Implementing American Heart Association Pediatric and Adult Nutrition Guidelines

Cardiovascular disease mortality rates have fallen by ≈50% over the past 50 to 60 years. However, cardiovascular disease prevalence remains high, and cardiovascular disease is still the leading cause of death and disability in the United States.^1,2 It has been estimated that preventive efforts have contributed to at least half of this decline, with the primary contribution coming from declines in mean blood cholesterol concentrations, mean blood pressure levels, and tobacco use rates. Regrettably, during this past decade, the increased prevalence of obesity and diabetes mellitus has dramatically slowed the secular decline in cardiovascular mortality rates.^1,3,4 In fact, in the United States, the contribution of prevention to the decline of cardiovascular mortality is now much lower than in other industrialized countries and the United States historically.^1,5

The continuing challenge is preventing the development of cardiovascular disease, especially early in life. Nutrition remains a cornerstone of that effort. Modernization and industrialization of the food supply and distribution patterns, as with our lifestyles, have produced many benefits but also unanticipated consequences.⁶ Decline in saturated fat and cholesterol intake, influenced by public awareness of adverse health consequences, coupled with increased availability of foods lower in cholesterol and saturated fat, has been associated with reductions in cardiovascular disease. However, recent studies of trends in the dietary patterns of the United States suggest a significant drift toward less healthful eating patterns and overconsumption of energy, which have been associated with increases in prevalence of obesity, metabolic syndrome, and type 2 diabetes mellitus.^1–4 These data strongly suggest that additional emphasis is needed on ways to implement current guidelines in contemporary society. A great benefit can be achieved from adopting a heart-healthy nutrition pattern at a young age, thereby preventing the rise in cholesterol and blood pressure levels associated with excess saturated fat, trans fat, and salt ingestion; minimizing the development of obesity; and establishing lifelong dietary habits.^7,8

Current American Heart Association (AHA) diet and lifestyle recommendations for both children and adults emphasize these goals: aim for a healthy body weight and recommended levels of blood lipids and lipoprotein, blood pressure, and glucose; engage in regular physical activity; avoid use of and exposure to tobacco products; and consume diets rich in vegetables and fruits, whole grains, low-fat and nonfat dairy products, legumes, fish (at least 2 times per week), and lean meat, coupled with food choices that minimize intakes of excess energy, saturated fat, trans fat, cholesterol, and salt.^9,10 The importance of focusing on the overall diet quality (dietary pattern) rather than individual foods or nutrients, balancing energy intake and expenditure, engaging in regular physical activity, and increasing the importance of following the AHA diet recommendations when eating outside the home is emphasized. Both pediatric and adult recommendations follow these guiding principles throughout the lifespan. Lacking but badly needed are more specific guidelines on how best to implement these recommendations.

The purpose of this scientific statement is to summarize current strategies on how to implement AHA nutrition recommendations for cardiovascular disease and stroke prevention throughout the life cycle, as well as providing suggestions and practical examples for strengthening these efforts. A similar approach has been developed recently for obesity.¹¹ Emphasized is the importance of a healthful overall dietary pattern within the complex nutrition environment of contemporary life. The Figure, adapted from several sources, presents a conceptual model for this complex environment and identifies facilitators or barriers to attaining AHA diet and lifestyle recommendations. The Figure shows nested concentric circles beginning at the individual level and working out toward the macroenvironmental level.^12–16 Each level offers a potential avenue for change, for helping individuals, families, and communities achieve AHA diet and lifestyle recommendations. It provides a framework for understanding the complexity of nutrition choices, organizing the existing literature on nutrition, and interpreting future research and its impact. This report follows the approach suggested by the Figure and developed in a recent AHA statement on obesity in developing an implementation argument.¹¹ Because of the broad nature of the topic, this report is meant to suggest new approaches to implementing a healthful diet within the context of contemporary eating patterns rather than developing new specific nutrition recommendations.

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Current AHA Dietary Guidelines

Tables 1 through 5 summarize the current AHA dietary recommendations for children, adolescents, and adults and strategies for implementation.^9,10 For adults, the emphasis is on dietary management to achieve optimal lipid and lipoprotein profiles, blood pressure and blood glucose levels, and body weight. In addition, the importance of engaging in regular physical activity and avoidance of the use of and exposure to tobacco products are emphasized (Table 1 and 2). For children >2 years of age, the emphasis is on a dietary pattern that meets nutrition requirements for growth and development while minimizing the development of cardiovascular risk factors, primarily high blood cholesterol, blood pressure and glucose levels, and excessive body weight gain (Table 4). At birth, breast-feeding is strongly recommended for all infants. Then, at all ages, adequate caloric intake is emphasized to maintain appropriate growth and development while minimizing excess weight gain. Individuals with diagnosed risk factors require therapeutic lifestyle changes that address those risk factors that are often multifactorial and beyond the scope of the present statement.^17,18

To achieve dietary goals, the AHA recommends consumption of an overall diet rich in a wide variety of fruits and vegetables, grain products (especially whole grains), fat-free and low-fat dairy products, legumes, poultry and lean meats, and fish, preferably oily fish, at least twice a week (Tables 3 and 4). The aim should be for a moderate fat intake (25% to 35% of energy), with primary sources of added fats coming from vegetable oils such as soybean, canola, corn, olive, sunflower, and safflower oils. Within each category, choices should minimize the intake of excess calories, saturated and hydrogenated (trans fatty acids) fats, cholesterol, salt, and sugar. An emerging area of research, useful to help better understand the importance of a comprehensive approach to diet, is analysis of overall dietary patterns (as opposed to studies of individual foods or nutrients) and the association of these patterns with chronic disease risk.^19,20

Current US Diet and Eating Patterns

Data on US eating patterns were previously monitored by the US Department of Agriculture (USDA) and are now collected by the National Center for Health Statistics as part of the joint nutrition monitoring system. The USDA Nutrition Monitoring System focused on dietary intake and assessed detailed measures of eating behavior over longer periods of time. Surveys were performed in 1965, in 1977 to 1978, in 1989 to 1991, and for the last time in 1994 to 1998. The National Center for Health Statistics began the National Health and Nutrition Examination Survey using 24-hour dietary recalls. This survey is called “What We Eat in America.”^21–24 Methodological differences among these surveys include major differences in the number of passes and approaches to questioning respondents, different coding of foods, shifting sources for food composition tables, and lack of a bridging methodology between the USDA and National Center for Health Statistics surveys. These problems have been partially overcome.²⁵ Another important limitation of the data presented in this section is that trends in eating behavior over the last 5 years have not been published.

Available data suggest that recommended intake of fruits and vegetables is not being achieved and that fluid milk and whole grains as a percent of energy intake are decreased. Dietary fiber intake is below recommended levels for all age groups.²⁶ Caloric intake has increased, consistent with increased body weight, in the US population.²⁷ These trends are seen across all age groups, including infants and toddlers, in whom there are significant increases in consumption of sugar-containing beverages.^28–30 For adolescents and young adults, it is important to note that the increased intake of snack foods and sugar-sweetened beverages (in place of milk) may be compromising overall nutritional diet quality.³¹

Equally important are the dietary patterns supporting these trends (Table 6). They include the following dimensions of eating behavior: increased number of eating events per day (snacks), larger portion sizes, greater proportion of food consumed away from home, higher energy intakes on weekend days (Friday through Sunday), and higher consumption of sugar-sweetened beverages.^32–39Table 6 also includes strategies that should be empirically evaluated.

Snacks, defined as eating at times other than traditional mealtimes, now represent ≈21% to 25% of total caloric intake, increased from 18% over the last several decades.^32–34 This is of particular note because the energy density of snack foods has increased over this time period, whereas the energy density of meals has not. The most common snacks are sugar-sweetened beverages and salty prepared foods such as chips that are low in nutrient density. In studies of smaller populations of elementary students, trends toward increased snacking have been observed despite participation in a high-quality dietary intervention program, suggesting that altering snacking behavior will be difficult.⁴⁰

Over the past 20 years, there has been a substantial shift in eating location, with a significant decline in meals eaten at home and increase in meals eaten at restaurants and fast-food establishments, particularly among younger individuals.³⁷ This has been associated with a shift in foods consumed, with significant increases in sugar-sweetened beverages, fruit juice, french fries, pizza, and salty snacks with declines in reduced-fat and whole milk.

Shifts in patterns of beverage intake have contributed to the doubling of per capita intake of beverage calories for adults since 1965. Soda and fruit drinks accounted for 70% of the increase in caloric intake.^29,30 There has been a significant rise in the use of low-fat presweetened dairy drinks over the same interval; however, dairy drink consumption overall has fallen. Similar changes are seen in children and adolescents, with recent data suggesting continuing increases in sugar-sweetened beverage intake, with 10% to 15% of caloric intake from this source.⁴¹ The impact of dairy and other additives to coffee/tea drinks is difficult to analyze but may be another source of increased caloric intake. A component of the increase in caloric intake related to beverages may be the lower relative satiety of beverages compared with solid foods.^42–45

With respect to specific eating patterns, there is consistent evidence that eating breakfast, including consumption of high-fiber ready-to-eat cereals and milk, is associated with improved overall nutrition and weight maintenance.^46–49 Families that regularly consume dinners together generally have healthier diet patterns, but it is not clear from these studies whether this is secondary to better family knowledge.⁵⁰ At least 1 large-scale prospective study of adolescents concluded that the frequency of eating family dinner was inversely associated with overweight prevalence at baseline but did not predict the likelihood of becoming overweight.⁵¹

For very young infants, up to 4 to 6 months of age, most daily energy intake is obtained from milk, either breast milk or formula. After that, a transition to solid food starts that continues throughout the second year as the child moves from milk feeding to baby foods and then to adult foods. A nationally representative study of infants, with data derived from a study based on telephone interviews and 24-hour dietary recalls, found that >20% of infants and toddlers did not consume 1 fruit or vegetable in a given day.²⁸ In contrast, >60% of infants 6 to 11 months and 80% between 12 and 24 months had at least 1 fruit drink a day. By 2 years of age, parents reported that 10% of total energy came from sugar-sweetened beverages other than fruit juice. French fries were the most common vegetable consumed, and none of the top 5 vegetables consumed by those <2 years of age was a green leafy vegetable. The frequency of consumption of nutrient-poor, energy-dense snacks increases with age.^52,53

Taste Preferences

It is important to understand the development of taste preferences when devising strategies to improve the overall quality of the diet. At the individual level, taste preference is critical to food choice. The basic biology of human sensory systems determines the sensory impressions of foods and beverages. Flavor experienced from food or drink consumption is a product of several sensory systems, most notably those of taste, smell, and irritation (eg, coolness of mint, burn of chili peppers). When foods or liquids are taken into the mouth, the perceptions that arise through the senses of taste and smell combine to determine flavor.⁵⁴ Not only is the ability to detect tastes and flavors well developed before birth, but infants start learning about these flavors before their first tastes of foods because the flavors of the foods eaten by mothers during pregnancy and lactation are transmitted and flavor amniotic fluid and mothers’ milk, respectively.^55,56

Responses to sweet, salt, and bitter tastes have evolved because of their functional importance in nutrient selection, especially in children whose responses to salt and sweet are heightened. Salt is a signal for nutrients such as sodium that often accompany other minerals in food. Sufficient salt intake protects against dehydration. Bitterness protects against foods that might be poisonous. Preferences for bitter foods (eg, dark green vegetables) and beverages (eg, coffee) are largely learned. Saltiness antagonizes bitter and thus improves palatability of useful foods with bitter or irritating taste.⁵⁷ The sensation of optimum saltiness can be influenced by an individual’s salt status and dietary level of exposure.^58,59

Children have an innate preference for sweet and, as a group, prefer a 0.60-mol/L sucrose concentration. Not only do children like sweets, but sweets make them feel better. When they taste something sweet, it reduces pain.^60,61 By late adolescence, sweet preferences decline to ≈0.3 mol/L sucrose. Findings from the USDA 1994 to 1996 Continuing Survey of Food Intakes⁶² paralleled the findings from basic research of an age-related decline in sweet concentration preferences. That is, in cross-sectional data, the proportion of energy obtained from added sweeteners peaks in adolescents, with ≈20% of energy derived from added sugars, and declines to ≈12.4% of energy for those ≥65 years of age. Longitudinal data suggest that consumption of foods with added sugar has increased over time.⁶³ There are striking individual and group differences in the levels of sweetness preferred. For example, across all age groups, blacks and non-Hispanics prefer significantly higher levels of sweetness than whites.^64,65

Because taste preferences drive food choice, an understanding of the source of taste preferences can suggest strategies for dietary change. Lactating mothers can influence taste preference in their infants by consuming fruits and vegetables, transmitting these flavors to the child.^55,56,66 Repeated offerings of healthy foods may increase acceptance. Memories of taste, flavor, and smell carry emotional content derived from culture, rewards, and pleasurable past experience that influences food choice; thus, early exposure to healthy foods may influence preference.⁶⁷ Although trying to limit sweet and salty food and beverage consumption is critical in reversing the obesity epidemic, this task will be difficult because of the inherent hedonic value of these tastes. These products are popular because they have undergone rigorous taste preference testing before release, correspond to natural taste preferences, and are heavily marketed. These observations provide the rationale for nutrition marketing to counter industry marketing concerning the pleasurable or normative quality of unhealthy foods.

Individual- and Family-Based Interventions to Improve Cardiovascular Health

There is substantial evidence for the usefulness of dietary interventions to improve blood pressure and lipoprotein profiles.^17,18 However, meeting these objectives in clinical practice is challenging. Two recent reviews of the obesity intervention literature have concluded that at present there is no significant evidence for the efficacy of current strategies in children.^68,69 Current Canadian clinical practice guidelines concluded that the evidence for recommending diet intervention for obesity is excellent but the evidence for efficacy of specific strategies is generally lacking and based largely on consensus.⁷⁰ In general, qualitative and meta-analytic data from family-based weight loss approaches for pediatric obesity as administered by trained behavioral therapists in university-based settings show a significant reduction of excess body weight compared with wait-listed controls or those with simple nutrition education.^71,72 In contrast, there is little evidence to support the general efficacy of information-based strategies to cause weight loss in obese children.⁷³ The challenge to the medical community is making the former efficacious programs more cost effective and available beyond the current settings.

Approaches to Implementation of Effective Diet Counseling

Diet counseling has historically been information based, more like teaching than counseling, with physicians and nutritionists providing factual information. The underlying assumption is that simply by learning the facts, patients and clients will change behavior. There are significant limitations to this strategy. First, counseling may not include an assessment of the patient’s interest in making dietary change. Second, primary care providers have a notoriously low estimate of self-efficacy with regard to nutrition counseling. Third, providers are unwilling to confront patients with regard to weight issues. Finally, time constraints and restrictions on reimbursement impose important limitations on traditional medical office visits. Written material is often provided, but these materials may not be easily adapted by patients to their specific circumstances. The patient’s literacy level may be too low to comprehend the material. The family’s eating pattern, determined by diverse economic and social factors, may not easily adapt to the recommended changes. Easy access to recommended foods may not exist.

A listing of many common barriers to implementing nutrition advice is provided in Table 7. In many settings, it may be more useful to identify barriers and then help families overcome them, if possible, before providing specific advice on dietary pattern. These barriers limit parents’ ability to act as role models for their children.

Improved outcomes to any intervention approach may be obtained by the use of general principles of behavior change theory, that is, by intervening at levels 1 and 2 of the Figure simultaneously.⁷⁴ The following discussion provides a summary of the sequential steps, which are summarized in Table 8. First, an assessment of readiness to change, a critical component of an intervention to change behavior, needs to occur. Concomitant with that assessment is the need for a self-evaluation by the patient of the behavior(s) targeted for change, which happens through, self-monitoring or keeping records over multiple days. The patient gets ready to make the change by understanding how frequently he or she does the targeted behavior. Second, goals are established for changing the target behavior over a defined period of time (eg, 1 week). Goals should be realistic, should be agreed on by the patient, and should allow success. Third, the goal is attempted while the patient monitors the target behavior. Continued monitoring is critical for behavior change. Finally, there is a repeat self-evaluation with goal review and reinforcement and adjustments up or down in goal setting, depending on the patient’s success in meeting prior goals. Effective counseling should generally reward behaviors that are considered satisfactory and ignore behaviors that are unsatisfactory. Critical to success is helping the patient maintain favorable self-esteem. A thorough review of behaviors useful in targeting in obesity management has been published.⁷³ Some examples are provided in Table 9.

An important question for promoting behavior change is the extent to which individuals and families are motivated and ready to change. Motivational interviewing is a series of clinical assessment strategies stemming from the drug and addiction field but more recently extended to the field of nutrition and pediatric weight control.⁷⁵ Those who do not perceive a problem or are too overwhelmed with other life challenges may not be receptive to prescriptions for dietary behavior change. The overarching aim of motivational interviewing is to help set the stage for behavior in individuals who are defensive or resistant to change by avoiding active prescriptions for behavior change or authoritatively telling patients what to do. Motivational interviewing uses strategies such as open-ended questions, reflective listening, rephrasing of statements, and identification of discrepant beliefs to raise motivation level. Motivational interviewing may help to ease the frustrations or power struggles between health professionals and patients and is an important area for future research.

Community-Based Interventions

Critical to community-based nutrition intervention will be access to healthier foods and the successful delivery of healthy nutrition messages that influence food choice. A large array of conflicting information about food and nutrition reaches the public, often with poorly documented claims and messages opposed to current diet recommendations.⁷⁶ Regulations on food marketing affect only health claims, allowing food and beverage marketers to make allusions to health without providing evidence. Many of these messages are directed at children who are unable to judge the merit of such advertising.^76,77 Consumers need reliable information on portion size, the caloric content of food, and the nutrient content of food to make choices.⁷⁸ This is particularly true for low–socioeconomic status groups at which unhealthy food marketing is often targeted and in which a prevalence of obesity is high.

Many studies addressing policy and environment have been conducted in schools; many of them have been reviewed in an AHA statement.⁷⁹ A smaller number of interventions have been nutrition interventions in communities or the workplace. Little research has been performed on community-based interventions to alter adult or elderly eating patterns; these studies have generally not been successful.¹³ Therefore, a significant limitation of this discussion is inadequate research in populations other than school-aged children on community-based interventions; conversely, there has been limited evaluation of and inadequate dissemination of information on those community-based interventions that have been attempted in scientific or other types of professional literature.⁸⁰ Another limitation is that for many community-based interventions, measurement of health outcomes is difficult because of impracticality or insufficient resources to make measurements.⁸¹ Newer research is starting to overcome these barriers; an example is the National Cancer Institute Black Churches Initiative.⁸²

Research in Schools and Other Influences on Children’s Eating Behavior

Although some school-based programs have had favorable effects on body mass index (BMI),^83–87 several have not.^88–90 Where findings show minimal effects, interventions may suffer from insufficient doses, barriers to effective implementation, and the inability to effectively target children at highest risk; in addition, the behaviors targeted by interventions may not relate directly to body weight or other cardiovascular risk factors. In general, these programs have produced modest and only short-term reductions (≈5%) in percentage overweight.^88,91–96 Several school-based programs have attempted to improve cardiovascular disease risk factors in grade school children.^{89,90,97–101} Other studies have investigated the impact of such initiatives on BMI.^83,84,86,102 To date, the results of these studies are mixed. Findings across interventions suggest that those that adopt a multifaceted integrated approach, ie, those that intervene in many components of the school environment simultaneously, are more likely to be successful.^83,84,86,102

Arkansas was the first state to implement BMI screening in schools. The Arkansas Center for Health Improvement, an independent entity, developed and validated a BMI measurement protocol, trained school staff on conducting BMI assessments, created a secure BMI database, and disseminated individual and confidential child health reports to parents.¹⁰³ Other states either have enacted similar legislation or have legislation or regulation under discussion. These programs are highly controversial; the Centers for Disease Control and Prevention, Institute of Medicine, and US Preventive Services Task Force have all published opinions on the issue, including recommendations on BMI screening in schools.¹⁰⁴ The efficacy of BMI screening may be difficult to assess. In Arkansas and Pennsylvania, screening was only part of a more comprehensive intervention that included increased access to healthier foods and physical activity initiatives. Although the Arkansas initiative met with early success, parents have raised concerns about labeling children as obese, and healthcare providers are concerned about the absence of effective treatments for identified children.

In the last few years, strengthening nutrition standards for foods sold in schools has been undertaken. The Institute of Medicine recently developed science-based nutrition standards for foods and beverages.¹⁰⁵ Putting these standards into practice will require significant policy work at the state and federal levels, industry reformulation of products, and a willingness to adopt standards such as these by communities, local school boards, school administrators, and staff. Substantial resistance to implementing the Institute of Medicine guidelines has emerged from sectors of industry, with legislation at the federal or state level preempting stricter standards in smaller jurisdictions. In 2006, the Alliance for a Healthier Generation (a partnership between the AHA and the William J. Clinton Foundation) negotiated with industry to establish voluntary nutrition standards for foods and beverages in schools. Annual assessment of this voluntary agreement will reveal the degree to which industry is implementing these standards and the extent to which schools are complying across the country. Careful research is needed to assess the impact of these programs on overall health.

The Child Nutrition and WIC [Women, Infants, and Children] Reauthorization Act of 2004 required schools to develop policies around nutrition education, physical activity, and overall school wellness and outline an implementation plan for these policies. The law required parents, students, school food service staff, school administrators, and members of local school boards to participate in the process through school wellness councils. School wellness councils or school health advisory councils are critical in creating a coordinated approach to a healthy school environment and are a leading factor in creating effective policies and maximal implementation.¹⁰⁶ To maximize the efficacy of school wellness policies, future reauthorizations of this federal legislation should address the transparency of the policies, quality of the wellness policies, periodic assessment of implementation and accountability for implementation, improved technical assistance, more permanent wellness committees within schools and districts, and additional outcomes research on the efficacy of wellness policy implementation.

Examples of other current initiatives to improve school foods include the following: farm-to-school programs (partnerships between schools and local farms), school garden programs, the Fruit and Vegetable Program authorized by the Farm Bill (recently expanded in new legislation), and school wellness policies. In this decade, some schools, school districts, and states have begun to make programmatic changes to reduce cardiovascular risk exposure, including reduction of poor-nutritional-quality foods in vending machines, reduction in presentation of deep-fried potatoes, increased recess, and creation of smoke-free environments.

However, it is important to keep in mind that not all foods and beverages consumed by children throughout the day are derived from school sources themselves.⁶³ Concurrently, children and adolescents are influenced by food advertising and marketing strategies. Young people see >40 000 advertisements per year on television alone.⁷⁸ They also are targeted by carefully crafted marketing tactics for unhealthy foods used in multiple environments such as the Internet, magazines, schools, product placement, incentive programs, video games, social networking sites, podcasts, and cell phones, all designed to improve brand recognition and increase sales.^107,108 Children tend to spend their discretionary income on high-calorie, low-nutrient-dense foods, and advertising certainly leads them in this direction.¹⁰⁹ Other research shows that exposure to food advertisements produced substantial and significant increases in energy intake in all children and that the increase was largest in obese children.¹¹⁰

Community Food Access

For people in disadvantaged areas, the grocery gap phenomenon can be traced back to the 1960s and 1970s when urban centers experienced population declines as residents fled inner cities for refuge in the suburbs. Among the factors that made the suburbs an attractive market were larger, less expensive tracts of land ready to be developed, simplified and business-friendly zoning and other regulations, more homogeneous consumer preferences, and less crime. Mirroring these demographic trends, supermarkets, along with other businesses, left urban areas. Studies to date demonstrate that lack of access to supermarkets is negatively associated with low-income residents’ health and economic well-being.¹¹¹ Residents have to travel out of their neighborhoods to purchase food or shop at smaller corner and convenience stores that generally have lower-quality and limited fresh or frozen, heart-healthy food choices.^111–116 These stores also tend to charge substantially higher prices.^117–119 Although low-income households spend less money on food, a greater proportion of their income is spent on food.¹²⁰ Programs such as the Fresh Food Financing Initiative in Pennsylvania is an example of a program to bridge access gaps by providing funds to operators locating in underserved neighborhoods.¹²¹

Interventions at community corner stores are a relatively new mechanism to affect dietary intake in communities.¹²² Programs typically include 1 or several components ranging from infrastructure changes (eg, the addition of refrigeration) to the use of social marketing. Current data suggest that these types of interventions hold promise for shifting shopping habits and knowledge.¹²³ A recent study demonstrated that proximity to a corner store selling healthy food was a positive predictor of fruit and vegetable intake.⁸⁰

The USDA, state governments, healthcare institutions, and not-for-profit groups have recently encouraged the establishment of farmers’ markets in communities with otherwise little access to healthy food.^81,124 Little research exists to date on the impacts of such markets on community health. Programs that support local agriculture such as the Farmers’ Market Nutrition Education Program and WIC Farmers’ Market Programs offer the dual benefit of increasing consumption of fruits and vegetables while supporting farmers who grow them.^125,126

With the number of meals people eat outside of the home increasing, consumers should have adequate information at point of purchase to make healthful choices in restaurants. Caloric intake is often underestimated in these settings.¹²⁷ For consumers to make healthier food choices in restaurants, they need accurate, sufficient information provided in a usable format at the point of service. Three municipalities—New York, NY; King County (Seattle, Wash), Washington (DC), and San Francisco (Calif) city and county—have passed menu-labeling legislation.

Workplace Interventions

Changing nutrition at work sites or at point of food purchase has received less attention. Interventions that have shown some success encourage purchase of healthier foods through price subsidies, adjusting prices so that healthy foods cost less.¹³ The few studies that have examined strategies manipulating the ease at which food is accessed (changing food availability in vending machines, assessing food availability in local groceries) have not shown substantial efficacy. Effective and rigorously tested program evaluation tools have begun to identify the best practices, including those that pertain to program design and implementation. Programs have considered mechanisms for disseminating nutrition education and offering employee support for changes. Results suggest that online and Web-based programs were more effective than print materials, and long-term and interactive intervention efforts were proven to have more sustainable outcomes than 1-time, temporary, and passive efforts (ie, kickoffs and pamphlets).^124–126 An additional benefit to workplace intervention might be cost savings for health expenses, but providing proof is challenging. Challenges to workplace interventions are listed in Table 10.¹²⁷ Currently, there is insufficient evidence detailing the aspects of successful workplace nutrition interventions, including biological measures of outcome, although tools like education or labeling programs seem promising.^128,129

An additional strategy to enhance community awareness is identifying the most appropriate individuals, beyond physicians, nurses, and dietitians, to carry the nutrition message. Focus group and training experiences from a federally funded program (http://www.womenshealth.go/bodyworks/) have shown that the characteristics that make good trainers are strong motivation, connection to the community, and previous experience teaching adult groups. Trainers know their audience and the barriers the audience faces in implementing recommendations. They may also be able to identify community members most receptive to intervention. Trainers should learn basic nutrition, interpretation of the food label, portion size, recommendations for physical activity, principles of behavior change, and how to encourage self-efficacy. These individuals may be recruited from such places as community health clinics, WIC programs, health departments, hospitals, and community organizations. Community-based intervention programs will require a combination of local financial support, grass roots improvisation to sustain community interest, and external educational support of trainers to sustain effective efforts. These individuals may be best suited to carry the healthy nutrition message into areas where conventional efforts have failed.

Finally, at the macroeconomic level, increasing attention has been paid to the relationship between the growth, regulation, and subsidization of the agriculture and the food industries.^6,12 Historically, the presence of a stable food supply was a vital social consideration and economic resource. Improvements in the ability to store and transport food have led to extraordinary reductions in food cost and increased convenience, ie, the ease with which food can be prepared (or have prepared outside the home) and consumed. This agricultural efficiency has been vital to the growth of the industrial and postindustrial economies. Food production has been driven largely by consumer preferences that, in turn, were driven by taste, cost, and convenience. The importance of nutrition in chronic disease (as opposed to infectious diseases) is a relatively new influence on consumer choice and has created a significant disjunction between capitalist economic forces driving the growth of the US food industry and nutritional needs of the population. This disjunction has been further abetted by the consolidation of economic control of the US food supply into fewer and fewer corporations that thus have greater opportunity to influence food choice through the media and other mechanisms.

Summary and Recommendations

Approaches to Implementation of Dietary Advice Are Needed

For encounters between healthcare providers and clients/patients, levels 1 and 2 of the Figure, providers should learn behavior change and motivational interviewing strategies; these strategies should be incorporated into educational programs for physicians, nurses, and dietitians. Efficacy of referrals from physicians to dietitians or other ancillary healthcare personnel must be evaluated. Healthcare professionals must develop evaluation tools that increase sensitivity to clients’ readiness to change eating behaviors, literacy level, ethnic preferences, and social constraints that affect dietary patterns.^130,131 It may be more important to focus on barriers to implementation before providing specific nutrition counseling. When time constraints are present in office encounters, healthcare providers should deliver simple positive messages directed at the major causes of poor nutrition. Examples include eating breakfast; eating fruits, vegetables, and whole grains; limiting intake of sugar-containing beverages to <12 oz/d; limiting snacks to once a day; eating smaller portions; weighing regularly; and adjusting dietary intake based on weight.

For level 3 of the Figure, we propose 5 community-based implementation strategies that should be evaluated for efficacy (Table 11). Create a healthy food environment means serving items of high food quality in schools and at work places. Collaboration with the various components of industry responsible for the food supply will be critical to achieving this goal. Subsidize AHA-recommended food choices means creating financial and other incentives for consumers to purchase and food producers to generate nutritious foods. Market nutrition means using media to counterbalance unhealthy food messages. Empower consumers means providing more comprehensive labeling of food and portion size. Train professionals in nutrition means improving the skill level of healthcare practitioners commonly consulted for nutrition advice and enlarging the pool of individuals qualified to provide nutrition advice. The net result of these strategies is to produce a food- and nutrition- literate society. For families, Table 12 provides ways for parents to make their home and food environment more nutritionally healthy.

At the macroeconomic level (level 4), the 5 principles described above can inspire governmental policy, industry, foundations, and voluntary agencies to influence social change. A strong advocacy agenda is being formulated around the country to implement these principles. The most effective strategies to curb the epidemic of tobacco use originated and were implemented, sometimes grudgingly, by these large social forces. Social intervention informed by outcomes research can drive effective public policy. Table 13 provides examples of policies that could be advocated to facilitate AHA guideline implementation.

Fundamental to implementation must be the recognition of the social and environmental context of eating.¹³² Strategies can no longer ignore the individual’s taste preferences, understanding of food and nutrition, familial eating patterns, social/economic constraints on food choice, ethnicity, and literacy. More research into making healthy foods more preferred is critical. Research designs must incorporate an understanding of these complex social processes; consideration must be given to how study end points fit into the complex social forces surrounding dietary patterns.^12,13 More population-based research in the community at large and dietary patterns must be undertaken. The observed adverse trends in US eating patterns must be reversed. Consumption of sugar-containing beverages and salty snacks must be reduced, along with a reduction in portion size and, most likely, eating frequency. Better strategies allowing consumers to make healthier choices outside the home must be established. The next era in nutrition research will be defined by the degree of success in this endeavor.¹³³

Footnotes