the 1979-1988 FDA Health and Diet Surveys. Washington, DC: Food and Drug Administration, Division of Consumer Studies, 1988.

8. Bender M. Status of nutrition and sodium labeling on processed foods: 1988. Washington, DC: Food and Drug Administration, Division of Consumer Studies, 1989.

9. CDC. CDC criteria for anemia in children and childbearing-aged women. MMWR 1989;38:400-4. 10. US Department of Agriculture. Nationwide Food Consumption Survey, Continuing Survey of Food Intakes by Individuals, women 19-50 years and their children 1-5 years, 1 day, 1985. Hyattsville, Maryland: US Department of Agriculture, 1985; NFCS, CSFII report no. 85-1. 11. US Department of Agriculture. Nationwide Food Consumption Survey: Continuing Survey of Food Intakes by Individuals, men 19-50 years, 1 day, 1985. Hyattsville, Maryland: US Department of Agriculture, 1986; NFCS, CSFII report no. 85-3.

12. Institute of Medicine, Food and Nutrition Board. Improving America\'s diet and health. Washington, DC: National Academy Press, 1991.

*When originally written, this objective incorrectly referred to ``daily sodium ingestion.'' Three to 6 g of salt is equivalent to 1.2-2.4 g of sodium.

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