Health Planning Bibliography Series Community Nutrition in Preventive Health Care Services A Critical Review of the Literature U S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Resources AdministrationHEALTH PLANNING SERIES The Division of Health Planning, Bureau of Health Planning and Resources Development, through the National Health Planning Information Center, is a primary resource for current information on a wide variety of topics of interest to health planners. To facilitate the dissemination of information to health planners, the Center issues selected publications in three series: 1. Health Planning Methods and Technology This series focuses on the technical and admin- istrative aspects of health planning. Included are such areas as methods and approaches to the various aspects of the health planning process, techniques for analyzing health planning information and problems, and approaches to the effective dissemination and utilization of technical information. 2. Health Planning Information This series presents trend data and data col- lection and analysis methods, including sources of data to support health planning activities. 3. Health Planning Bibliography Bibliographies related to specific subject areas in health planning are published in this series. "Community Nutrition in Preventive Health Care 'ervices" is the seventh publication in the Health anning Bibliography Series.Community Nutrition in Preventive Health Care Services A Critical Review of the Literature Prepared under Contract No. 282-77-0188-MS by: Anita Yanochik Owen, M.A., R.D. Nutrition Consultant and Lecturer The University of Michigan School of Public Health Ann Arbor, Michigan May 1978 HRP-0300701 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Resources Administration Bureau of Health Planning and Resources Development Center Building 3700 East-West Highway Hyattsville, Maryland 20782 DHEW Publication No. (HRA) 78-14017 For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402 PUS!!' Health lie r.at t ■ :l 7 ' C t i .-1 .... i , f! . . i M ■ -Jin. . FOREWORD As the Nation looks for ways to control health costs, prevent disease, and improve the quality and delivery of health care, nutrition—a critical factor in promoting health—becomes an increasingly important health planning consideration. Recognizing that many of the Nation's health problems stem from improper diets, the framers of the National Health Planning and Resources Development Act of 1974 (P.L. 93-641) cited nutrition as one of 10 National health priorities. To address this priority, the Bureau commissioned the development and preparation of this report. It is our hope that this publication will serve not only as a resource document for program planning and development of priorities by health planning agencies but will also be useful for health educators and nutritionists in their efforts to improve the eating patterns of Americans at every socio-economic level. ColinC. Rorrie, Jr., Hh.D. Acting Director 1 Bureau of Health Planning and Resources Development 5033 iiiACKNOWLEDGMENTS A number of individuals contributed to the preparation of this document. Recognition of these people is only a small token of appreciation for their efforts. The principal investigator for this report was Anita Yanochik Owen, M.A., R.D. Mrs. Owen is Nutrition Consultant and Lecturer, the University of Michigan, School of Public Health. Research assistants in this undertaking were Catherine F. Feldman, Laura R. Levitt, Richard D. Mattes, Robert M. Pestronk and Frances E. Thompson, all MPH students in the Nutrition Program at the University of Michigan School of Public Health. These students devoted many hours to library research and literature reviews which were essential to the development of this document. In attempting to obtain information on nutrition services and plans in the States (pub- lished and unpublished), the principal investigator contacted the Association of State and Territorial Public Health Nutrition Directors and Faculties of Graduate Programs in Public Health Nutrition. They contributed generously to this effort despite the short lead time to produce these materials. Many other persons contributed to this project by supplying literature and guidance. Mary Egan, R.D., and Frances Shoun, R.D., from the Bureau of Community Health Services, DHEW, were generous with their time and materials throughout the project. Other contributions were made by Morissa White, R.D., Sheryl Lee, R.D., and Jim Rye, R.D., of the Arizona Department of Health Services; Helen Gerig, R.D., Montana Department of Health and Environmental Sciences; Patricia Jensen, R.D., California Department of Health; Lois Earl, R.D., District of Columbia Department of Health; Merrill S. Read, Ph.D., Pan American Health Organization, WHO; Judy Brown, Ph.D., University of Minnesota; Fredrick Stare, M.D., Harvard University; William Moore, M.D., Ross Laboratories; Barry Popkin, Ph.D., University of North Carolina; and Alan Stone, Senate Select Committee on Nutrition and Human Needs. A special thanks to Jolan Cossairt for her assistance in editing and indexing this document, and to Josephine Arasteh, Ph.D., and to Phyllis E. Cromwell, project officers, from the National Health Planning Information Center. ivPREFACE The National Health Planning and Resources Development Act of 1974 (Public Law 93-641) states 10 priorities which deserve emphasis in the formulation of National health planning goals and in the development and operation of Federal, State, and area programs. The Health Systems Agencies (HSAs) are specifically advised to consider these priorities in the develop- ment of the Health System Plan (HSP) and the Annual Implementation Plan (AIP). Priority number eight states: "The promotion of activities for the prevention of disease, including studies of nutritional and environmental factors affecting health and the provision of preventive health care services." The impetus for this project is a direct result of the aforementioned priority. Its objectives are: 1. To systematically review the literature pertaining to nutrition and its role in preventive health care services from 1970 to the present. 2. To serve as a resource document for program planning and development of priorities for nutrition services within Health Systems Agencies (HSAs). An appropriate observation about this document would be to compare it to Professor Harold Hill who sang to his fellow salesman in the Broadway play, the Music Man, "You gotta know the territory." A great deal of "territory" has been covered in this document and hopefully this information will provide sufficient data to include nutrition in health care plans as one of the basic services. To introduce the subject, an historical perspective entitled, "Nutrition Planning, A Recurring Theme," demonstrates that nutrition planning was dicussed as early as 1917 and throughout the past half century. Many of the recommendations made in the early part of the century are truly a recurring theme since they appear on the lists of "things to accomplish" in 1977. The role of nutrition as cited in the National Health Planning Resources and Development Act of 1974 is to show where nutrition services can make a contribution to health planning. The importance of nutrition is stressed by discussing the cost of inadequate nutrition and the nutrition problems in our society. This report is divided into two parts. Part I contains an introduction to nutrition planning and explains its role as it relates to the health planning effort. It also includes general comments, summaries, and implications for planners on the following subjects: National Nutrition Status Studies Nutrition and the Life Cycle Delivery of Nutrition Services Nutrition Planning and Nutrition Policy Issues in Cost Containment vPart II reviews 230 selected articles by usine a format which includes the reference, geographical area (including HEW regions), study design, significant findings, evaluation, and applicability to planning agencies. The literature review is covered from five perspectives: 1. An Overview of the National Nutrition Status Studies includes the Ten-State Nutrition Survey; the Preschool Nutrition Survey; Health and Nutrition Exam- ination Survey (HANES); and the CDC Surveillance System. 2. Nutrition and the Life Cycle includes papers on the nutrition status of infants and children, adolescents, maternal, adults, and the elderly. A small sample of papers on nutrition-related diseases is also covered in this section. 3. Delivery of Nutrition Services, as an Integral Part of Community Health Care Systems is delineated by demonstrating how nutrition is part of all health care delivery systems. The components of delivering quality nutrition services are discussed. The Comprehensive Health Care Projects for Children and Youth (HEW) serves as a model for the delivery of nutrition and health services. Information on State nutrition programs is covered with brief descriptions of the nutrition services rendered in these States. Twenty-seven States reponded to the call for these materials. Every State that contributed data is listed and the data described. Two States, Arizona and Oregon, are covered in greater detail since their planning efforts and delivery systems are well defined and include organized systems for delivery of nutrition care. 4. Nutrition Planning Effort reviews elements in the nutrition planning process. Efforts at the international, National, institutional, and community levels offer a broad range of planning schemes. The need for a National nutrition policy is described along with a listing of papers from the Senate Select Committee on Nutrition and Human Needs, 1968 to the present. 5. Impact of Improved Nutrition Services on Nutrition Status; Cost-Benefit and Cost-Effectiveness covers several interesting and potentially useful articles which make strong recommendations that evaluation is a process that permeates all levels of a system. Examples of cost-benefit and cost-effectiveness analyses which have potential for use in developing these data for nutrition services are presented. Hopefully, this document will contribute to the health planners' base of knowledge about nutrition services in this country and its role in preventive health care services. viCONTENTS Foreword Acknowledgments Preface Summary PART I—AN OVERVIEW Chapter I. Introduction ....................................... Nutrition Planning—A Recurring Theme! Nutrition Has Major Role In Planning Chapter II. The Importance of Nutrition........................ Cost of Inadequate Nutrition Nutrition Problems in Our Society Provision of Nutrition Services Standards of Practice for Nutrition Services Planners and Providers of Nutrition Services Chapter III. Identification of Nutrition Problems.............. National Nutrition Status Studies General Comments Review of Literature Summary and Implications for Planning Agencies Nutrition and the Life Cycle General Comments Summary and Implications for Planning Agencies Chapter IV. Delivery of Nutrition Services..................... General Comments Nutrition—An Integral Part of Various Health Care Systems Delivery of Nutrition Services—Its Components A Model for Delivery of Nutrition and Health Care Summary and Implications for Planning Agencies Chapter V. Nutrition Planning and Nutrition Policy............. General Comments Summary and Implications for Planning Agencies Chapter VI. Issues In Cost Containment......................... General Comments Summary and Implications for Planning Agencies vii iii iv v ix 1 . 1 1 4 . 7 9 10 11 11 12 14 14 14 15 23 24 24 25 34 34 34 35 48 49 .51 51 52 .60 60 62PART II—LITERATURE REVIEWS 67 Chapter I. Identification of Nutrition Problems................................................68 Nutrition and the Life Cycle 68 Nutrition Status of Infants and Children 68 Nutrition Status of Adolescents 84 Mature Pregnancy 90 Nutrition Status of Adults 96 Nutrition Status of the Elderly 98 Nutrition Throughout the Life Cycle 115 Studies of Specific Areas 115 Nutrition-Related Health Problems 121 Chapter II. Delivery of Nutrition Services.....................................................132 Information from State Nutrition Programs with Two Models 132 Planning, Implementing, and Evaluating Nutrition Services in the Health Care System 167 Nutrition as a Component of Health Care Systems 183 Nutrition Services in Specific Programs 186 Nutrition Education 199 Food Assistance Programs 208 Chapter III, Nutrition Planning and Nutrition Policy...........................................213 Elements in Nutrition Planning 213 Planning at International, National, State, Community, and Institutional Levels 224 Elements in Nutrition Policy 233 Papers of the Senate Select Committee on Nutrition and Human Needs: Reports—1968 to 1977 259 Chapter IV, Issues in Cost Containment.........................................................268 Cost-Benefit and Cost-Effectiveness 268 Issues Related to Evaluation of Nutrition Services 276 Manpower Development 283 Program Evaluation 292 Bibliography 305 Index 317 TABLES Table 1. Levels of Nutritional Assessment in the Life Cycle 26 Table 2. Guidelines for Population Groups in Community Nutrition 38 Table 3. Directory of Members of the Association of State and Territorial Public Health Nutrition Directors and Faculties of Graduate Programs in Public Health Nutrition 133 Table 4. Senate Select Committee on Nutrition arid Human Needs 260 Committee Hearings and Prints, 1968 to 1977 viiiSUMMARY "Adequate food and sound nutrition are essential to good health. Not only are they crucial for human survival and key factors in the prevention and recovery from illness, but they are prerequisites for improving the quality of life. Many Americans at all socioeconomic levels do not eat well. Nutrition problems range from undernutrition and 'dietary subnutrition,' to obesity from overeating, to the quality and safety of the food supply." (1) As our country searches for ways to contain health care costs and improve health care delivery systems and the quality of care for our citizens, the science of nutrition becomes an important issue. In this report an attempt is made to explore many of these issues. The need for nutrition planning was documented as early as 1917, during World War I when concern was expressed about the large number of persons being rejected in Selective Service examinations; this was attributed to causes that might have been prevented by proper nutrition in early life. Nutrition has been a recurring theme throughout the past half century, yet many of the recommendations made have not been implemented. The importance of nutrition becomes evident when one realizes that it is a critical factor in promoting health, preventing disease and in recovering from illness. There are both direct and indirect costs to society from neglect of nutrition care in the total health care system. The impact of sub-optimal nutrition can be seen throughout the life cycle: in the complications of pregnancy in the poorly nourished woman, the increased chance of low birth weight infants, the high prevalence of obesity, and undernutrition in children and adults, widespread dental disease, the debilitation of the malnourished elderly and the high prevalence of chronic illness requiring dietary treatment. At the present time, seven of the leading causes of death in the U.S. have dietary implications: heart disease, stroke, hypertension, cancer, diabetes, arteriosclerosis and cirrhosis of the liver. The American diet and our life style are factors in each of these diseases. The most significant problems seen in the national nutrition surveys conducted in the 1960's was iron deficiency anemia, regardless of socioeconomic status. The prevalence of obesity was high, particularly among adult women of whom nearly one-third were obese. Evidence of retarded growth was apparent in children from families living in poverty. As the needs were identified, and the problems stated in this report, we then looked at some resolution to these problems. First, nutrition services should be built into all health care delivery systems as an integral component, to provide continuity of care. Primary care programs are the logical setting for initiating nutrition care services. At the secondary and tertiary level, nutrition services may constitute a major part of the planned treatment. There is a need for nutrition in preventive, diagnostic, curative and restorative services. The second area that was explored is the actual delivery of nutrition services, the components for delivering quality nutrition services to the people of this country. The five basic services that were identified include screening and assessment, intervention, assessing quality nutrition services, data collection, and monitoring and evaluation. Screening and assessment of individuals and groups who are at risk. The basic tools of nutrition assessment include biochemical measurements such as hemoglobin, hematocrit and cholesterol levels; anthropometric measurements such as height and weight; clinical assessment including current state of health and dietary assessment to determine eating patterns. Intervention including nutrition education, dietary counseling and referral systems. 1. Forward Plan for Health: FY 1978-82. Public Health Service, 1976, p.71 [168]. ixNutrition education, in order to be successful, must include assessing the needs, stating measurable objectives, determining a plan of action based on assessment of needs and selection of techniques which are appropriate for age, educational and cultural background, and evaluating progress in order to make necessary adjustments in the design of the plan. Nutrition education, or the absence of it, has received considerable attention recently. A landmark study on nutrition education from the Library of Congress was commissioned by the U.S. House of Representatives, Subcommittee on Domestic Marketing, Consumer Relations and Nutrition. The report, published in March 1977, revealed that the Federal government is presently sponsoring 30 separate nutrition education programs in eleven agencies at a cost of $70 million. The report concluded that these programs were uncoordinated, repetitious, and even contradictory in their message. At the hearings held to discuss these issues, consumers told the Subcommittee that they were unaware of Federal nutrition education programs and often relied on magazines and popular books for their information, often obtaining inaccurate data. As evidenced by this report, nutrition education that reaches the public with sound, factual information is a desperate need. Dietary counseling should be based on the specific needs of the individual. Referral systems provide an opportunity for individuals and groups to obtain services from other sources such as food assistance programs and are important to avoid duplication of services and to extend services to those who are in need. Assessing quality of nutrition services includes appropriate data collection. Evaluation is one of the most important components of any system of care. Proper planning, including measurable objectives, is the basis for a good program design. The manpower base for the delivery of nutrition services is the nutritionist/dietitian who is the professional practitioner, trained and educated to provide all aspects of nutrition care in a comprehensive health and medical system. Other members of the health team, such as physicians, nurses, social workers, and planners, play a significant role in the delivery of nutrition services. Nutrition planning and policy formation are major topics of discussion in this document since the need for effective nutrition planning and policy formation is becoming increasingly evident as more demands are put on our national resources. The resources are finite and the U.S. can no longer afford the luxury of uncoordinated policies and planning. Planning is best seen as a dynamic interactional process. It is generally discussed in terms of a sequence of steps, but in practice, it is rather "an iterative process that resembles the tango, four steps forward, three steps back, with an occasional turn-around." (2) Since nutrition planning is a process which should be applied to nutrition problems at all levels, this report reviews planning at the international, national, state, community and institutional levels. The need for a national nutrition policy has been stated in numerous documents in many ways in the last decade. The current health and nutrition programs lack focus and direction; the need for a nutrition policy in the U.S. is vital. Lachance recently restated the case for a national nutrition policy. "The U.S. needs a food policy, a nutrition policy and a health policy which recognizes the interrelationship between food, nutrition and health. The U.S. does not have a food policy; it has a hunger policy; it does not have a health policy; it has a disease policy." (3) Finally, the impact of nutrition services on nutrition status is an important question that is considered in this report. If the goal of nutrition services is to improve the nutrition status of the population served, then program evaluation must be built into all levels of the system. It cannot be over-emphasized that evaluation must be built into all levels of the system. The literature contains several methods for determining program effectiveness. Most are concerned with program outcome. While this is important information, additional data are needed on the cost of services. Researchers and planners must work together when planning services. While information on program outcome may satisfy the practitioner and the researchers, the cost of obtaining results concerns the health planners and administrators. 2. Berg A, Muscat R: An approach to nutrition planning. Am J Clin Nutr 25:939-954, 1972. [166] 3. Lachance: National nutrition programs—perspectives and policy. JADA 71:489, 1977. xTwo promising techniques of evaluation are the cost-benefit and cost-effectivenss models which may help to bridge the gap. Several cost-benefit and cost-effectiveness models have been proposed; however, there is a lack of consensus on how to place objective, measurable values on many intangible variables such as the quality of life and peace of mind. Weiss has stated that "Evaluation is a demanding and necessary business calling for time, money, imagination, tenacity and skill." (4) Probably the best case for evaluation was proposed by Hilleboe and Schaeffer. "The health and nutrition administrator who uses evaluation as an integral part of the processes of planning and the solving of problems has the best chance of changing tradition, of influencing public opinion, and of persuading political leaders to increase resources to meet health needs." (5) Perhaps an appropriate ending to this report would be a quote by H. M. Sinclair. "Medicine arose from dietetics; the Pythagoreans (including Hippocrates) used diet to prevent and cure diseases, and drugs only if these failed." (6) It is our hope that this report will make a contribution to the health planning efforts in the U.S. We feel our objectives have been met; to systematically review the literature pertaining to nutrition and its role in preventive health care services and to serve as a resource for program planning and development of priorities for nutrition services within the HSA's. 4. Weiss, CH: Evaluation and Research: Methods of Assessing Program Effectiveness. Englewood Cliffs, N.J., Prentice-Hall, (Methods of Social Science Series), 1972. 5. Hilleboe HE, Schaeffer M: Papers and Bibliography on Community Health Planning. New York, Albany Graduate School of Public Affairs, State University of New York, 1967. 6. Birch GG, Green LF, Paskett, LG (eds): Health and Food. New York, John Wiley and Sons, 1972, p. 23. xiCOMMUNITY NUTRITION IN PREVENTIVE HEALTH CARE SERVICES PART I An Overview., hri.f. ; o : o - liljbCHAPTER I. INTRODUCTION Nutrition Planning—a Recurring Theme! In order to take a holistic view of the country's nutrition problems, an historical perspec- tive is useful since it indicates the concerns over a period of time. It depicts the needs at various points in our history and gives insight into some of the recommendations posed through a span of several decades. A document entitled "Background Paper on the Recommendations of Conferences and Groups Related to National Nutrition Policy 1917-1974" provides an excellent review of historical perspectives of nutrition planning throughout the past half-century. (1) 1917-1918 In 1917, during the World War I years, several major conferences were related to food and nutrition. These, conferences addressed the concerns of the times which were: the awareness that many of the conditions responsible for rejection in Selective Service examinations were attributed to causes that might have been prevented or corrected by proper nutrition in early life; and a decision to make conservation and efficient use of available food a national emphasis. In 1918, the Children's Year Campaign was launched by the Children's Bureau and the Council of National Defense. Nine conferences were held across the nation to formulate "minimum" stan- dards for the public's protection of the health of mothers and children. The 1930's An expansion was seen in the knowledge of human nutrition and understanding of child growth and development, disease prevention and scientific agriculture. A White House Conference on Child Health and Protection was held. One of its tasks was to make recommendations for optimal nutrition for the children of our country. In 1935 the Social Security Act authorized grants-in-aid to the states for health services for mothers and children and opened the way for the application of both preventive and curative measures in nutrition as a basic component of child health care. During this period, surplus commodities were distributed to schools and a special repre- sentative was employed in each state to expand the school lunch program. (2) The 1940's The 1940's brought a landmark National Nutrition Conference for Defense held in Washington, D.C. in May 1941. The President opened the conference with the hope that it would "make recom- mendations to solve nutrition problems at national, state, and community levels as an essential part of defense and as a part of a continuing national health and welfare program." Among the twelve recommendations made at this conference, four are particularly relevant to discussions of nutrition today. 1. Egan M: Background paper on the Recommendation of Conference in Groups Related to National Nutrition Policy, 1917-1974 Prepared for the National Nutrition Policy Study Hearing, DHEW, May 1974. 2. Food and Nutrition Service, USDA: The National School Lunch Program, Background and Development. FNS-1963. Washington DC, Govt Ptg Off. 1971. 1The use of Recommended Dietary Allowances (RDA) as a general goal for good nutrition in the U.S., and as a yardstick by which to measure progress toward that goal. Translation of the RDA and other technical material into terms of foods and meals suitable for different economic levels and culture preferences. The mobilization of every educational method to spread the new knowledge of nutrition among laymen. More widespread education of doctors, dentists, social service workers, teachers, and other professional workers in the new knowledge of nutrition. The 1950's In the 1950's a greater appreciation of the influence of nutrition and health on the pro- ductivity of population groups became evident. The U.S. was becoming more aware of the needs of population groups at high nutritional risk, such as the elderly or the ill. In 1958, the National Conference on Nursing Homes and Homes for the Aged was called by the Public Health Service. The conference was conceived because of the increasing number of the Nation's chronically ill and infirm aged who were being cared for in nursing homes and homes for the aged. Several recommendations to improve nutrition services were made. During this decade the Third National Nutrition Education Conference was held with the idea of increasing the effectiveness of nutrition education. There was increasing recognition of the possibility of preventing mental retardation bv appropriate dietary treatment of inborn errors of metabolism. The 1960's The 1960's brought about a rediscovery of poverty in the U.S. In 1968 a report entitled Hunger, U.S.A. by the Citizen's Board of Inquiry into Hunger and Malnutrition in the U.S. found that programs such as food stamps and school lunch failed to reach the poorest of the poor One of the major events of this decade with the White House Conference on Food, Nutrition and Health in 1969 with its primary purpose to focus national attention and national resources on our country's remaining and changing nutrition problems. Several key recommendations made at this conference included: Establishment of a system for surveillance and monitoring of the state of nutrition of the American people. More attention focused on nutrition of vulnerable groups. More prudent information for the public by industry and government and to improve the adequacy, quality and safety of the food supply. Expansion of food delivery and distribution programs. Expansion of nutrition education programs. The National Academy of Sciences reviewed the data on maternal nutrition and pregnancy, re-focusing attention on the relationship of nutrition to pregnancy outcome. The 1970's Three major nutrition studies of the U.S. population were supported by DHEW to define nutrition problems and their effect on health. The Ten State Nutrition Survey of almost 30,000 families. (3) 3. Ten State Nutrition Survey in the United States, 1968-1970, Washington DC, (DHEW Publ (HSM) 72-8130-8134) Washington DC, Gov't Ptg Off. 1972 [1]. 2The Pre-school Nutrition Survey on a national probability sample of approximately 3,000 children. (4) The Health and Nutrition Examination Survey on a national probability sample of over 10,000 persons representative of the U.S. civilian and non-institutionalized population. (5) The Committee on Maternal Nutrition, National Academy of Sciences in 1970 made some important recommendations related to the role of nutrition in human reproduction because of concern about the relatively high neonatal and infant mortality rates in the U.S. Food programs for vulnerable groups were implemented. In 1972 Congress passed legislation that authorized the special Supplemental Food Program for Pregnant Women, Infants and Children. The program is significant because it is the only food assistance program which provides supplemental nutritious foods as an adjunct to good health care. Also in 1972, Title VII - The National Nutrition Program for the Elderly - was funded. The program provides nutritious meals for the elderly with high priority placed on projects serving low-income and minority groups. In 1974, the Senate Select Committee on Nutrition and Human Needs conducted hearings on a National Nutrition Policy Study. Panel reports included Nutrition and the International Situ- ation, Special Groups, Food Availability, Consumer, Health and Government. The purpose of the hearings was to stress the need for long-term National Nutrition Policy planning within the Federal Government. In 1977, the Association of State and Territory Nutrition Directors met and developed six priorities for the profession of Public Health Nutrition which included the development of the following: National" nutrition standards; Nutrition component in health planning; Payment mechanisms for nutrition services; Surveillance system; Cost effectiveness ratios for nutrition services; Staffing ratios for public health nutritionists. Dietary goals for the U.S. were developed by the Senate Select Committee on Nutrition and Human Needs in 1977. These goals constituted the first comprehensive statement by any branch of the Federal Government on risk factors in the American diet. In 1977 two committees in the House of Representatives held hearings on nutrition. The committees were: 1. The Committee on Science and Technology Subcommittee on Domestic and Inter- national Scientific Planning, Analysis and Cooperation (DISPAC). These hearings were entitled Nutrition-Related Oversight Review. 2. The House Agriculture Subcommittee on Domestic Marketing, Consumer Relations and Nutrition. The committee addressed the subject of the role of the Federal Government in Nutrition Education. It is evident from this chronology of selected events that nutrition planning is a recurring theme and that some progress has been made. Although a number of recommendations have been im- plemented, some important recommendations remain unfulfilled. 4. Owen GM, Kram KM, Garry PJ, et al: A study of nutritional status of pre-school children in the U.S. 1968-1970. Pediatrics 53:597-646, 1974 [2] 5. Preliminary Findings of the First Health and Nutrition Examination Survey U.S. 1971- 1972, Washington DC, DHEW Publ (HRA) 74-1219-1. 3The Health Planning Agencies have an opportunity to include nutrition as an important com- ponent of all health care delivery systems. With further implementation of these earlier recommendations, the HSA's can effectively improve nutrition and health care of the population. Nutrition Has Major Role In Planning Although priority eight specifically discusses nutrition as a component of preventive health care services, there are several areas within the legislation where nutrition plays a major role. In Section 1502, National Health Priorities, the role of nutrition can be stated in each of the ten priorities: "(1) The provision of primary care services for medically underserved populations, especially those which are located in rural or economically depressed areas." Davis and Marshall indicate three organizational models of health services delivery which appear promising. (6) Primary health centers staffed by full-time primary health practitioners rather than physicians; new types of group health practices and team approaches; and compre- hensive health centers providing a wide range of health and health-related services. Nutrition should be included as a component of primary health centers, new types of group health practices and team approaches, and comprehensive health centers. Training of health care providers by nutrition personnel is an important feature in all new and innovative models of health delivery. Adequate food and sound nutrition are essential to good health. Not only are they crucial for human survival, and key factors in prevention and recovery from illness, but they are prerequisites for improving the quality of life for Americans. (7) Problems of mal- nutrition, obesity, and the quality and safety of our food supply are issues which are relevant to rural as well as urban populations. There are several problems in the management of disease or other health problems which are initiated or aggravated by inappropriate diet, e.g., dental caries, diabetes mellitus, hypertension, obesity, iron deficiency anemia, and certain forms of arteriosclerosis and cardiovascular disease. These problems must be addressed in the three organizational models. "(2) The development of multi-institutional systems for coordination or consolida- tion of institutional health services (including obstetric, pediatric, emer- gency medical, intensive and coronary care and radiation therapy services)." "(5) The development of multi-institutional arrangements for the sharing of support services necessary to all health service institutions." Since nutrition plays a major role in obstetrics, pediatrics, emergency medical, and in- tensive, and coronary care services, it is important to include a nutrition component in these systems. Basic elements in nutrition services that should be included are assessment of nutri- tional status of individuals, including biochemical measurements of body fluids and tissues; clinical examinations, including assessment of growth; review of food availability and dietary practices; and screening for nutritional problems. These basic services should be included in any multi-institutional system. "(3) The development of medical group practices (especially those whose services are appropriately coordinated or integrated with institutional health ser- vices) , health maintenance organizations, and other organized systems for the provision of health care." Inclusion of nutrition as a component of health care may significantly reduce the number of people requiring sick care services and therefore contribute directly to strain on the nation's health care delivery system, a decrease in the rate of escalating health care costs, and an in- crease in the physical, mental and social well-being of people so that they may achieve and Davis K. Marshall R: Primary health care service for medically underserviced popula- tions. Papers on the National Health Guidelines. The Printing of Section 1502, 1977. 7. Forward Plan for Health FY 1978-82. Washington DC, Govt Ptg Off, 1976 [168]. Amaintain productive and independent lives. (8) A suggested pattern of nutrition services in a health maintenance organization has been developed by the American Dietetic Association and includes the following phases of the HMO operation: health appraisal and referral, environ- mental protection and disease prevention and health maintenance, acute and intensive care, restoration and extended care. Each is described with a nutrition care goal and a nutrition care activity. (9) "(4) The training and increased utilization of physicians' assistants, especially nurse clinicians." Training in nutrition of health personnel, particularly the physician assistants and nurse clinicians should be accomplished by the dietitian/nutritionist who is the professional prac- titioner prepared to provide nutrition services in community health programs. Among health care providers who can deliver nutrition services to the community with proper training are commu- nity health aides or nutrition aides, physicians, nursing personnel, social workers, physical/ occupational therapists, dentists, dental hygienists, health educators and behavioral scientists. Specific training in the science of nutrition is required to render quality services to clients. "(6) The promotion of activities to achieve needed improvement in the quality of health services, including needs identified by the review activities of the Professional Standard Review Organization under Part B of Title XI of the Social Security Act." Two documents published by the American Dietetic Association in 1976 entitled "Guidelines for Evaluating Dietetic Practice" and "Professional Standards Review Procedure Manual" were developed to assist the dietitian/nutritionist in delivering quality dietetic and nutrition services. Components of quality nutrition services in any health delivery system should include the following: Screening and assessment including biochemical, clinical, anthropometric and dietary information is required; Delivery of services including dietary counseling, nutrition education, community resources for nutrition and food assistance or referral system; Assessing quality of nutrition services; Recording and reporting pertinent data; Monitoring and evaluation. "(7) The development by health service institutions of the capacity to provide various levels of care (including intensive care, acute general care, and extended care) on a geographically integrated basis." Since nutrition is an important factor in intensive care, acute general care, and extended care, appropriate time and effort should be placed on integrating nutrition as a basic compo- nent into these services. Nutrition is a vital component in primary, secondary and tertiary care. "(8) The promotion of activities for the prevention of disease including studies of nutritional and environmental factors affecting health and the provision of preventive health care services." This document entitled: Community Nutrition in Preventive Health Care Services" addresses this priority in great detail. 8. American Dietetic Association: Position Paper on the Nutrition Components of Health Services Delivery Systems. JADA 58:538-540, 1971 [124]. 9. American Dietetic Association: Position Paper on Nutrition Services in Health Main- tenance Organizations. JADA 60:317-319, 1972 [123] 5"(9) The adoption of uniform cost accounting, simplified reimbursement, and utilization reporting systems and improved management procedures for health service institutions." Nutrition services should be a reimbursable service in all health delivery systems and should be included in the uniform cost accounting system as part of the total patient care plan. "(10) The development of effective methods of educating the general public concerning proper personal (including preventive) health care and methods for effective use of available health services." Nutrition education should be an integral part of personal (including preventive) health care, especially in areas such as cardiovascular disease, obesity, dental disease, retarded growth, delayed development, and anemia. As a preventive service it should be interdisciplinary and utilize resources from community services involved with promotion, maintenance, and treat- ment. Nutrition education should have specific behavioral objectives geared to the diagnosed health problem. As these objectives are learned by the client, knowledge gains are documented and should be correlated with subsequent behavioral changes, health status, improvement and maintenance. Nutrition education should be included in all types of health delivery systems being structured and implemented through the framework that assesses needs, states objectives, determines content, selects techniques and evaluates progress. For nutrition and health educa- tion to be effective, the concepts used must be adapted to meet educational, economic, social and cultural situations of groups of people served. Section 1512 Health Systems Agencies (3) Governing Body (C) Composition Consideration should be given to nutrition personnel being included as providers of health care services since the dietitian/nutritionist is a professional practitioner trained and edu- cated to provide all aspects of nutrition care in a comprehensive health and medical system. The dietitian/nutritionist must have knowledge of community organization and community health services and resources in order to provide consultation and direction in planning and imple- menting flexible and imaginative nutrition care. The role of the dietitian/nutritionist is in planning functions related to the nutrition component of health care; training and supervising personnel who carry out primary nutrition care activities; and for coordinating nutrition with other care components. (10) Section 1523 State Health Planning and Development Functions (II) In preparing the state health plan nutrition services should be included. Information on the nutrition problems in the state, the need for nutrition services, the kinds of programs developed to alleviate these problems, and an evaluation of the effectiveness of these services should be included in all planning efforts. Nutritionists at state and local levels can provide these data. Eleven states presently have data from the nutrition surveillance system which was developed by the Center for Disease Control. This information can be useful to the HSA's. The specific components of the Act mentioned have nutrition implications. Health planners should utilize nutrition professionals in their communities to include nutrition services in total planning for HSA's. 10. Preliminary Guide for Developing Nutrition Services in Health Care Programs, Bureau of Community Health Services, 1976 [171]. 6CHAPTER II, THE IMPORTANCE OF NUTRITION The subject of nutrition gained notoriety as a public policy issue in the 60's and 70's with individuals and groups who were concerned with social, political and economic development. Why has nutrition become such an important issue? Perhaps the best way to get at this question is to define nutrition. The American Medical Association's definition, although long, covers the broad scope of nutrition. They define it in this way: "Nutrition is the science of food, the nutrients and other substances therein, their action, itneraction, and balance in relation to health and disease, and the process by which the organism ingests, digests, absorbs, transports, utilizes and excretes food substances. In addition, nutrition must be con- cerned with social, economic, cultural, and psychological implications of food and eating." (11) This definition implies that nutrition like other sciences does not stand alone; it draws heavily on the basic findings in chemistry, biochemistry, microbiology, physiology and medicine. Nutrition must also be considered in terms of its place in the total health package as well as in the context of other dimensions such as poverty. (12) The role of environmental factors in nutritional disease is the result of their effect on the availability of nutrients, nutrition requirements and the intake of nutrients. The environ- ment includes not only the important physical and ecological environment but also the social or cultural environment. (13) The relation between nutrition and a number of social problems has long been recognized. It was in the 1960's that malnutrition became a national issue. The state of hunger and poverty in the U.S. was brought to the attention of the American public by the Southern Christian Leadership Conference. This led to the creation of the National Council on Hunger and Malnutri- tion in the U.S. of which Jean Mayer, now President of Tufts University, was elected the first chairman. Due to the Council's efforts, newspaper, radio and television networks took cogni- zance of the problem all over the country. A powerful CBS television documentary entitled "Hunger in America" was presented to the American public. This hour-long program marked a turning point in the fight againt hunger for it shocked the nation into the realization that ill- fed Americans could no longer be ignored. (14) The 1970's brought an emerging awareness that food resources are finite and while much of the world is suffering from the nutritional disease of poverty, a large portion of the population of the U.S. is suffering from diseases related to over-abundance and over-consumption of food. (15) As our nation looks for ways to control health care costs, develop new knowledge, prevent disease, improve health delivery systems and the quality of care for our citizens, the science of nutrition becomes an important issue. Nutrition is a critical factor in the promotion of health and prevention of disease and in recovery and rehabilitation from illness or injury. Evidence mounts that Americans who fail to attain a diet optimal for health can be found at every socioeconomic level. (16) 11. Council on Food and Nutrition: Nutrition teaching in medical schools, jama 183: 955-957, 1963. 12. Nutrition Development and Social Behavior. DHEW Pub No (NIH) 73-242, 1973. 13. Guthrie HA: Introductory Nutrition. 3rd ed. St. Louis, Mosby, 1975. 14. Mayer J: U.S. Nutrition Policies in the Seventies. San Francisco, W.H. Freeman, 1973. 15. Frankie R, Owen AY: Community Nutrition. The Art of Delivering Nutrition Services. St. Louis, Mosby (in preparation). Expected date of publication, September 1978. 16. The American Dietetic Association: Position paper on the nutrition component of health services delivery systems, JADA 58:538-540, 1971 [124], 7The impact of a sub-optimal diet on the health of the nation is seen in: Increased risk of complications of pregnancy in the poorly nourished woman. Increased chance of low birth weight infants and thus the accompanying risk of retarded physical and mental development. High prevalence of overweight and underweight children and adults. Debilitation of the malnourished elderly. Widespread dental diseases in the total population. High prevalence of chronic illness requiring dietary treatment, monitoring and follow-up. For these reasons, many health professionals, Congressmen and the general public became interested in nutrition and its role in preventive medicine. This interest is evidenced by the following comments: In 1971, Dr. Jean Mayer, now President of Tufts University and Chairman of the White House Conference on Food, Nutrition and Health in 1969, stated: "In terms of money as in terms of human suffering, one can well argue that every dollar spent on nutrition instruction may save tens of dollars in later medical care." This statement implies the potential of nutrition as a component of health care. The pre- mise is that the inclusion of nutrition is the health care system will significantly reduce the number of people requiring crisis intervention and curative care. DHEW's Forward Plan for Health 1978-82, published by the Department of Health, Education, and Welfare in August 1976, clearly stated the Department's concern about nutrition in the following statements: "Adequate food and sound nutrition are essential to good health. Not only are they crucial for human survival and key factors in the prevention and recovery from illness, but they are prerequisites for improving the quality of life." In March 1975, the Secretary approved a Policy Statement on the Health Aspects of Nutri- tion, expressing the Department's commitment to improving the nutritional status of all Americans. (17) Two Senators spoke out on the issues of nutrition. In July 1976, Senator Charles H. Percy of Illinois, stated: "National food and health policies, however effective, can help only those who help themselves. Increasingly, research findings tell us that we are, in large measure, responsible for our state of health. It is becoming common knowledge that cardiovascular disease, most cirrhosis of the liver, obesity and its consequence, and many gastrointestinal problems are self- induced by over-eating, smoking, over-drinking and eating the wrong foods. Changes in bad eating and drinking habits, therefore, can make dramatic improvements in the health of the population. Such improvements, however, depend to. a great extent on the will and capability of the people to take personal responsibility for their own health." 17. Forward Plan for Health, 1978-82. Washington DC, Govt Ptg Off, 1976 [168]. 8Senator George McGovern of South Dakota, Chairman of the Senate Select Committee on Nutrition and Human Needs, commented: . the eating patterns of this century represent as critical a public health concern as any now before us. We must acknowledge and recognize that the public is confused about what to eat to maximize health. If we as a Government want to reduce health costs and maximize the quality of life for all Americans, we have an obligation to provide practical guides to the individual consumer as well as set national dietary goals for the country as a whole. Such an effort is long overdue. ..." Cost of Inadequate Nutrition There are both direct and indirect costs to society from continued neglect of nutrition services in the total health care systems. A paper prepared by Barry M. Popkin of the Institute of Research on Poverty at the Univer- sity of Wisconsin in 1969 for the Senate Select Committee on Nutrition and Human Needs entitled, "Economic Benefits for the Elimination of Hunger in America," attempts to demonstrate the cost to society. Although the information presented is based on assumptions and statistical in- ferences, it does present some interesting concepts in relation to costs of inadequate nutri- tion care. The author estimatfes annual savings in the following areas: Education - Improved nutrition improves learning, prevents an interruption of cognitive development and increases the ability to concentrate and work ($6.4 - 19.2 billion). Physical performance - Improved nutrition increases the capacity for prolonged physical work and raises the productivity of workers and increases the motiva- tion to work ($6.4 - 25.8 billion). Morbidity - Improved nutrition results in higher resistance to disease and lowers the severity of the disease ($201 - 502 million). Mortality - Improved nutrition decreases fetal, infant, child and certain types of material mortality ($68 - 157 million). Intergenerational Effects - Improved nutrition makes healthy mothers who have healthy children ($1.3 - 4.5 billion). (18) Testimony presented by George M. Briggs, Professor of Nutrition at the University of Cali- fornia at Berkeley, before the Senate Select Committee on Nutrition and Human Needs in 1972 revealed that our nation's poor dietary habits cost the country about 30 billion dollars in health care each year. This is a tremendous bill to continue paying. At that time, this was about one-third of the nation's health care cost. Dr. Briggs' estimate was based on a report issued in 1971 by the Department of Agriculture entitled "Magnitude of Benefits from Nutrition Research." (19) Another rather staggering statistic came from John W. Farquhar of Stanford University Medical Center who told the National Nutrition Policy hearings that the elimination of obesity in the United States would cut in half the 24 billion dollars being spent on the treatment of premature cardiovascular disease. These dramatic estimates can lead to only one conclusion: a mandate for better nutrition services. 18. Popkin BM: Economic Benefits for the Elimination of Hunger in America. Institute of Research on Poverty at the University of Wisconsin. Madison, WI, July 1969. 19. USDA: Magnitude of Benefits from Nutrition Research. Agricultural Research Service, August 1971. 9Nutrition Problems in Our Society At the present time, six of the ten leading causes of death in the United States have been related to diet: heart disease, stroke, hypertension, cancer, diabetes, arteriosclerosis and cirrhosis of the liver. These diseases are caused largely by factors that do not lend them- selves to direct medical solutions. The American diet and lifestyle are implicated in each of these "killer diseases." The urgency and seriousness of these diseases demand that our popula- tion understand and practice the basic principles of good nutrition. The reasons for nutrition problems are many and complex. Inadequate income is a major determinant of poor nutrition status. Other factors also have an effect such as lack of know- ledge; lack of interest; lack of skills; complications of disease; sedentary life styles; mental and emotional factors; social isolation; lack of means for food purchasing, lack of cooking and storage facilities; consumer confusion and misinformation; over-abundance of foods of low nutritive value and high cost; food faddism; and geographic location. In order to define nutrition problems and their effect on health, three major nutrition studies have been sponsored by the Department of Health, Education and Welfare during the past decade: the Ten State Nutrition Survey of 1968-70 involving approximately 30,000 families, chiefly low income; the Pre-School Nutrition Survey, a national probability sample of approxi- mately 3,400 children; and the Health and Nutrition Examination Survey (HANES) which will study a total of 30,000 persons in Cycles I and II. These studies will be discussed in greater de- tail later. Only highlights are reviewed in this section. Iron deficiency anemia was a common finding in all of the national studies. The Ten State Survey found low hemoglobin or hematocrit in 25% of the persons below the poverty level and 12% of those above the poverty level. For the Pre-School Nutrition Study, iron deficiency anemia was a common finding among children 1 to 5 years of age, regardless of their socioeconomic status. In the Ten State Survey and HANES, the prevalence of obesity was high, particularly among adult women of whom nearly one-third were obese. These investigations have demonstrated that Americans, at every socioeconomic level, can fail to have a diet which is optimal for health. To publicize the nutrition problems in this country, Senator George McGovern called a press conference in January 1977 to release the first comprehensive statement made by any branch of the Federal government about risk factors in the American diet. This statement was called "The 1977 Dietary Goals for the United States." These goals are considered controversial since they call for specific changes in the diets of Americans. Despite the degree of controversy surrounding these statements it did bring to light once again the need for a nutrition policy in this country. He stated the simple fact that our diets have changed radically in the last 50 years with extensive and often harmful effects on health. Too much fat, too much sugar and too much salt can be, and are, linked directly to heart disease, cancer, obesity and stroke among other killer diseases. Senator McGovern emphasized that those within the government have an obligation to acknowledge this drastic change in the composition of the average diet in the United States. He stated that the public wants some guidance, wants to know the truth, and "hopefully today we can lay the cornerstone for the building of better health for all Americans to better nutrition." He presented the following grim statistics: Last year every man, woman and child in the United States consumed 125 pounds of fat and 100 pounds of sugar. Consumption of soft drinks has more than doubled since 1960 replacing milk as the second most consumed beverage. In 1975 there was an average per capita intake of 295 12-ounce cans of soda. Early in this century almost 40% of caloric intake came from fruits, vegetables and grain products. Today, only a little more than 20% of the calories comes from these sources. The evidence is overwhelming that nutrition problems do exist in this country. What will reverse these trends? 10Provision of Nutrition Services Traditionally nutrition care services have been provided in four settings, by the private physician, the hospital outpatient department or clinic, state and local health programs, and comprehensive health care projects including Maternity and Infant Care programs, Children and Youth projects, and Neighborhood Health Centers. The quality and quantity of services varied considerably with each model. As the nation seeks workable alternatives to institutional care, this will mean that nutrition care services should be built into ambulatory and home health care. Hospital outpatient departments, family and neighborhood health centers, health main- tenance organizations, group practice, hospital and public health clinics, rehabilitative and mental health centers are some of the settings in which nutrition care services can be effec- tively and economically provided. /Primary care programs are logical settings for initiating nutrition care services/' The availability of nutrition services to persons in their own homes makes earlier discharge from the hospital and nursing homes feasible, thus enabling many people the comfort of being at home for longer periods of time. Continuity of care, regardless of the setting, is an important factor in the delivery of nutrition care services. In planning a system of continuity of care, nutrition care services should be included as an integral part of the system. Comprehensive planning should consider such other community resources as day-care centers and community nutrition programs for the elderly. (20) /Nutrition services should be included in primary, secondary, and tertiary levels of care. At the primary care level, nutrition content should be included in screening and diagnosis, health maintenance and health supervision.'' Health promotion activities involving community- wide efforts, such as the development of food assistance programs, water fluoridation and nutri tion education, are also important. At the other levels of care, which include the secondary and tertiary, nutrition is an important aspect of diagnosis, treatment and rehabilitation. Expertise in specialized areas of nutrition may be required in medical centers which receive patients with complex nutrition problems. (21) The complexities of delivering nutrition services to the population of the U.S. become evi dent when one realizes that nutrition needs may be considerably different between younger and older children, between children growiftg at different rates, between the sick and well child, adult and elderly. The problem becomes more acute when one considers the varying abilities of individuals and families to cope with nutrition needs for reasons of income, lack of education, and inadequate transportation. Quality nutrition services can best be achieved by providing continuity of care from the hospital setting, to the community, to the home setting. Intensive care units are at one end of the spectrum, community health centers at the other; nutrition care has a major role throughout the entire process. Preventive services will be adequate when education for health becomes a dynamic part of school systems and available to the public throughout the life cycle. Standards of Practice for Nutrition Services The following nutrition services should be included in every health care program: Screening for nutrition problems; Assessment of the nutrition status of individuals including dietary assessment: review of food availability and dietary practices to reflect socioeconomic, cultural and other factors; biochemical measurements of body fluids and tissues; clinical examination by a physician; anthropometric examination—assessment of growth. 20. Collins ME, Forbes C, Kocher R, et al: Position Statement on Implementation and Delivery of Nutritional Care Services in the Health Care Systems of the Panel on Nutrition Health. U.S. Senate Select Committee on Nutrition and Human Needs, Part 6, Washington, June 21, 1974, Washington DC, Govt Ptg Off, 1974. 21. Preliminary Guide for Developing Nutrition Services in Health Care Programs. Rock- ville, MD, DHEW Health Services Administration, Bureau of Community Health Services, 1976. 11Planning and implementation of care for individuals with nutrition and diet problems: individual and group counseling to meet normal and therapeutic dietary needs; an effective nutrition education program which is responsive to consumer beliefs, attitudes, environmental influences, and understanding about food; a nutrition education program that can be evaluated, i.e. the amount and type of behavioral change which occurred due to this counseling; provision of, or referral to, community food resources, home delivered meals, community meals for the elderly, supplemental food programs for high-risk groups such as pregnant women, infants and children (WIC), food stamps, child care services, school lunch and breakfast programs, and child day-care feeding and any other identified community service. The provision of these services are the basic elements in developing quality nutrition care for the population of the United States. Planners and Providers of Nutrition Services At the White House Conference on Food, Nutrition and Health in 1969, public health nutri- tionists and dietitians were identified as the only health professionals whose education and training have been directed toward the application of food and nutrition science to the health care of people. (22) As a "specialist educated for a profession responsible for the nutritional care of individuals and groups," the registered dietitian (R.D.) not only has completed basic academic and experience requirements and has passed the qualifying examination for registration, but is also expected to update her knowledge with continuing educational activities. (23) The nutritionist/dietitian should have major responsibility for leadership, planning and implementing the nutrition component of health care programs, for recruiting, training and super- vising nutrition personnel, for coordinating nutrition with other care components and for evalu- ating the effectiveness of the services. Auxiliary personnel, such as nutrition aides with proper training, may be used to extend the services of professional nutritionists. Many other disciplines are involved in the planning and providing of nutrition services such as health administrators, health planners, physicians, nurses, social workers, health edu- cators, and legislators. These disciplines have a role in nutrition services and can make a significant contribution to the delivery of nutrition services. Contributions made by these nutrition counselors include the following. Health Administrator - An administrator of health care programs must be aware of the significance of nutrition in order to interpret its importance to policy- makers, legislators and other groups in order to gain support for these vital services. Health Planner - The planner helps to identify needs and resources and to struc- ture the environment for the delivery of all health care services, including nutrition. (24) Legislators - The legislator is a key person in developing public policy. Under- standing of the role of nutrition in health care will enhance his ability to obtain legislation which will provide the necessary support to deliver quality nutrition and health services. Public Health Nutritionist/Dietitian - The nutritionist/dietitian has responsibility for leadership in planning, organizing, and managing nutrition services. His role is to establish appropriate standards, policies, and criteria for nutrition services. 22. White House Conference on Food, Nutrition and Health. Final Report. Washington DC, Govt Ptg Off, 1970. 23. Committee to Develop a Glossary on Terminology for the Association and Profession. American Dietetic Association; Titles, definitions and responsibilities for the profession of dietetics 1974. JADA 64:661, 1974. 24. Mitchell HS, Rynberger HJ, Anderson L, et al: Nutrition in Health and Disease, 16th ed. Philadelphia, J.B. Lippincott, 1976. 12The nutritionist/dietitian is the primary nutrition counselor on the health care team. This person is a translator of the science of nutrition into the skill of furnishing optimal nourishment to people. (25) Physician - The role of the physician is to provide medical direction and participate in establishing standards and criteria for nutrition services. They identify and make recommendations concerning the nutrition component of health counseling. He may undertake the role of nutrition counselor or more frequently, he refers the client to the appropriate team member. Nurse - Nursing personnel may be of great assistance in helping a client to understand and accept his nutrition care plan. They may consult with the nutritionist/dietitian when assisting a client to establish a plan, or they may be the team member who refers the client to the nutritionist/dietitian. Social Worker - The social worker can assist in mobilizing community resources and services needed to support adequate nutrition care. They also assist in developing referral mechanisms. Health Educators (and behavioral scientists) - These persons can assist in the development of educational programs and activities designed to influence the behavior of individuals and organizations in ways which lead to improved nutrition/health of populations. Other Members of the Team, such as physical therapists, occupational therapists, dentists, dental hygienists, and other health disciplines can be helpful in counsel- ing individuals whose health problems interfere with adequate nutrition. Each team member has a vital contribution to make in delivering quality nutrition services to people. In planning nutrition services essentially the same steps that any health planning effort would use include: Identifying and specifying health problems and unmet needs of the target population; Assessing available and potential resources; Planning to meet needs by establishing objectives and analyzing alternative courses of action according to specific criteria; Formulating the necessary administrative action to achieve program objectives, considering alternatives and setting priorities; and Evaluating success in meeting program objectives, including impact on the target population. (26) 25. Study Commission on Dietetics: The Profession of Dietetics. Chicago, American Die- tetic Association, 1972. 26. Preliminary Guides for Developing Nutrition Services in Health Care Programs. DHEW Health Services Administration, Bureau of Community Health Services, Rockville, MD, 1976. 13CHAPTER III. IDENTIFICATION OF NUTRITION PROBLEMS National Nutrition Status Studies General Comments Three major nutrition studies were undertaken in the 1960's. They occurred because of the realization that we knew very little about the nutrition status of the population, particularly the vulnerable groups. The studies included: The Ten State Nutrition Survey; (1) the Pre- School Nutrition Survey (2) and the Health and Nutrition Examination Survey (HANES). (3) As an outgrowth of the Ten State Nutrition survey and the need for nutrition data which could be utilized by local communities, the Center for Disease Control developed a pilot Nutri- tion Surveillance System. It is important for the health planner to be aware of some of the nutrition jargon before an understanding of the nutrition studies can evolve. Owen points out that the nutritional status of a population group, or of a community, is best evaluated by correlating results of dietary, clinical and biochemical studies. (4) This information tells us an individual's condition of health as it is influenced by his intake and utilization of nutrients. Thus the information obtained forms the baseline data for a nutrition survey. Nutrition Surveys versus Surveillance Nichaman describes a nutrition survey as the most traditional data gathering method. It is the examination of a population group at a particular point in time and thus is considered a cross-sectional examination. The "cross-sectional" survey provides information on the preva- lence or magnitude of a condition or characteristic in a population at a specific time; it does not provide data on the number of individuals who may be expected to develop a condition during a period of time. (5) The ultimate goal of a nutrition survey is to develop measures to control and eradicate mal- nutrition, including under- and over-nutrition in a population. Surveillance, as contrasted to survey, implies continuity, a frequent and continuous watching over. Repeated surveys do not accomplish this, particularly if the period of time between popu- lation sampling is protracted. Therefore, an activity that monitors individual groups, particu- larly high-risk groups on a continuous, uninterrupted basis is desirable. Surveillance implies an ongoing system intimately linked to an active health program. The major components of a surveillance system are nutrition assessment, nutrition monitoring and nutrition surveillance. Nutrition assessment includes the measurement and description of the nutrition status of a population in relationship to economic, socio-demographic and physiological variables. Nutrition monitoring is the measurement of change over time in the nutrition status of a population or specific group of individuals. Monitoring thus requires repeated comparable 1. Ten State Nutrition Survey, 1968-1970, Washington, D.C., DHEW Pub. No. (HSM) 72-8130- 8134 [1]. 2. Owen GM, Kram KM, Garry PJ, et al: A study of nutritional status of pre-school children in the U.S. 1968-1970. Pediatrics 53:597 - 646, 1974 [2]. 3. Preliminary Findings of the First Health and Nutrition Examination Survey U.S. 1971-1972, Washington, D.C., DHEW Pub. No. (HRA) 74-1219-1. 4. Owen GM, Lippman G: Nutritional status of infants and young children. U.S.A. Pediat Clin North Am 24:211-227, 1977. _____ 5. Nichaman MZ: The development of a nutritional surveillance. JADA 65:15-17, 1974. 14assessment at regular intervals. Surveillance is a frequent and continuous watching over. It gives direction for the early detection of community nutrition problems so that they can be corrected. A good surveillance system not only gathers and analyzes data but it also quickly presents the data to those who make administrative decisions which will affect the health and nutrition of the community. For these reasons, the Center for Disease Control developed a pilot surveillance system using a sample of convenience with data sources from such places as the EPSDT portion of Medi- caid, which is Early Periodic Screening, Diagnosis and Treatment program, Maternity and Infant Care Projects, Children and Youth Projects, Public Health Well Baby Clinics, Maternal and Family Planning Clinics, Head Start data, and data from the school systems. These are a few of the readily available sources where data can be generated without major expense. This surveillance system is discussed since it has the greatest potential for information at the local level. It actually builds the system on data from ongoing health programs. This is very beneficial to the HSA's and planning efforts in a given community. Review of Literature The major national nutrition studies are covered in the following reviews. Each review con- tains the following information; reference, geographical area, study design, significant find- ings, evaluation, and applicability to planning agencies. The studies include: Ten State Nutrition Survey Pre-School Nutrition Survey HANES Surveillance System 1. U.S. DHEW, Ten State Nutrition Survey in the United States, 1968-70. Publ No HSM 72-8130- 813A, Washington DC, Govt Ptg Off, 1972 Geographical Area Ten states: New York, Massachusetts, Michigan, California, Washington, Kentucky, West Vir- ginia, Louisiana, Texas, South Carolina Study Design The sample 30,000 families were chiefly low income. The objective of the survey was to make appropriate recommendations after determining the prevalence and location of serious hunger, malnutrition and resultant health problems that occur in low-income populations. 23,846 families participated in the survey. More than 50% of the persons examined were under 17 years old; 30% were from 17-40, and 17% were above 44 years old. The study design included: extensive demographic information on each of the families; clinical evaluation including a medical history, physical examinations, anthropometric measure- ments, x-ray examinations of the wrist; dental examinations; biochemical assessment, including hemoglobin, hematocrit, total serum protein, serum albumin, serum Vitamin A and carotene, and serum Vitamin C; urinary analysis—creatinine, thiamine, riboflavin index; and dietary food intake data. Significant Findings General Significant proportion of population surveyed was malnourished or at high risk of developing nutrition problems. Elements of malnutrition vary from one locale to another and in different populations within localities. Malnutrition was found most commonly among Blacks, less commonly among Spanish-Americans and least among white persons. Increasing evidence of malnutrition in 95th per- ideal weight Parent will identify Biochemical 1965. centile) range rather than lose weight. ideal weight for his/her infant Title XIX (EPSDT) Headstart Child Abuse & Hemoglobin CDC Standards adjusted for alti- Anemia Identify cause of anemia (mal- Parent/participant will identify causes, Neglect Center Hematocrit Serum Choles- terol tude. Cyanmethemoglobin method for hemo- globin. Wybenga method on micro-sample Elevated serum cholesterol (>160 mg/100 ml absorption, dietary, bleeding) Investigate other cardio- vascular disease risk factors. symptoms, and conse- quences of anemia. Client/parent will identify cardio- vascular disease risk factors and state those which can be modified. Food Stamps Commodity FoodsTable 2 (continued) Infants and Children Intervention GeJeral Sample Client Refeirral Determining Risk Standard Criteria Problem Guidelines Behavioral Objectives Sources (Technique/Equipment/ Standards Clinical Birth Weight Birth weight <5 1/2 Monitor low birth lbs. weight infant to Blood Pressure Sphygmomanometer with determine catch up Parent explains mean- child-size cuff. Diastolic blood growth rate. ing of systolic and Dental Caries Quiet environment. pressure for 3-12 year olds greater Caution should be diastolic readings. than 90 mm. exercised in Parent explains fac- labeling children tors which contribute as hypertensive because of psy- chosocial and economic implica- tions; use of the term "high normal blood pressure" is appropriate during evaluation & followup.* to hypertension. Dietary 24-hour recall 24-hour recall or At risk of nutri- Identify key Parent will explain or food fre- food frequency ent and energy in- nutrients, factors affecting quency form take inappropriate function & food weight gain during to age according sources. infancy. Feeding development to RDA. Describe intro- Parent will identify duction of foods eating problems that & food prepara- occur during in- tion. fancy and lead to obesity Discuss weaning. Parent will identify appropriate feeding skills for their infant or child. *Report of the Task Force on Blood Pressure Control in Children, Pediatrics, 59:797-820, 1977.Table 2 (continued) Adolescents Intervention Determining Risk Standard Criteria Problem General Guidelines Sample Client Behavioral Objectives Referral Source Anthropometric (Technique/Equipment/ Standards) Height Weight Skinfold thickness Balance scales, steel measuring tape, calipers. NCHS growth grids for ht/age and wt/age and wt/ht before puberty. Teenage pregnancy Concentrate on fact that mother is still physi- ologically developing, as well as support- ing growth of fetus. Client will identify the reason for in- crease nutrient and energy needs due to 1) her own physiologi- cal development, and 2) her pregnant state. Prenatal Care WIC M&I Project Obesity (wt/ht > 95th percentile in pre-puberty) Explain relation between weight, self-image, and peer acceptance. Client will explain how obesity relates to social problems in adolescence, and hyper- tension, diabetes, cardiovascular di- sease risk, and obesity as an adult. Weight Watchers Physical fitness programs and recreational facilities Biochemical Hemoglobin Hematocrit CDC Standards, adjusted for altitude. Anorexia Nervosa Concentrate on psychological factors and in- fluence of entire family. Client will identify ideal weight for age and sex and health risks associated with rapid weight loss. M.D., Psychologist or Guidance Center Serum Choles- terol Cyanmethemoglobin method for hemo- globin Wybenga method on micro-sample. Alcohol & Drug Abuse Investigate social enviorn- ment in terms of peer pressure and peer acceptance. Client will state energy/nutrient re- quirements and ex- plain how substance abuse affects satis- fying these require- ments . Drug Treatment Centers Alcoholics Anonymous Free Clinics Neighborhood Health Centers Non-traditional, alternative health servicesTable 2 (continued) Adolescents (continued) Intervention Determining Risk Standard Criteria GenJral Sample Client Refelrral Problem Guidelines Behavioral Objectives Sources (Technique/Equipment/ Standards) Clinical Blood Pressure Sphygmomanometer. Quiet environment. Dental Caries Drug & Alcohol Abuse & VD Questionnaire Dietary 24-hour Recall 24-hour recall or food or Food frequency form Frequency Table 2 (continued) Maternal ■e~ ro Intervention General Determining Risk Standard Criteria Problem Guidelines (Technique/Equipment/ Standards) Anthropometric Height Balance scales Short stature Promote adequate weight gain and Pre-pregnant weight Steel tape measure Underweight nutrient intake. Weight gain Follow pattern of National Academy of Sciences weight gain grid. Weight loss or inadequate weight gain Biochemical Hemoglobin CDC Standards adjusted for Anemia Promote regular and early use of Hematocrit altitude. Diabetes prenatal services. Urine Clinical Stick test for sugar, ketones, protein. Toxemia Obstetrical Questionnaire Repeated pregnancy Encourage decision history and lactation at in- tervals of less than on breast vs. bottle feeding Blood Pressure Smoking, alcohol and drug intake questionnaire Sphygmomanometer 1 year. Previous problem pregnancies. High parity Mothers age 19 to 35 yrs. old. during last tri- mester . Sample Client Behavioral Objectives feJri Refehrral Sources Client will identify difference between nutrient needs during pregnant and non-preg- nant states. M&I Project Prenatal care WIC Participant will plot Food Stamps and determine the components of her weight gain during pregnancy. Participant will iden- Regional perinatal tify reasons for early programs, use of prenatal ser- vices and the relation- ship to outcome of preg- nancy . Participant will iden- Title XIX tify reasons to breast feed or bottlefeed an infant. MCH Services Smoking, alcohol and drug use increase risk of low birth weight or birth defects.Table 2 (continued) Maternal (continued) Intervention Determining Risk Standard Criteria Problem Genferal Guidelines Sample Client Behavioral Objectives Refelrral Sources (Technique/Equipment/ Standards) Pica and allergies. Dietary 24-hour recall or food frequency 24-hour recall or food frequency form OJTable 2 (continued) Adults Intervention GeJeral Sample Client Refelrral Determining Risk Standard Criteria Problem Guidelines Behavioral Objectives Sources (Technique/Equipment/ Standards) Anthropometric Height Balance scales Obesity Relate obesity to Client will explain Weight Watchers (>20% over ideal chronic health association between Weight Steel tape measure, weight for height) problems. obesity and chronic calipers Develop personal- health problems. Metropolitan Life ized intervention Client will identify Physical fitness Insurance Height & plan on desirable which disease risk program and Weight tables. lifestyle modifies- factors he has and recreational tions that include how he can modify facilities. Skinfold Triceps skinfold diet & exercise. them. thickness according to Stop smoking Seltzer, Mayer; Postgraduate Medicine 38:A-101, 1965 clinics Biochemical Anemia Hemoglobin CDC Standards, Diabetes Concentrate on Client will describe Alcoholics adjusted for personal diet relation between Anonymous Hematocrit altitude Elevated Choles- modifications us- insulin, physical terol ing diabetes activity and diet Food Stamps Serum choles- (>200 mg%) exchange list. intake; and impor- terol and other Hyperlipidemias tance of reaching lipids. Types I - V and maintaining ideal weight to Blood glucose Hypertension (Blood pressure >140/90) control diabetes. Table 2 (continued) Adults (continued) Determining Risk Standard Criteria Problem GeJeral Guidelines Intervention Sample Client Behavioral Objectives Refelrral Sources (Technique/Equipment/ Standards) Clinical Blood pressure Sphygmomanometer Risk of heart attack, stroke and certain Investigate caused factors in sub- Client will state energy/nutrient Cardiovascular disease risk Treadmill cancers (lung, eso- phagus and bladder). stance abuse and suggest coping requirements and explain how sub- factor question- naire; family history, dia- betes, smoking, physical ac- tivity, stress Alcoholism and drug abuse Lung function test Increases with number and severity of risk factors such as over- weight, fat intake, hypertension, ele- vated cholesterol, smoking, inactivity, and stress. Alcoholism and drug abuse mechanisms. stance abuse affects satisfying these requirements. Dietary 24-hour 24-hour recall or recall or food frequency food form frequency Table 2 (continued) Elderly Intervention GeJeral Sample Client Refelrral Determining Risk Standard Criteria Problem Guidelines Behavioral Objectives Source (Technique/Equipment/ Standards) Anthrometric Obesity Height Balance scales (>20% over ideal Increase nutrient Client will identify Title VII weight for height) density of diet to own decreased energy Weight Steel tape measure, adjust for de- needs and name speci- Congregate calipers creased energy fic foods high in meal site need. nutrients, low in Metropolitan Life Insurance height & Anemia Stress importance calories. Meals on Wheels weight tables. of food in social Client will identify Food Stamps Diabetes environment food/social programs Skinfold Triceps skinfold for which he is eli- thickness according to Elevated Choles- gible and which are Seltzer, Mayer: terol available in his Postgraduate (>25mg%, with community. Medicine 38:A-101, elevated propor- 1965 tion of low den- sity to high density lipoproteins) Biochemical Hypertension Hemoglobin CDC Standards, (Blood pressure adjusted for >140/90) Hematocrit altitude Risk of heart attack Serum choles- stroke and certain cancers (lung eso- other phagus and bladder). lipids. Increases with number and severity of risk Blood glucose factors such as over- weight, fat intake, hypertension, elevated cholesterol, smoking, inactivity, and stress. Table 2 (continued) Elderly (Continued) Intervention GeJeral Sample Client Refelrral Determining Risk Standard Criteria Problem Guidelines Behavioral Objectives Sources (Technique/Equipment/ Standards) Clinical Blood pressure Sphygmomanometer Osteoporosis Cardiovascular Treadmill Inadequate food intake disease risk due to poor dentures, factor ques- Lung function low income, and deprived tionnaire; family history, diabetes, smok- ing, physical activity, stress Dental test social environment. Socioeconomic status Dietary 24-hour recall 24-hour recall or or food fre- food frequency quency form Food assistance programs administered federally by the U.S. Department of Agriculture, but in some cases supervised at the local level: —National School Lunch Program —School Breakfast Program —Summer Food Service Program —Child Care Food Program —Non-food Assistance Program —Special Milk Program —Food Stamp Program —Commodity Distribution Program —Special Supplemental Food Program for Women, Infants and Children (WIC) Planners should be aware of existing food assistance programs in their localities since it is an important part of nutrition services to high-risk groups. A Model for Delivery of Nutrition and Health Care The Comprehensive Health Care Project for Children and Youth (C&Y) provides an excellent model for planners who are concerned with the integration of nutrition services in health pro- grams. Project orientation is toward complete care and nutrition is clearly defined as one of nine functional areas in the project. (7, 8) C&Y projects provide maintenance and treatment services for a voluntarily enrolled group of clients in a specific geographic area. Administration of the projects is equally divided between state and local health departments and medical schools or hospitals affiliated with medical schools. Services are delivered by a multidisciplinary team. Certain principles characterize the project. There is concern with the total environment of the child. Care begins with the mother and is family oriented. Referrals are made to involve health-related social services. Efforts are made to ensure that all relevant disciplines are involved in the delivery of services and that services are available and accessible to all families. In addition to comprehensiveness, continuity of health care is a basic objective. The inclusion of nutrition as a fundamental discipline in the C&Y projects necessitates that a plan be formulated for the delivery of specific services. This involves some standard adminis- trative practices such as planning, organizing resources, assembling resources (funds, people, facilities, equipment), providing instructions, and evaluating performance according to plan. Consideration must be given to program context and constraints, content and process, output and outcome. In other programs these tasks may be performed exclusively by health planners or admin- istrators. In the C&Y projects trained nutrition personnel have a major role in the planning and supervision as well as the provision of care. The resulting services are more effective because the essential components of nutrition services as well as the basic premises of the C&Y projects are considered at the planning stage. To ensure comprehensiveness and continuity a sequential case process for health care is ed. It includes health assessment, development of a case plan, intervention or treatment, and health supervision, both long-term and on-going. The focus is on the primary level of care where clients enter the system and arrangements can be made if secondary or tertiary care is required. Nutritionists provide nutrition education, screening, assessment, therapeutic nutrition care plans, and extended care services in the C&Y projects. A strong evaluation component has been developed for these projects. A Quarterly Summary Report provides a system for standardized reporting. The report has two parts. The Uniform sec- tion, which is common to all projects, reports the flow and volume of services by recording the client's progress through the sequential health care system. The Non-Uniform section in- cludes unique aspects of the projects such as internal referrals reflecting teamwork, screening activities, family data and group teaching. To increase the reliability of the data and the interpretation of the statistics, operating definitions, or standard descriptions of common services or program elements are used. For example, detailed descriptions of the kind of 7. Hallstrom BJ, Lauber DE: Learning from the C&Y Model: Utilization of Multidisciplinary Manpower with Nutrition Component of Comprehensive Health Care Delivery, 1969 '[117]. 8. Richmond J, Weinberg H: Essential elements for comprehensive health care for children and youth. Conference Proceedings: The Role of Maternal and Child Health and Crippled Child- ren's Programs in Evaluating Systems of Health Care, University of Michigan Medical Center, March 23-25, 1970 [115]. A8personnel involved in the nutrition functional area or the procedures involved in nutrition assessment are provided. The elements of a nutrition care plan are listed and the criteria developed for referral to the nutrition functional area are explicitly outlined. The Comprehensive Health Care Project for Children and Youth has been carefully designed to provide complete and continuous care. It encompasses all aspects of health care service: preventive, diagnostic, curative, and restorative, in a highly organized, well-coordinated system. This model has been in operation, tested, and evaluated. Its objectives and design can be reproduced in planning other programs. Summary and Implications for Planning Agencies The section on delivery of nutrition services indicates that there are apparent strengths, weaknesses and needs in the system. At the workshop in May 1977 sponsored by the Bureau of Community Health Services, DHEW, and the Association of State and Territorial Public Health Nutrition Directors (ASTPHND), six priorities for implementation in 1978-79 were developed. The need for a national coordinated effort to develop and implement nutrition care standards in ambulatory care was voted the first priority. The consensus of attending Federal, State, local and graduate faculties in nutrition was that standards should be developed which include criteria for structure (staffing), process (methods), and outcome (end product) since all facets of a delivery system should be measurable. The other five points identified were: — Involvement of nutritionists in health planning efforts — Inclusion of nutrition services within reimbursable payment systems — Expansion of a national nutrition surveillance system to include data from public and private sectors for local program use —Development of cost-benefit—cost-effective ratios — Development of staffing standards for public health nutrition programs. Some of the weaknesses in the nutrition delivery system, particularly the area of nutrition education were voiced recently by Congressman Fred Richmond of New York. The Committee on Agriculture, Subcommittee on Domestic, Marketing, Consumer Relations and Nutrition, commissioned a landmark study from the Library of Congress. The report published in March 1977 revealed that the Federal government is presently sponsoring 30 separate nutrition education programs in 11 agencies at a cost of $70 million. The report concluded that these programs were uncoor- dinated, repetitious, and even contradictory in their message. Hearings were held by the sub- committee where 50 witnesses gave their concerns about nutrition and their perception of the Federal effect on nutrition education. According to the witnesses, there is no single visible source of objective and useful information on food, diet and health in our country. In the ab- sence of reliable information, the American people are turning to magazines, popular books, health food stores and faddists for accessible, if dubious, answers. Consumers want direct answers to their questions about the nutrition controversies of the day. The problem of nutrition education for the public is a complex one; however, every effort must be made to assure that sound nutrition facts are relayed to people. With the interest of Congress, the Federal government, and the American people on this subject, perhaps some new approaches to reaching the American public with sound nutrition information will be forthcoming. Ten states currently utilize a surveillance system coordinated through the Center for Disease Control which allows for simultaneous data collection and delivery of care. Surveillance data provide the basis for evaluation of program effectiveness and indicate trends that may be useful to the planner in designing programs to meet changing needs of the population. Data for surveillance programs may be collected by screening. Minimum screening procedures should be designed to diagnose those conditions specific to the population being screened. Health care services should include a nutrition component. The preventive aspect as well as the curative should be stressed. Nutrition education should be integrated into all health care systems where it is applicable, but it will not be effective unless the following conditions are considered: Services need to be tailored to the particular group served. Traditional educational structures need to be adapted to meet contemporary needs. Nutrition education programs should be designed to change attitudes rather than to present facts. 49Nutrition education curriculum should be cumulative. In order to assess the effectiveness of any education program, an evaluation compo- nent must accompany it. Malnutrition affects all societal groups; existing programs do not make provisions for the nutrition problems of a large percentage of the population who traditionally have been con- sidered well nourished. In many instances, existing community resources can be expanded to provide nutrition services. For example, family planning agencies can add nutrition services for mothers and children. They provide a portal of entry to the health care system and encourage continued use of the system. Social services for the elderly are ideally combined with food service. Traditional care facilities or methods of care can be modified to meet community needs. Increasingly, hospital outpatient facilities are being used to provide a place in which nutri- tion information can be presented. In one instance, a hospital dietary staff developed a plan designed to increase the use of an existing food distribution program in a community where mal- nutrition was identified. Effective nutrition services have been provided by community nutrition workers recruited from the area to be served. In programs in Arizona and Maryland, indigenous aides who were supervised by trained nutritionists were extremely effective because, being familiar with the customs, life style and language of the communities, they were able to establish good rapport with the families and to elicit reliable information. Although the provision of nutrition services should be planned and administered by public health nutritionists, a wide variety of specially trained personnel are available to implement the services. These include nutritionists, dietitians, home economists, and community aides. Allied health professionals can also be instrumental in the provision of nutrition services. The use of a multi-disciplinary health team simplifies referral procedures and, by pooling competencies, expands the level of health care offered to clients. Variances due to geographic and cultural differences must be considered in the development of nutrition services. Economic and social policy has a major influence on nutrition status. Although no comprehensive nutrition plan exists at the Federal level, numerous Federal programs serve specific populations. There is a need for coordination at the Federal, State, and local levels to prevent the duplication of services and inconsistencies in the dissemination of information. Coordination at the local and state levels can result in increased political leverage at the Federal level. One outcome can be an expanded and continuous level of funding. 50CHAPTER V, NUTRITION PLANNING AND NUTRITION POLICY General Comments Three major areas are reviewed in this section. Elements in Nutrition Planning—covers the importance of national and international food and nutrition policies for health, and offers some approaches to nutrition planning. Efforts at International, National, State, Community and Institutional Levels are cited. Nutrition Policy—reviews the need for a policy. It specifically addresses issues such as need identification, regulatory activities, agriculture, education, health, financing and the international situation. Nutrition planning and policy formations are interrelated components necessary to effec- tively deal with food and nutrition problems. Planning is best seen as a dynamic interactional process. Planning is generally discussed in terms of a sequence of steps, but in practice, it is rather "an iterative process that resembles the tango, four steps forward, three steps back, with an occasional turn-around." (1) The sequence of steps generally include: Identifying the problem; Setting objectives; Setting criteria for evaluation of alternatives; Identifying and comparing alternative interventions; Identifying implementation actions; Evaluating results. Policy is defined by Webster as "a governing principle, plan, or course of action." In itself, it is static—the result of a decision-making process. Policies give direction to activities by describing the mode of operation and the ends desired. The need for effective nutrition planning and policy formation is becoming increasingly evident as more demands are put on our national resources. We are becoming increasingly more aware that our resources are finite and that the U.S. can no longer afford the luxury of un- coordinated policies and planning. The health costs of such inaction make national nutrition planning and policy formation all the more important: six of the ten leading causes of death in the U.S. are related to diet. These diseases—heart disease, stroke and hypertension, cancer, diabetes, arteriosclerosis, cirrhosis of the liver—are not curable, but they can be prevented, or at least delayed by a change in the American diet and lifestyle. In the past, consideration of proper nutrition care has been linked to the clinical manage- ment of disease states with modified diets. However, it is patently apparent that this is now too limited a focus. 1. Berg A, Muscat R: An approach to nutrition planning. Am J Clin Nutr 25:939-954, 1972. 51Summary and Implications for Planning Agencies Nutrition planning is simply the application of a planning process to the problems of nutrition. The techniques used by health planners and urban planners are directly transferrable to nutrition. Health and nutrition planning are in their infancies. Most of the literature and the attempts at health and nutrition planning have arisen from the rationalist model of planning which is based on the principles of quantification, predictive models, decision-making, and rational human behavior. The main elements of the systems approach are: definition of the problem; selection of objectives; synthesis of systems; analysis of systems; selection of the best alternatives, and plan for action. (2) While the remainder of the discussion will focus on the use of the rational model for planning, it is wise to remember that other models are possible also. Nutrition planning then, is a process which should be applied to nutrition problems at all levels: national, international, state, community, institutional. Nutrition Planning at the National and International Level Berg, Muscat, and others stress a systems approach to national plannine. This planning approach relies on conceptual analysis of the sub-systems embracing the consumer and nutrition activities and the interrelationships of those sub-systems. This systems approach is then set in a political and administrative framework on the rationale that only government can effectively intervene at the national level, for only government has the resources and the mandate to do so. As Berg and Muscat emphasize, the systems approach helps decision-makers identify some of the major factors affecting nutrition status such as income redistribution and agriculture which are often outside of the traditional interests of the nutrition planners. (3) This then allows identification of critical points for policy leverage and thus program alternatives, and requires comparison of alternatives with regard to their effect on other areas. Implementation is to follow analysis of the system, and both are to be constantly reworked as new information is included in the model. The AID approach is similar but allows for the adaptation of the systems approach in two different ways: First, within each area and gradually encompassing one or more areas simultaneously; Given commitment and agreement of national policy-makers on the need to develop a nutrition plan and its place in the administration and decision-making framework, an integrated national intersectional planning approach develops. (4) The FAO/WHO document emphasizes the activity of planning rather than the theory of nutri- tion planning. (5) While national planning on an aggregate level is necessary, decentralized planning is just as important to deal with deprivation of specific population groups. Outcomes of national planning efforts reflect both national policies and local programs. Congruent with the AID document, the FAO/WHO document also used the role of the national nutrition planning process in clarifying policy issues leading to more effective decision- making. While data are important to planning, the lack of complete data should never stop planning. Organizational requirements for effective planning include a central planning body which is: Placed in such a position as to require relevant nutrition information from depart- ments in government to affect their decisions regarding nutrition; 2. Burkhalter BR: A Critical Review of Nutrition Planning Models and Experience. Ann Arbor, Mich, Community Systems Foundation, 1974 [164] 3. Berg A, Muscat R: An approach to nutrition planning. Am J Clin Nutr 25:939-954, 1972 [166] 4. Planning National Nutrition Programs: A Suggested Approach. Vol I: Summary of the Methodology. Vol II: Case Study. Washington DC, Agency for International Development 1973 [165]. 5. Food and nutrition strategies in national development. Ninth Report of the Joint FAO/ WHO Expert Committee on Nutrition. FAO Nutr Meet Rep No 56, 1976 [163]. 52Responsible for overview and analysis of the nutrition effects of all programs; Able to analyze the national nutrition situation in addition to assisting regional and local planning. Nutrition Planning at the Institutional Level Developing the patient care plan is essential to quality care. The patient care plan, as defined by Treadwell, is a systematic written guide which should define goals and preparation, coordination and implementation of measures to meet these goals. (6) Kocher and Treadwell dis- cuss planning in long-term care facilities, calling for a process for planning patient care to coordinate nutrition goals with other aspects of care, a planned schedule of purposeful visita- tion to monitor and evaluate food intake and appetite, a continual review evaluation, and an update of nutrition goals specified in the patient care plan. (6,7) Galbraith discusses planning patient care in the hospital setting and emphasizes the need for dietitians to adequately plan for all stages of each patient's episode. The dietitian's role in patient care is increasing in importance as pressures are put on hospitals to decrease length of stay and to plan for continuing care of the patient after discharge. Galbraith also points out that the patient should be intimately involved in long-term goal setting. (8) Planning at the Community Level Newmann, et al, emphasized the need to plan and evaluate small-scale nutrition programs and asserts that smallness should not hamper evaluation. (9) Measures of program impact have to be designed for field use. Data systems should be simple but elegant; outside consultants may be most useful at this point. Continuous monitoring and evaluation of the program should be built into the program design as an internal staff activity. The American Public Health Association's document, Nutrition Practices: A Guide for Public Health Administrators (1955), offers many valuable suggestions on planning for nutrition services at the community and state level. (10) In addition to national data, the local administrator has available to him other sources of information about nutrition needs, e.g., hospital medical records, industrial medical records, local agency reports, and population perceptions of nutri- tion problems or needs. Likewise, it is essential at the community level to have a clear under- standing of the resources available—both potentially and presently—to deal with nutrition needs. An advisory committee with broad community representation can help identify needs and resources, promote joint planning among community agencies, and promote communication and good public relations between the agency and the community. Nutrition Planning at the State Level Nutrition planning at the state level is beginning to grow and thrive. Several states have developed mechanisms for nutrition planning, and several state nutrition plans are now available. Two states with particularly sophisticated planning efforts are Oregon and Arizona. 6. Treadwell DD: Planning the nutrition component of long-term care. JADA 64:56-60, 1974 [175]. 7. Kocher RE: Monitoring nutritional care of the long-term patient. JADA 67:45-46, 1975 [174]. 8. Galbraith AL: Hospital dietetics in transition. JADA 67:439-444, 1975 [173]. 9. Newmann, AK, Newmann GC, Ifekwunigwe AE: Evaluation of small-scale nutrition programs. Am J Clin Nutr 26:446-452, 1973 [106]. 10. Nutrition Practices: A Guide for Pubic Health Administrators. New York, Am Pub Health Assoc, 1955 [172]. 53Oregon Nutritionists are located throughout the Oregon State Health Division. Nutrition has been incorporated into the State Health Plan (draft) in the form of two specific goals, and many objectives. Nutrition is similarly incorporated into specific program plans, e.g., the Family Planning Program Nutrition Plan. Thirdly, there are specific nutrition program plans, such as the Women, Infants and Children (WIC) plan. Each program plan is organized around the POME format—Problems, Objectives, Methods and Evaluation. Further, WIC program planning process calls for an evolution of POME's from the state to the local WIC programs. The state WIC-POME defines state health and nutrition objectives and the local WIC-POME defines local health and nutrition education objectives. Arizona The Arizona nutrition planning process was begun in 1966 when a Chief Nutritionist was appointed to the Bureau of Nutrition in the Arizona Department of Health Services to work for the eventual development of a State Nutrition Program. In 1968, the State Nutrition Council, which included representatives from 30 agencies and organizations in the areas of nutrition, education, health, agriculture, government and business, prepared a nutrition plan for Arizona entitled, Comprehensive Plan for Nutrition Services, and submitted it to the Comprehensive Plan for Planning Authority in 1971. (11) This docu- ment stated the nutrition problems in Arizona, current efforts, need for additional efforts and specific recommendations. The plan is implemented on a yearly basis and an evalua- tion of services is completed. In 1977, over 80% of the recommendations made in 1971 were implemented by the Arizona Department of Health and other agencies included in the Nutrition Council. The Arizona Department of Health nutrition delivery system is a well-organized plan with specific quantifiable objectives. The data base for this system is a nutrition surveillance system completed in conjunction with the Center for Disease Control. The Arizona system includes screening, monitoring, referral, and manpower development as part of the total delivery system. Many elements necessary for effective implementation of a planning process are evident in these examples. First, and perhaps most important, is the commitment by top policy-makers to the need for a plan. Secondly, the formation of a broadly representative advisory council in the early stages of planning served the purposes discussed in the APHA document. (12) Use of the POME format provided a simple and useful tool for the actual development of the plan. This format is used in a variety of settings, i.e., for different programs and at differ- ent levels, probably helping to ease the development of interrelationships between programs and personnel. The process is dynamic and interactional, flowing between state and local pro- grams. And public health nutritionists are involved in every step of the planning process. Nutrition Policy Numerous organizations and leaders in the field have been drawing attention to the need for a national nutrition policy since the early 1900's. The Children's Bureau in 1918, the White House Conference on Child Health and Protection in 1930, the National Nutrition Conference for Defense in 1941, the National Food and Nutrition Institute in 1952, the White House Conference on Food, Nutrition and Health in 1969, the Nutrition Policy Studies in 1974, and many others have made recommendations concerning nutrition policy. While many individual recommendations have been implemented, the setting of a clear, com- prehensive policy on a national level has never occurred. Thus, today we have many categorical programs attempting to deal with specific problems in specific population groups, but no articu- lated policy statements. The result is de facto policies, many of which conflict with each other, fail to fill gaps, or are outright counterproductive. 11. Nutrition Council of Arizona: Comprehensive Plan for Nutrition Services. Phoenix, AZ, Arizona Department of Health Services, 1971. 12. Nutrition Practices: A Guide for Public Health Administrators. New York, Am Pub Health Assoc. 1955 [172], 54Thus, the push for a national nutrition policy has become more evident in the 1970's. A multitude of nutrition experts have begun impressing upon the public and decision-makers the need for nutrition policies. In general, these experts are attempting to draw attention to the need for a national food and nutrition policy and are making recommendations about the issues such a policy should address and the means for incorporating nutrition policy-making into the federal government. Numerous issues have been identified as being essential to a food and nutrition policy. Generally they can be grouped into the following categories: Need identification (nutritional status, food consumption, nutritional surveillance, food and nutrition attitudes, and similar components); Manpower development (dietitians/nutritionists, other health professionals, social service professionals and educators); Regulatory activities (nutrient labeling, fortification/enrichment, advertising, food safety); Nutrition and agriculture (nutrient quality of foods, food availability); Nutrition and education (nutrition education in public school system, in feeding programs, and in other intervention programs); Nutrition and health (nutrition in local health care facilities, community health programs, state health programs, national health programs); Financing of nutrition services; Nutrition and the international situation. Some of the recommendations are summarized below. Need Identification While much is already known about the general nutrition problems in the U.S., more needs to be known about the specifics. Exactly who is suffering from what nutrition problem and why? The health effects of nutrition must be better quantified. For example, what is the optimal weight gain during pregnancy? What are the implications of decreasing cholesterol in- take on health? How can diabetes best be managed? How can hypertension be prevented? How can obesity be prevented? And, what are the effects of food additives on cancer? Hegsted and others advocate the development and implementation of a nutrition surveillance system at the regional or state level, so that nutrition problems can be continuously monitored and program effects evaluated. (13) What are people eating and why? There is a need for timely surveys on household consumption and continuously updated food composition data. And, finally, what are the best ways to deliver services? Representatives at the Nutrition Symposium conducted by Mount Sinai Hospital, New York, recommend that more health research money be devoted to the evaluation of alternative approaches to altering food behavior. (14) And the Senate Select Committee's Subgroup on Nutrition and Health recommends that more money be devoted to the development, implementation, and evaluation of nutrition care programs. 13. Hegsted DM: Food and nutrition policy: now and in the future. JADA 64:367-371, 1974 [181]. 14. Prevention of disease through optimal nutrition. A Nutrition Symposium, Mt. Sinai Medical Center, New York, and the Institute on Man and Science, Rensselaerville, New York, April 22-25, 1976 [186]. 55Manpower Development It is a well recognized fact among leaders in the nutrition field that health professionals in general have limited knowledge or appreciation of the importance nutrition plays in health status. Many authors have thus keyed in on this problem and recommended the inclusion of nu- trition in the training of health professions: particularly physicians, nurses, dentists, and primary care professionals. At the same time, other non-health professions in direct contact with at-risk groups, such as teachers, should be trained in the basics of nutrition. Training of the public health nutritionist must also respond to expanded needs. Peck dis- cussed the skills and knowledge needed by the professional nutritionist: thinking and reasoning in the use of scientific and problem-solving methods, scientific and technical knowledge and skill, and knowledge of, and ability to intervene in the human environment. (15) While nutri- tionists are generally quite competent in the knowledge and practice of clinical nutrition, they are often lacking in the knowledge of political, economic, and social factors of individuals and groups and in the application of problem solving methods to program development. Congruent with these observations, members of the Association of State and Territorial Public Health Nutrition Directors recommend that nutritionists improve their skills in program planning and management by incorporating program planning into undergraduate and graduate programs and by planning postgraduate workshops. Nutrition and Agriculture Mayer and others point out the changing nature of the food supply in the U.S.: over 50% of today's products are highly processed. Members of the Nutrition Symposium point out that there is a steady narrowing in the genetic bases of commercial crops and uncertainty about the nutrition quality of animals bred in the U.S. (16) Food habits are changing along with the changing food supply, as snack and prefabricated foods become more popular, and as more meals are eaten in restaurants and fast-food estab- lishments. Hegsted recommends a closer look at the agricultural practices of the U.S., pointing out that our intensive technology and high energy agricultural methods are an inefficient use of scarce resources. Further, he points to the inefficient use of plant resources in the U.S. to produce animal protein. He also recommends that production of more nutritious foods be en- couraged including decreasing the cholesterol content of food. (17) A system of tax and subsidy policies, as discussed in FAO/WHO's Food and Nutrition Strategies in National Development, could be an effective mechanism for achieving this. (18) Nutrition and Education Recommendations for more and better nutrition education are plentiful. There is a need for the development of nutrition education programs to be coordinated among health departments, schools, and other public and private agencies. Also needed is provision of nutrition education specialists to assist public school teachers in the design and implementation of nutrition education curricula. The Society for Nutrition Education emphasized the need for sound nutrition advice to the general public. This information should allow consumers to choose a more healthful diet and to evaluate nutrition claims made by food advertisements. 15. Peck EB: A model'for professional development. Presented at the 57th Annual Meeting, of the American Dietetic Association, Oct 11, 1974 [192] 16. Prevention of disease through optimal nutrition. A Nutrition Symposium, Mt. Sinai Medical Center, N.Y. and the Institute on Man and Science, Rensselaerville, N.Y., April 22-25, 1976 [186]. 17. Hegsted DM: Food and nutrition policy: now and in the future. JADA 64:367-371, 1974 [181]. 18. The A.I.D. Nutrition Program Strategy. Washington DC, Agency for International Development, 1973 [169]. 56Dwyer and Mayer sum it up by distinguishing three levels of nutrition advice needed: prac- tical nutrition advice for consumers, cultural nutrition literacy for the intelligent public, and civic nutrition literacy for professionals. (19) Nutrition and Health Overwhelmingly, the authors agree that nutrition should be perceived as a health service and should be integrated into the planning, organization, and implementation of health care systems. The Bureau of Community Services (DHEW) document, Preliminary Guide for Developing Nutrition Services in Health Care Programs, reiterates the need for the provision of nutrition services in health programs. Specifically, the activities which should be performed in the nutrition ser- vice are: Screening and assessment; Delivery of services, including Dietary counseling, Nutrition education, Referral for nutrition and food assistance, Coordination and referral; Assessment, of quality of nutrition services; Recording of pertinent data; Monitoring and evaluation. (20) The Panels on Nutrition and Health (Senate Select Committee for National Nutrition Policy Studies 1974) further recommended explicit linkage between non-health nutrition services (such as feeding programs) and nutrition components in health services. (21) Regulatory Activities Much dissatisfaction with advertising practices of the food industry has been voiced. Mayer points out that advertising is greatest in the promotion of the least nutritious foods. (22) Attendees at the Nutrition Symposium sponsored by Mount Sinai Hospital in New York recommended that the Federal Communications Commission require a balancing of the food adver- tising directed at children by requiring a certain proportion of public service messages on pro-nutrition topics. They also recommended a strengthening of regulations regarding deceptive advertising and labeling. The Society for Nutrition Education (Dwyer) focused its recommendations on nutrient labeling requirements. (23) Specific recommendations included regulations calling for universal nutrient labeling, including information on polyunsaturated and saturated fatty acids, and complex and simple carbohydrates; full ingredient labeling; unit pricing; and open dating. Funding of Nutrition Services Proposals for financing nutrition services are varied, but most nutrition leaders agree that there is a need for the provision of some mechanism for the adequate financing of nutrition care services. Until provision is made for the financing, needed nutrition care will not be pro- vided. 19. Dwyer JT, Mayer J: Beyond economics and nutrition: the complex basis of food policy. Science 188:566-570, 1975 [179]. 20. Preliminary Guide for Developing Nutrition Services in Health Care Programs. Washing- ton DC, Govt, Ptg Off, 1976. 21. Subgroup of Panel on Nutrition and Health for Senate Select Committee on Nutrition and Human Needs: National Nutrition Policy. 1974 [188]. 22. Mayer J: Toward a national nutrition policy. Science 187:237-241, 1972 [183]. 23. Dwyer J: Challenge of change—nutrition and policy. J Nutr Ed 9:54-56, 1977 [178], 57The problem is difficult in our current system of financing with its wide array of funding mechanisms and types of delivery. Publicly provided health services are funded through federal and/or state monies, as specific categorical programs or traditional health departments. Pri- vately provided health services are financed through general tax revenues (Medicare, for example), specific categorical monies (such as Neighborhood Health Centers), quasi-public health insur- ance (Blue Cross-Blue Shield), private health insurance, and out-of-pocket monies. Thus, poli- cies dealing with financing of nutrition services have a wide range of issues to consider. Recommendations with regard to the current health care financing system emphasize matching the costs of nutrition services reimbursable through third party payors. The Bureau of Com- munity Health Services document focuses on categorically-funded programs and public health departments by emphasizing that every health program using Bureau of Community Health Service monies should include nutrition as a specific budget item. However, the important issue is not the present system of financing, but rather the future system. What part will nutrition, and preventive services in general, play in the coming national health insurance scheme? The provisions made for financing will determine almost totally the quantity and quality of preventive services in the coming years. Millar, in his paper, "The Future of Preventive Services," points out that, while the financing of personal preventive services is provided for in all national health insurance schemes now proposed, there is no provision in any of the proposals for the financing of com- munity preventive health services. (24) These services include disease control and prevention, family planning, health education, maternal and child health, and nutrition. The implications are clear: without financing, these services will probably not be provided. Millar recommends that local and state governments and HSA's press for inclusion of community preventive services in the national health insurance proposals. International Concerns The food and nutrition problems and actions of the U.S. cannot be seen in isolation from the rest of the world. A food and nutrition policy for the U.S. cannot be complete unless it includes statements on commitments to the rest of the world. Hegsted points out the relationship between the technology used in the U.S. for agricul- tural production and that advocated for use in the "Green Revolution." (25) He suggests that since both are inefficient in the use of energy, neither developing countries nor the U.S. can afford to depend on them much longer. Hegsted also points out the disadvantage of foreign aid based on surplus foods. These programs are often counter-productive; just as in the U.S., the commodity distribution program encouraged the eating of less nutritious foods. He asserts that foreign aid pro- grams which provide food must rest on a moral and economic commitment of the U.S., and that this will in turn affect U.S. agricultural and nutrition policies. Efforts of Nutrition Consortium and the Senate Select Committee on Nutrition and Human Needs on Nutrition Policy In preparation for the 1974 Senate hearings on a national nutrition policy, the National Nutrition Consortium designed a five-part document which discussed: The need for a national nutrition policy; The goals of a national nutrition policy; Measures for attaining the goals of a national nutrition policy; The programs needed to meet those objectives; and Requirements for the establishment of a national nutrition policy. 24. Millar JD: The Future of Preventive Services. Presented at the meeting of State and Territorial Health Officers, Washington DC, Dec 16, 1975 [181]. 25. Hegsted DM: Food and nutrition policy: now and in the future. JADA 64:367-371, 1974. 58The Senate Select Committee on Nutrition and Human Needs opened its National Nutrition Policy Study hearings in February of 1974, continuing through the year with a wide variety of expert testimony. The experts presented evidence concerning the role of nutrition in coronary heart disease, diabetes mellitus, hypertension, liver disease, alcoholism, cancer, anemia, and others. It is clear that policy-makers and planners must understand that nutrition services should be included in the planning and delivery of health programs. However, as Nichaman and Collins point out this cannot be achieved if nutrition services are tied to categorical funding. (26) Neither can it be achieved if plans continue to address only limited or specific age groups. A truly comprehensive approach to the delivery of health services is needed both in the delivery and financing of health services. National health insurance, which includes funding of community preventive services is needed. Public health nutritionists must be consulted and involved in the important planning goals if progress is to be made. 26. Nichaman MZ, Collins GE: Nutrition programs in state health agencies. Nutr Rev 32:65-67, 1974 [104]. 59CHAPTER VI. ISSUES IN COST CONTAINMENT General Comments In this section an attempt was made to look at cost containment and program evaluation; the areas of cost-benefit and cost-effectiveness are reviewed. Several topics were covered includ- ing proposed methods for evaluation, developing criteria and approaches for program evalua- tion. Actual studies utilizing various evaluation techniques were reviewed and manpower develop- ment was considered. The goal of all nutrition services and programs is to improve the nutrition status of the population being served. Program evaluation is a requirement for ensuring the realization of this objective. As Suchman points out, evaluation must be recognized as a process which per- meates all echelons or levels of the system. (1) Thus, Weiss contends that an evaluation com- ponent contains potential benefits on each level, from the policy-maker through the program director and practitioners to the consumers of the service. These benefits, if properly utilized by health planners, can serve as a valuable tool for prioritizing alternatives and demonstrating program effectiveness. Evaluation also serves many additional purposes including: To discover whether and how well objectives are being fulfilled; To determine the reasons for specific successes and failures; To uncover the principle underlying a successful program; To direct the course of experiments with techniques for increasing effectiveness; To lay the basis for future research on the reasons for the relative success of alternative techniques; and To redefine the means to be used for attaining objectives, and even to redefine subgoals, in the light of research findings. (2) A crucial question in evaluative research pointed out by Suchman is, "What do we mean by a successful result? All programs have some effects, but how do we measure these effects and how do we determine whether they are the particular effects we are interested in producing? Our main problem is one of selecting from among the myriad of possible effects those most relevant to our objectives. (1) One of the factors which complicates this problem is as Weiss states, that in contrast to most other kinds of research, evaluation research takes place in an action setting. (2) To cope with this situation, in the last century, the range of evaluation techniques has greatly expanded. When the concept was first implemented, its application was limited strictly to measurement. Factors such as the number of individuals served by a program or limits of aid dispensed were simply counted. The field then passed into a period of appraisal. In addition to the assessment of quantitative factors, qualitative criteria were also considered. Adminis- trators realized that issues like program acceptance played a vital role in program 1. Suchman EA: Evaluative Research. Russell Sage Foundation, 1967. 2. Weiss CH: Evaluation Research. Prentice Hall (Method of Social Science Serv.), 1972. 60effectiveness. Today the concept has become even more sophisticated and health planners think in terms of assessment. The recognition of indices such as effort, effect, process, appropriateness, adequacy, effectiveness, efficiency and side-effects are now considered an indispensible part of a good program evaluation component. Unfortunately, the incorporation of evaluation components into nutrition programs has not experienced the same growth as the concept and techniques suitable for use in the area. Accord- ing to Gordon and Scrimshaw, part of the difficulty rests with the differences in the training and attitudes of investigators and administrators. (3) They point out that while scientific methods prescribe careful organization and assessment of results, administration is more con- cerned with resources and staff to do the work. The administrator may also be convinced that the inherent value of the intervention is apparent or that demonstrated success of methods in one situation assures the procedure's efficacy universally. In addition, there is the mis- conception that the results obtained from an experimental field trial will automatically be duplicated in a wide-scale general application. Other administrators simply feel that their task is limited to program implementation. This may occur because of a lack of interest in the less attractive task of formal evaluation or an objection to the costs involved or occasionally even a disinclination really to know a suspected lack of result. The problems certainly do not lie exclusively with administrators. Often there is lack of agreement in the scientific community on what criterion or procedure is valid for assessing program effectiveness. In addi- tion, the science of evaluation and assessment is still young. Two promising techniques of evaluation are the cost-benefit and cost-effectiveness models. Cost-benefit analysis has been characterized in many ways by different people. A general view offered by Gross is that it is, "an effort to provide more explicit and logically organized information about the effects or outcomes of specific programs or projects." (4) Steiner proposes a more detailed description. He feels cost-benefit analysis is, "a process that is based on the assumptions that a specific problem can be identified; that the cost of its conse- quences can be measured within a permissible range of accuracy; that it can be eradicated or controlled at some predetermined level by a new program; and that the cost of the new program can also be measured." (5) Thus, as Hyman points out, cost-benefit analyses are able to trans- late alternative choices into a common denominator of dollars and cents and that this is then a useful tool for comparing the merits of various objectives. (6) The cost-effectiveness model is a variation of the original cost-benefit analysis model. Again, its purpose is to find the best way or alternative (at the least cost) for obtaining a desired objective. This model, however, includes analysis of both monetary and non-monetary data. According to Spears, it is applicable in cases where an attempt is made to minimize dollar cost, subject to some goal requirement which may not be measurable in dollars or the con- verse, which is to maximize some measure of output subject to a budgetary constraint. (7) That is to say, the technique possesses widespread potential applicability. Many promising cost-benefit and cost-effectiveness models have been proposed; however, there continues to be a lack of consensus on how to place objective quantitative values on the many intangible variables involved. Program evaluation thus calls for combining the skills of both the investigator and the administrator. Most program evaluations in community nutrition can be grouped into five broad classes: Programs with the simple objective of food supplementation; Service programs; Comprehensive nutrition programs incorporating related health disciplines; 3. Gordon JE, Scrimshaw NS: Evaluating nutrition intervention programs. Nutr Rev 30:263-265, 1972. 4. Gross M: The new systems budgeting. Pub Admin Rev 29:113-137, 1969. 5. Steiner KC, Smith HA: Application of cost-benefit analysis on a PKU screening program. Inquiry 10:34-40, 1973 [203]. 6. Hyman HH: Health Planning and Systematic Approach. Germantown, MD, Aspen Systems Corp., 1975. 7. Spears MC: Concepts of cost effectiveness: accountability for nutrition productivity. JADA 68:341-344, 1976 [200]. 61Programs located In choice local areas; and Action programs. (8) Program directors have the responsibility of developing and implementing the most effective services possible. Use of findings from evaluations of related studies as well as incorpora- tion of an appropriate evaluation component in the proposed program is essential to fulfill this obligation. The brevity of this section is a reflection of the paucity of material in this area. Efforts were made to obtain findings from as many areas and sources as possible. The majority of reports were based on national and international programs and services. Hopefully, the value of this data will be recognized and efforts to contribute to the field will be stimulated. Summary and Implications for Planning Agencies The papers presented in this section offer ample evidence of the potential positive impact of improved nutrition services on (a) nutrition status; and (b) cost-benefit and cost-effective- ness ratios. In addition, numerous important and thought-provoking issues were elucidated. Statistics from several studies will illustrate these benefits and topics. Nutrition Status Evidence of the impact of improved nutrition services on nutrition status is available, although most difficult to find. Examples of positive impacts from improved services can be found in the paper, "Evaluation of USDA Food Programs" by Hiemstra. One study concerned a low- income area in Texas where major emphasis was focused on school lunch and breakfast pro- grams. (9) The National Nutrition Survey in that area indicated that the nutrition level of the children was far superior to that of other low-income areas surveyed. Van Duzen studied the nutrition impact of several food programs on Navajo preschool child- ren. Between 1969 and 1973, hospital admissions dropped 18%. The number of children with a diagnosis of malnutrition dropped from a yearly average of 123 to 75.4. Marasmus practically disappeared. Kwashiorkor dropped by about 50% from a yearly average of 3 to 1.6. Height data also indicated that the incidence of malnutrition dropped. In 1967, 30% of the boys and girls were below the third percentile of the Boston Growth Curve. Based on the same scale, in 1973 the figures were 11% and 16%, respectively. (10) These are just a few examples of the many nutrition benefits which can be realized from expanded use and application of nutrition services. The validity of this contention is masked only by the general lack of studies in this field. Cost-Benefit - Cost-Effectiveness There are several examples of the use of cost-benefit and cost-effectiveness analyses. Dahl demonstrated that increasing the allocation of funds to the nutrition functional area of the Children and Youth Project by one percentage point would likely reduce the total cost per registrant per year by 1/11 of a percentage point. Converted to figures, the annual registrant cost would be $271.52 which is estimated to be $29.30 lower than it would have been had there been no nutrition functional area in the program. In another study, he projected a savings of 13.7% by increasing the funding of a medical functional area. (11) 8. Gordon JE, Scrimshaw NS: Evaluating nutrition intervention programs. Nutr Rev 30:263-264, 1972. 9. Hiemstra SJ: Evaluation of USDA food programs. JADA 60:193-196, 1972 [227]. 10. Van Duzen J, Carter JP, Vander ZwaggR: Protein and calorie malnutrition among pre- school Navajo children. Am J Clin Nutr 29:657-662, 1976 [29]. 11. Dahl T: The Nutritional Functional Area in Comprehensive Health Care Delivery Per- formance and Cost. Presented at the American Dietetic Association Workshop on Health Mainten- ance Organizations, The Mayflower Hotel, Washington DC, June 23, 1972 [229]. 62Amadio applied a cost-benefit analysis model to numerous public health programs in Jackson County, Illinois and obtained these impressive results: (12) Public Health Program Benefit/Cost 1. New Jersey Influenza Vaccination (conservative) 64.22:1 (liberal) 149 il 2. D.P.T. Multiple Vaccination 104:1 3. Rubella Vaccination 151:1 4. Measle Vaccination 15:1 5. Smallpox Vaccination 93:1 6. Tuberculosis Control 20.23/1+xl 7. Kidney Disease Screening (conservative) 14.6:1 (liberal) 39.2:1 8. Home Dialysis and Center Dialysis .65:1 & .21:1 9. Food Sanitation Inspection (conservative) 23:1 (liberal) 189:1 10. Air Pollution 10:1 11. Monroe County Home Care/Hospitalization 4.75:1 12. Stroke Patient Home/Hospital Care 8.27:1 13. Skilled Nursing Home Care (3 visits/week) 2.5:1 (1 visit/week) 7.35:1 14. Home Maintenance 5.2:1 In a study by Steiner, the cost-benefit analysis of a phenylketonuria screening program in Mississippi was undertaken. A retrospective approach yielded a ratio of 1 to 1.66 while a pros- pective study resulted in a ratio of 1 to 2.60 per patient living 70.8 years in an institution. This means that, in the first case, each dollar spent on implementing the screening program would have resulted in a savings of 1.66 dollars and the return figure for the prospective study was 2.60 dollars for each dollar spent. (13) A study in Canada predicted that an investment of 25 to 38 million dollars in community nutrition services would result in a savings of from $5.50 to $8.00 for every dollar spent. (14) Another study was performed in Canada by Sabry. The author estimated that the cost of hospitali- zation, medical-dental care and loss of productivity due to premature death and absenteeism caused by diseases and disorders related to nutrition was $7,797,120,000 per year. The estimated potential savings from improved nutrition were $2,462,982,000 per year, thus suggesting that improved nutrition services can have a tremendous economic impact. (15) Cost-Effectiveness Stason and Weinstein applied a cost-effectiveness model to the treatment of hypertension. Their model generated data of great potential value to health planners who must prioritize their alternatives. For example, they found that the cost-effectiveness ratio for men ranged from $3,300 at age 20 to $16,300 at the age of 60; for women, from $8,500 at age 20 to $5,000 at the age of 60. It was also found that in a male patient whose initial blood pressure was 110 mm Hg, the ratio value was $10,800 if this level was lowered and maintained at 100 mm Hg, and $3,700 if 80 mm Hg was attained. (16) This type of information would allow the health planner to deter- mine that, for example, funds spent to improve adherence may well be a better use of resources than efforts to screen a maximum number of clients or that treatment priorities favor higher initial diastolic blood pressures in younger men and older women. 12. AmanioJ, Mueller J, Casey R: Benefit/Cost Ratios in Public Health. Springfield, 111, Illinois Dept Pub Health, 1976 [199]. 13. Steiner KC, Smith HA: Application of cost-benefit analysis to a PKU screening program. Inquiry 10:34-40, 1973 [203]. 14. The Land of Missed Promises. Canada, 1970 [201]. 15. Sabry ZI: The cost of malnutrition in Canada. Can J Pub Health 66:291-293, 1975 [202] 16. Stason WB, Weinstein MC: Public Health Rounds at the Harvard School of Public Health: allocation of resources to manage hypertension. N Engl J Med 296:732-739, 1977 [196]. 63While the paper by Hiemstra on "Evaluation of USDA Food Programs" does not actually calcu- late ratios, it addresses the issues involved in such an approach. The author pointed out that in 1972 approximately $3.7 billion was appropriated to all of the USDA programs. It was reported that the stated objectives of the programs were to provide either food or food purchasing power to needy persons who are most likely to be in need of additional food, or school children. In 1972 roughly 14 million people were participating in the Family Feeding Programs; 10.5 million in the Food Stamp Program, and 3.5 million in the Food Distribution Program. In 1970 the total figure was only 6.8 million. Under the School Lunch Program 25 million children were being served in 1972 compared to 22 million in 1970. (17) These figures indicate that the increased money is going to feed the kinds of people for which the programs were intended. Based on these parameters, the programs appear to be very cost-effective. In addition to these quantitative parameters, the studies reviewed highlighted many crucial issues and questions of a more general nature. These included: discussions on the number and type of measurement techniques required to assess nutrition status; the relative value of surveillance vs. the use of surveys; the need to consider both the costs and effectiveness of any program; the need for improved communication between researchers, administrators, and the public; and the lack of replicative studies in the field. The evaluation components of the studies reviewed varied greatly. Some were based solely on 24-hour dietary recalls while others utilized dietary habits as well as clinical, biochemical, and anthropometric measurements. The latter produced a greater quantity of reliable data. It is well acknowledged that use of only one of these tools yields findings of questionable valid- ity. For example, in studies where only dietary habits were evaluated, the subjects may have been consuming adequate quantities of the necessary nutrients and, as a result, were rated as healthy. However, because of some malabsorption problem, they could have been suffering from significant deficiencies. Administrators may claim that the use of clinical, biochemical, anthropometric and dietary tests would exceed the program's budgetary allotment for evaluation. While scientists are not prepared to omit any of these measures, studies have been done by Guthrie and Owen, among others, which have demonstrated that the number of tests in each area may be greatly reduced without sacrificing the quality of the results. (18) At the same time, administrators must recognize the need for a reliable evaluation component. As Weiss states, "Evaluation is a demanding and necessary business calling for time, money, imagination, tenacity and skill." (19) Attempting to cut budgetary corners in this area may prove effective initially. In the long run, however, this practice could result in the failure of the entire program. As all health planners know, resources are scarce. Thus, in order to obtain necessary funds, administrators must have good evidence to present to the funding source that their pro- posal or program will be or is worthwhile. Hilleboe and Schaffer point out, "The health, nutri- tion administrator who uses evaluation as an integral part of the processes of planning and the solving of problems has the best chance of changing tradition, of influencing public opinion, and of persuading political leaders to increase resources to meet health needs." The evaluation component will generate this evidence if it is properly administered. (20) There are two approaches to evaluation. Surveys must be used which yield cross-sectional information or surveillance may be adopted which generates data on an ongoing basis. Surveys are the more traditional method and, because of their short duration, appear to be less costly. This last point is erroneous when one considers the long-term costs. In order to obtain data even resembling that generated by surveillance, numerous periodic surveys would be necessary. The repeated start-up expenses of these surveys would cost more than a continuously functioning system. As pointed out earlier, a good surveillance system not only gathers and analyzes data, but it also quickly presents the data to those tho make the administrative decisions which will affect the health and nutrition of the community. Thus, if a problem arises, it can be quickly corrected before time, energy, and money are misused. Administrators will derive the maximum benefits from an evaluation component if they view evaluation as a dynamic process beginning at the inception of a program and continuing throughout it. Very few of the studies presented utilized a surveillance type evaluation component. 17. Hiemstra SJ: Evaluation of USDA food programs. JADA 60:193-196, 1972 [227]. 18. Guthrie HA, Owen GM, Guthrie GM: Factor analysis of nutritional status data on pre- school children. Am J Clin Nutr 26:497-502, 1973. 19. Weiss, CH: Evaluation Research. Prentice Hall (Method of Social Sciences Series), 1972. 20. Hilleboe HE, Schaefer M: Papers and Bibliography on Community Health Planning. Albany Graduate School of Public Affairs, State University of New York, 1967. 64The literature contains several methods for determining program effectiveness. Most are concerned with program outcomes. Measuring how well a program's stated objectives were met was the most common approach. While this is vital information, it is incomplete. The point was made in the introduction to this section that researchers and administrators must work together when planning services. Information on objective attainment may satisfy scientists but, the costs of obtaining the results concerns health planners, and rightly so. Considerable effort has been focused on this issue by Dahl (21), Stason and Weinstein (22), Amadio, (23) and others. They have proposed the techniques of cost-benefit or cost-effectiveness analysis. Presently, cost-benefit or cost-effectiveness analyses appear to be the most promising approaches to bridge the gap. Unfortunately, the techniques have not been utilized to their full advantage. They have the potential for generating valuable data for health planners who must prioritize their alternatives. Using these techniques, costs of adopting one approach or another are determined and based on a comparison of the relative costs and other relevant variables, then a decision as to which should be implemented is made. The most significant drawback to this method is the lack of consensus among researchers on the value of the numerous variables involved in any pro- gram. This is particularly true for intangible factors such as the participant's peace of mind. This lack of agreement on terminology is not limited to cost-effectiveness schemes. The problem was repeatedly discussed in the literature. The consequences of this lack of clarity can be considerable. For example, in the study by Emmons et al on school feeding programs, criteria to be used in determining participant eligibility would be radically altered by whether the stated objective of the program was to spare the financial resources of families of low in- come or to supplement the diet of those found nutritionally needy. (24) The problem is magnified when one considers programs with an international orientation. One interesting approach to this issue was presented by Longhurst and Call. (25) They reported on an application to the "Delphi" technique. This is a system designed to open the communications channels between experts in a given area. It promotes discussion of controversial issues in an attempt to derive some consensus on the particular matter. In addition to the general lack of data on program effectiveness, there is a total absence of replicative studies. Most grants and contracts have been for isolated studies, rather than evaluative research in which the same intervention or action is retested in different settings or with carefully controlled variations. Finally, many authors pointed out the need for all parties concerned to be open to new methods and attitudes on the topic of program evaluation. It is only through the free flow of ideas that progress can be made in improving the quality of the techniques used in program eval- uation and the frequency of their application. Delivery of the highest quality health care is dependent on progress in this area. 21. Dahl T: The Nutritional Functional Area in Comprehensive Health Care Delivery Per- formance and Cost. Presented at the American Dietetic Association Workshop on Health Mainten- ance Organizations, The Mayflower Hotel, Washington DC, June 23, 1972 [229]. 22. Stason WB, Weinstein MC: Public Health Rounds at the Harvard School of Public Health: allocation of resources to manage hypertension. N Engl J Med 296:732-739, 1977 [196]. 23. Amadio J, Mueller J, Casey R: Benefit/Cost Ratios on Public Health. Springfield, 111, Illinois Dept of Pub Health, 1976 [199]. 24. Emmons L, Haye M, Call DL: A study of school feeding programs. JADA 61:262-268, 1972 [230]. 25. Longhurst RW, Call DL: Scientific consensus, nutrition programs and economic planning. Am J Clin Nutr 28:1177-1182, 1975 [215]. 65 VdPART II LITERATURE REVIEWS 67CHAPTER I. IDENTIFICATION OF NUTRITION PROBLEMS NUTRITION AND THE LIFE CYCLE Nutrition Status of Infants and Children 5 Cunningham GC, Hawes WE, Madore C, et al: Intrauterine Growth and Neonatal Risk in California. Sac amento, Calif, Department of Health, State of California, 1976 Geographical Area California, HEW Region IX. Study Design This report contains standards for evaluating intrauterine growth and neonatal risk in California. The standards are based on vital statistics data of 1,424,637 single and 29,837 multiple births. Significant Findings Twenty-four graphs estimate intrauterine growth curves and neonatal risk according to race, sex and plurality. Evaluation This report represents an important undertaking stemming from a desire to develop standards that were more appropriate for California than the Denver growth curves. It is also important in that it demonstrates differences in male, female and ethnic group neonatal loss patterns. Applicability to Planning Agencies The new National Center for Health Statistics growth grids represent an improvement over the older grids that were used formerly. While it is not feasible for all states to develop their own standards, it is possible to develop future standards that could be used all across the country. However, in order for these standards to be applicable, separate curves should be considered for different ethnic groups which consider parent size. 6 Fomon SJ: What are infants fed in the United States? Pediatrics 56:350-354, 1975 Geographic Area National Implications. Study Design This article presents information about the kinds and amounts of foods that are fed to infants in the U.S. Note: Reviews 1 through 4 appear in Part I of this document. 68Significant Findings Total Calorie Intake and Calories from Milk or Formula A chart shows the amount of milk or formula that male infants consume and the percent con- tribution of milk and formula to total caloric intake. Most infants in the U.S. consume solid foods in addition to milk or formula by age six weeks. Feeding of Various Types of Milk and Formula At most, 20% of U.S. infants less than one month old are breast fed. Commercially prepared formulas are the predominant sources of formula during an infant's first few months of life. As the infant gets older, fluid milk increasingly replaces formula. Commercially Prepared Formulas Similac, Enfamil, and SMA are the main formulas fed to infants. Their compositions are similar with respect to calorie, protein, fat and carbohydrate content. Isomil, ProSobee, Neo-Mull-Soy, and Soyalac are milk-free formulas. The composition of these formulas varies according to product. Little information is available on the amount of table food consumed by infants, although it probably is a minor source of calories. Also, it is not known how much commercial strained and junior foods are sold for specific age groups. By 9 to 12 months, table food probably provides two-thirds of an infant's calories. Evaluation Further research should be conducted to determine the caloric contribution of solid food to infant diets, information about the caloric contribution of commercial strained and junior food versus table food, and age-specific data on the calories provided by strained and junior food. Applicability to Planning Agencies It is important to know the kinds and amounts of formula and food that are fed to infants for determining national trends. This information is important to the nutrition professional in order to determine the types and amounts of foods consumed by infants in this country. These data can assist the planner in developing sound programs and setting priorities for infant nutrition needs. 7 Maternal and Child Health Service: Nutrition and Feeding of Infants and Children under Three in Group Day Care. Washington, DC, Govt Ptg Off, 1971 Geographical Area National Implications. Study Design This booklet is designed to assist day care centers in providing appropriate foods and a proper environment for serving food to preschool children. Significant Findings Information is provided on the frequency of meal provisions in day care centers, breast feeding and formula feeding, vitamin and mineral needs, solid food feeding and methods of feeding these children. Attention is also given to food sanitation and preparation, equipment, nutrition education, record keeping, and community resources to use for consultation. Evaluation This booklet is useful for directors of day care centers and should be used in conjunction with federal and state standards and guidelines. 69Applicability to Planning Agencies Because a larger percentage of children each year spend many hours in day care centers and receive a significant portion of their daily food at these centers, it is important that these children receive adequate meals and snacks. Adequate funding and nutrition consultation must be provided to these centers to assist in providing foods that will optimize the health of these children. 8 Ho CH, Brown ML: Food intake of infants attending well-baby clinics in Honolulu. JADA 57:17-21, 1970 Geographical Area Honolulu, Hawaii, Region IX. Study Design Fifty-two infants, 3 weeks to 10 months of Only bottle-fed infants were included. Mothers consumed. The purpose of this study was to determine this low-income background and particular area. Significant Findings The sample was divided into three groups according to age: less than four months old; four to six months; greater than six months. Intakes were compared to amounts recommended in the 1968 Dietary Allowances and by the American Academy of Pediatrics. Most infants received sufficient calories, protein, calcium, Vitamin A, thiamine, and riboflavin. The average sodium intake increased two-fold after the first four months of life and was above requirements. Iron, niacin, and Vitamin D intakes were below recommended levels in many infants. Evaluation age from low-income families were studied, kept 3-day food records of the amount of formula the nutrient and food intakes of infants from Given the association of sodium with hypertension, and the high levels seen in the sample infants, the author recommends investigating the possibility of reducing sodium intake in in- fants. Also, many mothers were not giving the iron supplements that were supplied by the clinic to the infant. Applicability to Planning Agencies Because no clinical tests were undertaken, it is not possible to say whether those infants with nutrient intakes below recommended levels actually exhibited signs of nutrient deficiencies. Also, the availability of more iron-fortified formulas probably makes iron intake higher in most infants today. However, the possibility of reducing the future incidence of hypertension by preventing excessive sodium intake in infants may be an important preventive measure that merits con- sideration. Finally, children from low-income families are often at-risk nutritionally and special attention should be given to this group by local planners. GENERAL STUDIES ON CHILDREN 9 American Academy of Pediatrics: Standards of Child Health Care. Evanston, 111., American Academy of Pediatrics, 1977 Geographical Area National implications. Study Design This book is the most recent edition of the American Academy of Pediatric's guidelines for the delivery of quality medical care to children in sickness and in health. 70Significant Findings This book contains 9 chapters that cover the following topics: delivery of perinatal care; preventive child health care; care of the child during illness; equipment, procedures and office facilities needed; use of non-physician personnel; pediatric medical records; continuing eaucacion, peer review and recertification; community responsibilities of the pediatrician; and the etiquette and ethics of consultation and referral. Evaluation In most respects, this is a comprehensive book and covers several aspects of health care de- livery to children. However, it is marred by its most conspicuous omission of the role and importance of nutrition and health education in the provision of health care for this age group. No mention is made of the importance of nutrition counseling in prenatal care. No mention is made made of the importance of good nutrition in the achievement of optimal physical and mental develop- ment and in the prevention and control of anemia, obesity, poor growth, diabetes mellitus, and so on. Finally, no mention is made of the role of the nutritionist in the provision of health care. Applicability to Planning Agencies The failure to include nutrition and health education services in this document makes it an inadequate guideline for the comprehensive health care of children. 10 Fomon SJ: Nutritional Disorders of Children. Prevention, Screening, and Follow-up. Washington, D.C., Govt Ptg Off, 1976 Geographical Area Applicable to all areas. Study Design This book offers guidelines and standards for health care delivery organizations that screen and provide follow-up care to specific groups of children. Significant Findings The first part of this book deals with the screening process (assessment, interpretation, follow-up) for nutrition assessment, physical examinations, dental examinations, growth, skin- fold thickness, and laboratory findings. Information about the community, family, and the child is needed prior to screening. The second part of the book deals with the prevention of obesity, atherosclerosis, dental caries, and iron deficiency anemia—all critical problems found in America's children. The diseases are described and possible preventive actions are suggested. Evaluation This text is committed to the premise of preventive health care in children. Screening and follow-up activities are logical procedures for prevention of ill health in children. The four specific diseases described are key problems in today's children. Applicability to Planning Agencies This is an important document that should be used as a reference for all child health pro- grams. Health care providers and administrators should select topics from this book that are pertinent to their agencies and health problems in order to develop protocols for the provision of preventive health care services. 11 Owen GM: Assessment and recording of measurements of growth of children: report of a small conference. Pediatrics 51:461-466, 1973 Geographical Area National Implications. 71Study Design This paper presents information based on papers delivered at a conference of the American Academy of Pediatrics. It deals with how to conduct various anthropometric measurements and the use of these data in disease detection. Significant Findings Specific directions are given on how to determine weight, recumbent length, height, and head circumference in children. Because children from affluent backgrounds may be reaching maximum heights, the trends of decreasing physical activity and increasing caloric intake may lead to fatter children. The author recommends the use of skinfold calipers for determining body fatness and the development of skinfold standards. Some guidelines for interpreting abnormal growth patterns must be developed to assist in the screening function of growth data. Series of growth measurements on children provide useful information. Growth charts currently used do not tell what kinds of growth are abnormal. Evaluation The author makes an excellent point that current growth charts do not provide sufficient information to aid in the identification of abnormal growth patterns. New growth grids have been formulated by the National Center for Health Statistics and are an improvement over the older ones, although they do not allow for racial and ethnic variations. Applicability to Planning Agencies Norms that can assess the growth of children of all ages is an important tool that can be used by all local nutrition and health programs. Norms based on cross-sectional studies and on studies of specific racial and ethnic groups would be valuable for screening and for evaluating the effects of local intervention programs. 12 Owen GM, Lubin AH, Garry P, et aj.: Preschool children in the United States: who has iron deficiency? J Pediat 79:563-568, 1971 Geographical Area and Study Design National Implications: Cross-sectional sample of the preschool population in the U.S. used for the Pre-school Nutrition Survey (Owen, et al, 1974). This study focuses upon hemoglo- bin, hematocrit, and transferrin saturation data from the study and examines it according to age and socioeconomic status. Significant Findings The authors found a positive relationship between socioeconomic status, hemoglobin and plas- mas iron levels in the children. Using cut-off standards of hemoglobin of 10 mg/100 ml for children between 1 and 2 and 11 gm/100 ml for children ages 2 to 6, 5% of the sample children were anemic. Based on serum transferrin saturation below 15%, some 20 to 30% of preschoolers more than 2 years of age were judged to have iron deficiency. Those children with heights under the 25th percentile had lower transferrin saturation and hemoglobin levels than did children whose heights exceeded the 25th percentile. Iron deficiency in U.S. preschoolers is not un- common and may be associated with less than adequate growth. Evaluation Iron deficiency (with or without anemia) is still a common problem in children ages 1 through 6. Although it appears more commonly in children from low-income families, it occurs in children from all socioeconomic levels. Applicability to Planning Agencies The problem of iron deficiency is sufficiently common and widespread among infants and young children that this report has applicability to planners in any community. 7213 Fryer BA, Lamkin GH, Vivian VM, et al: Diets of preschool children in the North Central Region. JADA 59:228-232, 1971 Geographical Area HEW Regions V, VII and VIII. Twelve states in the North Central Region: Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin (V); Iowa, Kansas, Missouri and Nebraska (VII); North Dakota and South Dakota (VIII). Study Design 3,444 preschool children randomly selected from 2,000 households. Three-day food records of the children were analyzed for energy, protein, carbohydrate, and fat intake. Significant Findings Protein intakes of children increased until 18 months of age and then began decreasing; carbohydrate intakes rose until age 2 and then dropped, and fat consumption increased until 9 months and from 12 to 24 months. About two-thirds of the sample children consumed the RDA for calories and all consumed the recommended levels for protein. Boys did not consume more nu- trients than girls once controlled for body weight. No correlations of income and nutrient intake were found. Evaluation Basically a well-designed and controlled dietary survey. The rate of participation was relatively high: a good response rate. The objectives of the study as stated by the authors appear to have been achieved. Applicability to Planning Agencies It is valuable for a broad regional view of the dietary intake of preschool children in the North Central Region, but it cannot be extrapolated to a specific state. As with any dietary survey, care must be taken to avoid over-interpretation of data particularly with respect to individuals with low intakes. 14 Fox HM, Fryer BA, Lamkin G, et al: Diets of preschool children in the North Central region. JADA 59:233-237, 1971 Geographical Area Same 12 North Central states as noted in previous study. Study Design Same sample as in previous paper except here the authors examined the intake of calcium, phosphorous, and iron in these children. Data discount vitamin/mineral supplements because the nutrient contributions to their diets was minimal. Significant Findings Calcium intake in most of these children met the values recommended by the RDA although intake did decrease as children got older and consumed more solids and less milk. The amount of calcium consumed was related to the amount of money the family spent on food but was not related to family income or the mother's education level. Most phosphorus intakes met RDA values. The majority of children in this study did not have iron intakes that met the 1968 RDA. Evaluation This is a good article that shows changes in intake of calcium, phosphorus, and iron as preschool children grow older and relates it to the changes in the kinds of food they eat. This article was written at a time when little information on the nutrient requirements and intakes of preschoolers was available. 73Applicability to Planning Agencies The finding of low iron intake in this sample has been found in many other studies of pre- school children. Although one cannot extend these findings to more specific groups, investiga- tions need to be made in smaller areas to determine, by location, areas of low iron intake and iron deficiency anemia. 15 Fryer BA, Lamkin GH, Vivian VM, et al: Growth of preschool children in the North Central region. JADA 60:30-37, 1972 Study Design The 12 states reported in two previous studies and the sample preschool sample were used. This study examined the height and weight of these children compared to the norms used in 1972 and these measures, in turn, were compared to the children's nutrient intake and family income. Significant Findings Both boys and girls in this sample had rapid increases in growth during the first year and slowed up to the sixth year. Compared to a variety of growth standards, these children appeared to be normal for growth. As weight, height, weight/height and age increased so did the intakes of calories, protein, fat, carbohydrate, calcium, phosphorus, iron and niacin equivalents. All growth measures were significantly related to family income. Evaluation This is a good article on growth that logically follows the two previous studies on dietary intakes. Appropriate and useful measurements of growth are made. Also based on these findings, most children in the North Central region are achieving their growth potential. Applicability to Planning Agencies Studies such as these make excellent use of the growth standards that are available. That is, they are used to evaluate the growth status of groups of children. 16 Owen GM, Nelson CE, Garry PJ: Nutritional status of preschool children: hemoglobin, hemato- crit, and plasma iron values. J Pediat 76:761-763, 1970 Geographical Area National Implications. Study Design A cross-sectional sample of 725 preschool children, ages 1-6, was conducted Arizona, California, Colorado, Illinois, Indiana, Louisiana, Michigan, Missouri, Ohio, Oklahoma, Tennessee, Texas, and Utah. Significant Findings According to hemoglobin and iron-binding capacity standards, 6 to 8% of the designated as anemic and about 45% had unacceptable plasma iron levels. The percentage of children from low-income families having unsatisfactory plasma iron levels was greater than among children from higher income families. Evaluation for Arkansas, Pennsylvania, children were This study is one of the earlier ones that examines the iron status of preschoolers from an unbiased population sample. 74Applicability to Planning Agencies Iron deficiency and iron deficiency anemia are common health problems in preschool children. While it is not necessarily income related, planners should be aware that it is more prevalent in children from low-income families. BLACK CHILDREN 17 Owen GM, Yanochik-Owen A: Should there be a different definition of anemia in Black and white children? Am J Pub Health 67:865-866, 1977 Geographical Area National Implications. Study Design Most of the authors' comments were based on data from the Pre-school Nutrition Survey. The authors compared hemoglobin, serum iron, total iron-binding capacity, and transferrin saturation values of 1,755 white children, ages 1 to 6, to 266 Black children of similar ages. Significant Findings In the survey, Black children had slightly lower hemoglobin values than their white counter- parts, after controlling for age and socioeconomic status. A probability plotting of hemoglobin values of children with normal transferrin saturation showed that at the 50th percentile, hemo- globin values for Black children are 0.5 gm/dl lower than white children. Evalution The authors have observed that there is a difference in hemoglobin values between normal Black and white children. The authors plotted data on children with normal transferrin and hemo- globin values. It would be appropriate to look at children with anemia to determine if Black- white differences exist. Applicability to Planning Agencies As the authors conclude, separate norms on iron status should be developed for Black and white children. If Black children are found to have lower hemoglobin values for anemia than white children, such data could be useful for local nutrition programs. It would increase cost-effectiveness by including only those children who truly require iron enrichment of their diet, thus meeting the needs of more high-risk children. 18 Gam SM, Clark DC: Problems in the nutritional assessment of Black individuals. Am J Pub Health 66:262-267, 1976 Geographical Area National implications. Study Design Using data from the Pre-school Nutrition Survey, Ten-State Nutrition Survey, HANES, and the National Collaborative and Kaiser-Permanente Surveys, differences in growth, skeletal maturation, and hemoglobin levels between Black and white children are examined. Significant Findings Black infants are smaller than white infants at birth, even after adjusting for income and gestation. However, after the second year, Black children are taller than their white counter- parts. These differences disappear in adulthood. Bone ossification and dental eruptions occur 75earlier in Black children, and their skeletal masses are denser throughout life. Finally, hemo- globin levels of Black people of all ages are consistently lower than those in white people. Evaluation Differences in growth patterns and hemoglobin values between Black and white children are important for public health workers. However, the data on bone ossification and mineralization are more useful for the health worker dealing with curative rather than preventive medicine. Applicability to Planning Agencies According to the authors, separate growth and hemoglobin standards for Black and white children may be appropriate. Such standards would more accurately detect Black infants and child- ren who are truly at-risk for growth and low iron status. 19 Owen GM, Lubin AH: Anthropometric difference between Black and white preschool children. Am J Dis Child 126:168-169, 1973 Geographical Area and Study Design This article is based on the data obtained in the Pre-school Nutrition Survey (Owen, et al, 1974). The authors attempted to determine the nature of the anthropometric differences between Black and white children based on height, weight, and lateral thoracic skinfold thickness measurements. The study included 271 Black and 1,524 white children. Family occupation, source of family income, and dwelling type and area were used to determine socioeconomic status. Significant Findings Black children were taller, weighed more and had less subcutaneous fat than white children. These differences were magnified when Black and white children of comparable socioeconomic status were compared. Because these differences, on an individual basis are not great, the authors conclude that there is no need for race-specific growth standards in clinical practice. However, such standards could be useful in trying to use these parameters in measuring the nutriton status of groups of children. Evaluation This work agrees with others who have found Black-white differences in height, weight, and fatfold measurements. Applicability to Planning Agencies Race-specific growth charts would be beneficial to all programs providing health care to children. However, it is unlikely that such growth charts will be developed in the forseeable future because it is impractical. At the present time, it is most important that health planners using growth data, height and weight, be cognizant of the Black-white difference. This difference must be considered when height of Black children is evaluated using commonly avail- able growth charts (Stuart, Meredith or NCHS) which are largely based on white children. 20 Futrell MF, Kilgore LT, Windham F: Nutritional status of Negro preschool children in Mississippi. JADA 59:224-227, 1971 Geographical Area Oktibbeha County, Mississippi, HEW Region IV. Study Design This paper examined the nutrient intake of 139 Black preschool children in Mississippi in relation to maternal education level. Intakes were obtained from a three-day recall and a four- day food record. 76Significant Findings Iron intake, followed by low hemoglobin levels, was extremely low in all children except those whose mothers had a college education. A positive correlation was found between maternal educational attainment and calcium, caloric, and ascorbic acid intakes in the children. Those children with low hydroxyproline indexes (indicates caloric and/or protein deficiency) had mothers with less than a fifth grade education. Evaluation This study indicates the importance of the mother's educational level in predicting the child's nutriton status. However, this paper does not examine other important variables such as income level or the presence of one or two parents. Applicability to Planning Agencies Maternal education level may be used as a risk factor for determining which children may be potentially at nutrition risk. DISADVANTAGED CHILDREN 21 Cook RR, Davis SB, Radke FH, et al: Nutritional status of Head Start and nursery school children. JADA 68:120-126, 1976 Geographical Area Maine, HEW Region I. Study Design Eighteen children participating in Head Start who came from families receiving USDA commodi- ties were compared to 17 middle-income children attending nursery school. Three-day dietary records and anthropometric measurements were taken from each group prior to and after their respective programs. Also, pre- and post-program, three-day food records were given to the mothers to determine the effects of Head Start education on mother's meal preparations. Significant Findings Although Head Start children consumed smaller amounts of nutrients than the nursery school children, the former consumed significantly less calcium and ascorbic acid in the fall, but only less ascorbic acid in the spring. Both groups had low iron intake. More nursery school children received vitamin and mineral supplements than Head Start children. Height, weight, head circumference, chest circumference, mid-arm circumference, and triceps skinfold measure- ments were comparable between the two age groups and fell within normal values. Nursery school mothers in the fall session consumed significantly more calories, calcium, phosphorus and as- corbic acid than Head Start mothers. However, in the spring, the difference was significant only for ascorbic acid. Head Start mothers' diets contained less than two-thirds of the RDA for calcium, iron, Vitamin A, ascorbic acid, riboflavin, and thiamine. Head Start improved the diet of those children regularly attending but had not changed the meals at home. Evaluation The meal provision component of the Head Start program improved the diet of these children in Maine. Had the sample size been larger, perhaps more significant differences in nutrient intake prior to the program would have been found. The observation that the diet of the children returned to the lower levels after completion of the Head Start program is a source of concern. Applicability to Planning Agencies Provision of meals alone is not sufficient to ensure continued improvement in the diet of children, or for that matter, of all age groups. Nutrition education on a continuous basis must be provided to ensure the success of such programs. 7722 Driskell JA, Price CS: Nutritional status of preschoolers from low-income Alabama families. JADA 65:280-284, 1974 Geographical Area Montgomery, Alabama, HEW Region IV. Study Design This study examined the nutrition status of 40 preschool-age children from low-income families attending the city-county clinic in Montgomery. The majority of the children were Black and most came from families receiving food stamps. Heights, weights, hemoglobins and hematocrits were taken and dietary information was obtained from 24-hour recalls. Results were compared to data obtained from the Pre-School Nutrition Survey (Owen, 1974). Significant Findings Ten percent of these children fell below the 10th percentile for height and weight. Heights and weights did not vary according to race, sex, or Food Stamp participation. Thirteen percent of the children had subnormal hemoglobin concentration and 34 percent had subnormal hematocrits. This occurrence did not vary according to sex, age, race, or Food Stamp participation. Calcium and iron intakes were low. The white children consumed significantly more calcium and less Vita- min A than the Black children although this may not be a true finding of the small (3) number of white children involved. The authors concluded that the results from this study parallel results obtained from the Owen Pre-school Nutrition Survey. Evaluation It is difficult to compare the results of a statistical study with a small sample size to results of larger national cross-sectional studies. However, it is always important to receive information on the nutrition status of a specific local population. Applicability to Planning Agencies Iron status, growth, and various nutrient intakes are adversely affected by low income. 23 Sanstead HH, Carter JP, House FR, et al: Nutritional deficiencies in disadvantaged preschool children. Am J Dis Child 121:455-463, 1971 Geographical Area Nashville, Tennessee, HEW Region IV. Study Design This study investigated the relationship between nutrition status and results on Stanford- Binet tests of intelligence in children form disadvantaged homes. One hundred preschool children from Nashville were examined for height, weight, head and chest circumference, and fatfold thick- ness. Complete blood analyses were performed. Dietary information based on a modified 24-hour recall and diet histories were obtained for only 29 children. Significant Findings Vitamin D, ascorbic acid, thiamine, niacin, pyridoxine and folic acid fell below the RDA values for this age group. Serum values of these nutrients reflected intakes lower than those reported by mothers. Many of the children displayed physical signs of malnutrition. A correla- tion was found only between I.Q. and thiamine pyrophosphate. No correlation was found between measurements and I.Q. Positive correlations were found for height and Vitamin A, height and iron, head circumference and iron, head:chest ratio and transketolase, head circumference and TPP. The lack of correlation between nutrition status and I.Q. was expected because of greater impact of early-life events on the development of intelligence. 78Rvaluation The authors attempted to correlate the indexes of nutrition status on I.Q. Their nutrient intake data were not complete due to difficulty in gathering this information and the limited utility of the intake data received. Data were reported on only 26% of the children. Integra- tion of the anthropometic findings, particularly skinfold thickness and height, is handicapped somewhat because of the investigator's selection of inappropriate reference data. Applicability to Planning Agencies This investigation is of limited value to the planner today because of faulty design, impro- per methods and interpretation. Investigations of this nature are difficult to obtain under ideal circumstances. 24 Patterson L: Dietary intake and physical development Of Phoenix area children. JADA 59:106-110, 1971 Geographical Area Phoenix, Arizona, HEW Region IX. Study Design This study investigated the effect of socioeconomic status on the food habits and growth in a random sample of 92 fourth, fifth, and sixth graders from three schools in Arizona. Two of the schools contained children from lower socioeconomic backgrounds and the other school con- tained children from a higher socioeconomic background. Significant Findings Many children from the lower socioeconomic status schools had intakes less than two-thirds the 1968 RDA for ascorbic acid, iron, Vitamin A, calcium and thiamine. Fewer children from the higher socioeconomic status school had intakes of these nutrients that were less than two-thirds the RDA with the exception of iron which reached 49.0%. Children from the former group were shorter and thinner than the children from the latter group. No growth difference was found between the Mexican-American and Caucasian children. The children from more affluent backgrounds were more likely to express a dislike for school lunches. Between-meal snacks provided a con- siderable caloric contribution to children from both groups. Most children were able to select foods which should be eaten every day from a list. Evaluation This is an interesting study because it examines not only the nutrient intake of the child- ren but also some of their ideas on food and nutrition. Despite socioeconomic status, there are common nutrition deficiencies, patterns of snacking, and knowledge of foods to eat to remain healthy. Applicability to Planning Agencies It is especially noteworthy that the children from the higher socioeconomic status group had similar deficiencies in nutrient intakes as the lower socioeconomic group. Nutrition problems may occur in people from affluent backgrounds as well as in people of lower socioeconomic status. 25 Brown ML, Smith DS, Mertz JL, et al: Diet and nutrition of preschool children in Honolulu. JADA 57:22-28, 1970 Geographical Area Honolulu, Hawaii, HEW Region IX. 79Study Design This study investigated the effect of income on the nutrient intake and nutrition status of children from low-income families. The study included 281 children, ages 2 and 3, and children from low- and moderate-income families were compared. Three-day food records, a physical exami- nation, and blood and urine samples were obtained and evaluated. Significant Findings Nutrient Intake Children of middle-income families had significantly higher intakes of calcium, riboflavin, ascorbic acid, and Vitamin A than children from low-income families. Also, two-year old children from the higher level income families had significantly higher caloric intake than their lower income counterparts. Nutrient Supplements Vitamin supplements were used by 34% of the low-income children and 77% of the higher-income children. Although the diets of the lower-income children taking supplements did not improve sig- nificantly, there was a trend for those diets to more closely approach two-thirds of the RDA. Medical History and Clinical Examination Children from low-income families had higher occurrences of childhood diseases, diarrhea, ear infections and hospitalization rates than children from middle-income families. Height and Weight No significant difference was found between the two groups. Biochemical Evaluation There were no significant correlations between nutrient intakes and blood and urine analysis. Evaluation The lower intake of calcium, riboflavin, ascorbic acid, and Vitamin A of low-income children may mean that there is a greater possibility for these lowered intakes to occur at lower income levels. Applicability to Planning Agencies Income may be an important factor affecting nutrition status of children. Therefore, plan- ners should be especially concerned with children from low-income families as high-risk areas for nutrition services. 26 Burroughs AL, Huenemann RL: Iron deficiency in rural infants and children. JADA 57:122-128, 1970 Geographical Area Conchella Valley, Southern California, HEW Region IX. Study Design A group of 168 children ages 6 months to nine years from low-income, rural families were studied. This study examined the occurrence of iron deficiency anemia as measured by biochemical measurements and dietary intakes. Other factors such as feeding practices, parity, age, and pica are examined for their effects on the iron status of these children. 80Significant Findings The majority of the infants and children were not receiving the recommended dietary allow- ances for iron; the infants had the lowest intakes. Fifty-two percent had subnormal hemoglobins and 88% had subnormal serum iron levels but normal iron-binding capacity, indicating iron de- ficiency but not necessarily iron deficiency anemia. No consistent correlation between blood variables and milk intake was found. Fourteen percent consumed less than 80% of their caloric allowances, whereas 11% consumed more than 120% of such allowances. Compared to the Stuart- Meredith growth grids, the boys had higher percentiles for weight than height while the girls were in low percentiles for both height and weight. Children consuming less than 80% of their calor- ies were underweight. No significant correlations were found between intake of protein, carbo- hydrate, phosphorus, ascorbic acid, Vitamin A, thiamine, riboflavin and niacin with the various blood indicators of iron status. Evaluation This study does an excellent job of investigating the association between nutrient intake and iron status. Applicability to Planning Agencies Infants and children from low-income and rural backgrounds across the country may not be receiving sufficient iron and total calories in their diets. This could not only affect iron status but it could also impair physical and, in the extreme, mental development. If such popu- lations exist in HSA areas, planners must be aware of the special needs of these children. MIGRANT CHILDREN 27 Chase HP, Kumar V, Dodds JM, et al: Nutritional status of preschool Mexican-American migrant farm children. Am J Dis Child 122:316-324, 1971 Geographical Area Northeastern and southeastern Colorado, HEW Region VIII. Study Design This study investigated the nutrition status of 300 Mexican-American migrant farm children ages 6 and below. Children were given medical histories and physical examinations and were measured for height, weight, and fatfolds. No dietary intake information was obtained. Significant Findings Mothers of these children had several pregnancies with a high rat« of pregnancy wastage and neonatal mortality. One-half of the children did not receive immunizations. A large percentage of the children exhibited inadequate heights, weights, and head circumierences, as well as clinical signs of nutrient deficiencies. Almost half had subnormal hemoglobins and hematocrits. Below normal values for other nutrients were as follows: serum folacin - 29 children; serum Vitamin A - 159 children. Positive correlations were found between vitamin supplementation dur- ing pregnancy and Vitamin A levels in children, total serum protein values in children and addi- tional parental employment beyond migrant labor, and serum Vitamin A values and the appearance of clinical manifestations of Vitamin A deficiency. Evaluation This excellent study demonstrates a wide variety of social and economic factors that adversely affect the health of Mexican-American migrant children. 81Applicability to Planning Agencies This study dramatically demonstrates the poor nutrition status of Mexican-American migrant children, especially with regard to Vitamin A status. For those areas with migrant populations, special attention such as the provision of food and nutrition education must be provided as a means of improving the health of these children. NATIVE AMERICAN CHILDREN 28 Horner MR, Olson CM, Pringle DJ: Nutritional status of Chippewa Head Start children in Wisconsin. Am J Pub Health 67:185-186, 1977 Geographical Area Northern Wisconsin, HEW Region V. Study Design Sixty-seven Chippewa children of low-income families attending Head Start programs were examined. Determination of nutriton status was based on health, biochemical, anthropometric, dietary, and clinical assessments. Significant Findings Most children had normal heights for their age. Twenty-eight percent were overweight and 25% had subnormal hemoglobin values. Iron was low, about 80% of the RDA. Infections were common but no clinical signs of malnutrition were found. Evaluation This paper provides a concise explanation of the nutrition status of Chippewa children in northern Wisconsin. Applicability to Planning Agencies Given that obesity and diabetes are common problems in Native Americans, preventive measures should be initiated in early childhood. Those children identified as overweight by this study should be the target of nutrition intervention programs so that attempts can be made to combat future occurrences of these diseases. 29 Van Duzen J, Carter JP, Vander Zwagg R: Protein and calorie malnutrition among preschool Navajo Indian children. Am J Clin Nutr 29:657-662, 1976 Geographical Area Tuba City, Arizona, HEW Region IX. Study Design A previous survey revealed the existence of protein and calorie malnutrition among Navajo preschool children. Since that time numerous food sources have been made available. However, changes in eligibility requirements and the almost continuous shifting of programs has resulted in various quantities and types of food being available at different times. The objective of this study was to assess the effect of supplemental foods on children. The procedure used was a comparison of all Navajo preschool children admitted to Tuba City Hospital in Arizona with malnutrition, marasmus, and kwashiorkor from 1969 to 1973 to a similar sample from 1963 to 1967. The heights and weights of Navajo Head Start children were recorded and plotted from all over the reservation during September 1973 and compared to the data pre- viously collected. The data were collected from 84 schools on 1,462 children from 36 to 71 months of age. 82Significant Findings The total number of admissions in the 1969 to 1973 period dropped 18%. The number of child- ren with a diagnosis of malnutrition dropped from a yearly average of 123 to 75.4. Marasmus prac- tically disappeared. The clinical diagnosis was made only four times between 1970 and 1973. Kwashiorkor dropped by 50% from a yearly average of 3 to 1.6. The biggest drop occurred in the last four years. Height-weight data demonstrated that the incidence of malnutriton has dropped. In 1967 the height data showed 30% of the boys and girls were below the third percentile of the Boston Growth Curve. In 1973 the figures were 11% and 16%, respectively. In 1967, 8% of the girls and 9% of the boys were below the third percentile for weight and in 1973 the figures for both sexes was 6%. Evaluation The nutrition problems of this population are well documented. The dramatic improvement in the area of malnutrition must be attributed largely to the introduction of the different food programs. Other factors such as improved sanitation also are significant but do not explain all of the results. This study clearly demonstrates the value of such food programs. The statistical analysis of this study seems quite good except for one shortcoming. The applicability of the Boston Growth Curve to the Navajo children may not be valid. While the comparative evaluation is sound, judging health status on absolute values is questionable. Different groups of people present varying relative body proportions; thus height and weight comparisons across ethnic, religious or race lines are not recommended. While this study is valuable and significant, the use of the presence or absence of disease may not be the best indication of nutriton status. Further studies evaluating dietary habits, clinical data and biochemical indices would present a more complete picture of the nutrition status of these children. It would also be useful to attempt to evaluate the significance of the different programs which were present. Applicability to Planning Agencies The present study clearly demonstrates the value of supplemental food programs. In popula- tions where several socioeconomic factors combine to the disadvantage of the population, severe nutrition inadequacies can result. This can be avoided or minimized by the implementation of supplemental feeding programs. The savings in reduced incidence of disease can outweigh the costs of implementing the programs. 30 Nobmann ED: Iron Deficiency Anemia in Alaskan Natives: Summary of Studies 1971-1976. Anchorage, Alaska Area Native Health Service, 1976 Geographical Area Alaska, HEW Region X. Study Design This paper reviews the iron status of Alaskan Natives based on several studies. Significant Findings Alaskan Native children have a higher incidence of low hemoglobin than other preschool children in the U.S. This situation has existed for 23 years. In a study of 2,234 Alaskan Native children, the highest rate of low hemoglobin or hematocrit occurred in those 16 and over (21%) and those less than 6 (19%). In children under age 1, 35% had low hemoglobin. Evaluation This document provides an excellent data base for planning intervention programs that would reduce the high incidence of poor iron status and anemia. 83Applicability to Planning Agencies HSA's in Region X will find this paper most helpful in locating these iron-deficient indi- viduals. Given that this problem has remained constant for over 20 years and that anemia in a severe form can cause poor growth and development and susceptibility to infections, planning and assistance should be given to health centers attempting to remedy this problem. 31 Wallace HM: The health of American Indian children. Am J Dis Child 125:449-454, 1973 Geographical Area National implications. Study Design This paper reviews the health problems common to Native Americans and Alaskan Natives. Significant Findings Infant, neonatal, and post-neonatal mortality are extremely high in American Indian and Alaskan Native populations. Childhood mortality is three times as high in these groups com- pared to the U.S. as a whole and is mainly caused by infectious diseases and accidents. Prob- lems in small children include diarrhea, otitis media, marasmus and kwashiorkor. Older children suffer from tuberculosis, iron deficiency anemia, poor growth and mental health problems. Evaluation This article provides considerable insight into the health problems of Native Americans and Alaskan Natives. Problems such as infant and neonatal mortality, diarrhea, malnutrition, anemia, and inadequate growth all have nutrition components. Applicability to Planning Agencies Clearly the American Indians and Alaskan Natives have serious health problems. While nutri- tion care, food and education are imperative, equally imperative is the need for services that deal with the sources of these problems: poverty, loss of identity as a culture, and low level of education. Nutrition Status of Adolescents 32 Gaines EG, Daniel WA: Dietary iron intakes of adolescents. JADA 65:275-280, 1974 Geographical Area Jefferson County, Alabama, HEW Region IV. Study Design This study investigated the relationships between the intake of iron in 370 low-income ado- lescents ages 11 to 18 attending a Children and Youth Project in Alabama and their sex, race, sexual maturity (an index of growth), and age. Dietary intakes were based upon 24-hour recalls. Significant Findings Black and white boys and girls had similar intakes of iron at the onset of puberty. Intakes of iron increased for both Black and white males throughout puberty. The iron intake of white girls increased except at the end of adolescence. In Black girls, iron intake decreased to levels below those at puberty. Most of the adolescents consumed less than two-thirds the RDA for iron. The rate of sexual maturation is a better indicator of iron need than chronological age. 84Evaluation The authors have made an excellent point that iron needs for adolescents may vary according to their rate of maturation. This seems logical given that iron needs vary in other periods of growth and development. However, the results of this study would have been more informative had they included the results of the laboratory analysis, indicating whether or not these subjects were anemic. Applicability to Planning Agencies Because adolescence is a critical growth period and nutrition plays an important role in this priod, accurate means of assessing the nutrition status of adolescents must be obtained. 33 Huenemann RL, Hampton MC, Behnke AR, et al: Teenage Nutrition and Physique. Springfield, 111, Thomas, 1974 Geographical Area Berkeley, California, HEW Region IX. Study Design This book presents findings from the authors' four-year longitudinal, cross-sectional studies of body size, activity levels, food intakes, and prevalence of obesity in 1,000 teenagers from the Berkeley area. One-third were Black, one-tenth Oriental, and the remainder were white. Subjects attended grades 9 through 12 in the Berkeley school system. Significant Findings Ten to eighteen percent of the subjects were classified as obese. Skeletal growth occurred in both boys and girls. Differences in various anthropometric measurements occurred according to ethnic group. Obese boys were taller than non-obese boys in the ninth grade whereas leaner girls were taller than the other girls throughout high school. As determined from a series of 7-day dietary records, a large number of the subjects consumed less than two-thirds of the RDA for calcium and iron. Highest caloric and nutrient intakes according to sex occurred in average weight boys and lean girls. Obese individuals ate less frequently and skipped more meals. Snacking occurred often and supplemented the diet. Activity levels of both boys and girls were low. As a result, they found low correlations between caloric intake and amount of body fat, and inactivity with greater amounts of body fat. Obese boys and girls scored lower in physical activity tests and received lower grades in school than the other subjects. Both sexes ex- pressed dissatisfaction with their body conformation. Males wanted to gain weight or size through exercise and girls wanted to lose weight through diet. Caucasian girls perceived themselves as fatter than they really were. Ethnic differences were apparent in the areas of body conformation, selection of diet, and preferred physical activities. Evaluation This is an excellent comprehensive study of body size, activity, and body-image in teenagers. This book is unique in its focus. Applicability to Planning Agencies The prevention of obesity must begin with measures aimed at young people. Although no single plan for effecting weight loss is available, such a plan should include education, dietary restriction, physical activity, group support, and attempts to insure truer body images in people. Further, such a plan must be sensitive to generic, racial, and cultural differences. Prevention of obesity in the teen years or earlier can lead to the prevention of obesity and other chronic diseases that are secondary to obesity in later life. 1.5 8534 Faigel HC: Hematocrits in suburban adolescents. A search for anemia. Clin Pediat 12:494-496, 1973 Geographical Area Connecticut, HEW Region I. Study Design This study investigated the occurrence of anemia in 323 adolescents from high-income families from suburbs of Connecticut. Significant Findings Hematocrit levels in boys increased as adolescence progressed whereas they remained at the same levels throughout adolescence for girls. Girls who ate more regularly and consumed more meat had higher hematocrit levels. Maternal attitudes about nutrition, along with the habits of peers, influenced teenagers' intake more than nutrition classes in school. Teenagers with low hematocrit had mothers who knew the essentials of good nutriton but were afraid to assert this knowledge. Twelve percent of the girls and 5% of the boys had low hematocrit. Evaluation Anemia is mild And not very prevalent in teenagers of affluent families. Applicability to Planning Agencies Iron requirements are increased for adolescents because they are in a period of active growth. For adolescents with anemia, its cause is related to the kind of diet consumed. There- fore, nutrition education, as provided by the nutritionist, physician, or nurse, that is more interesting and persuasive to the teenager, and that will encourage mothers to utilize their nutrition knowledge, may provide the most effective means for treating anemia. 35 Huenemann RL: Food habits of obese and non-obese adolescents. Postgrad Med 51:99-105, 1972 Geographical Area National implications. Study Design This paper reviews the literature on the eating habits and activity levels of obese and non-obese teenagers. Significant Findings Teenagers have a wide variation in eating habits that cuts across sex, race, and socio- economic status. Many studies show that obese subjects eat fewer calories than non-obese sub- jects. Low activity levels appear common despite body-fat type. Teenagers in general receive many nutrients from snacks. Teenage girls tend to go on weight reduction diets more than teen- age boys. However, these diets are rarely successful. Evaluation Given the wide variation in eating habits of teenagers, researchers that attempt to charac- terize differences between obese and non-obese subjects may find their attempts frustrating. While these general studies may provide theories to explain adolescent obesity, they cannot replace the important information that is gained from individual assessments. 86Applicability to Planning Agencies Identification of adolescents who are obese is an important first step that must be taken at the local level. Given the association of obesity with major chronic diseases such as dia- betes and coronary artery disease, preventive action should be aimed at this primary cause. By taking action against obesity in adolescence, we may be able to reduce the future incidence of the complications of obesity. 36 Schorr BC, Sanjur D, Erickson EC: Teenage food habits. JADA 61:415-420, 1972 Geographical Area Western New York State, HEW Region II. Study Design This study examined the food habits of 118 students in grades 7 through 12 in a small village in New York State. The authors also tested the hypothesis that the complexity of the teen- agers’ diet habits correlates with the complexity of other life style variables, such as age and sex, family size, employment status, household head occupation, mother's educational level, social participation, and number of sources of nutrition information. Significant Findings Thirty-four foods were listed as "like most" by at least 10% of the respondents, none of which were good sources of Vitamin A. The male teenagers in the study had larger intakes of foods containing calcium, iron, ascorbic acid, and Vitamin A than the females. However, intakes of these nutrients fell below two-thirds RDA by 44%, 69%, 21%, and 51%, respectively. The teenager's diet became more diverse as the following variables increased: household head occupa- tion, mother's education and the teenager's social participation and employment status. The complexity did not increase according to age, sex, family size or number of nutrition information sources. As the complexity of the diet increased, so did the intake of calcium, iron, ascorbic acid, and Vitamin A. Evaluation Unfortunately, few studies in the 1970's examined the nutrition status of American teen- agers. However, indirectly this study found low consumptions of calcium, iron, ascorbic acid and Vitamin A. The diversity of a teenager's diet is associated with many life style variables. Applicability to Planning Agencies It is important to determine patterns of food consumption in teenagers as a means of iden- tifying possible habits that could result in some impairment to nutrition health in later years. By knowing possible problems, nutritionists will be able to intervene with nutrition education. 37 Huenemann RL: A review of teenage nutrition in the United States. Health Serv Rep 87:823- 829, 1972 Geographical Area National implications. Study Design This paper reviewed the literature conct..iing the nutrition status of teenagers in the U.S. Significant Findings Assessment of nutrition status has four components: anthropometric, biochemical, clinical, and dietary measurements. Major but not representative surveys of teenagers' nutrition status include the Ten-State Nutrition Survey and the 1965 Household Food Consumption Survey of the Department of Agriculture (HANES had not started as of the printing of this article). Reports 87from these and other small surveys show Inadequate Iron Intake for girls, low intakes of Vitamins A and C and calcium for boys and girls, adequate caloric and protein intakes and physical inactiv- ity. Other common nutrition problems in this age group include dental caries, diabetes, hyper- tension, and atherosclerosis. There are no good data on the nutrition status of all American teenagers and nutrition education must adapt teaching methods to changing life styles and eating habits. Evaluation This paper reviews most of the literature that has been written on the nutrition status of teenagers in America. Surprisingly, the bulk of these studies was conducted in the 1960's and few in the 1970's. Applicability to Planning Agencies There is a paucity of current information on the nutrition status of American teenagers. Because this age reflects the last major period of growth, nutrition plays an important role in achieving growth potential. Before nutrition intervention programs can be legislated, studies must be made that investigate their status of nutrition on national, regional, and local levels. Adolescent Pregnancy 38 Weigley ES: The pregnant adolescent. JADA 66:588-592, 1975 Geographical Area National implications. Study Design This paper reviews the literature on the nutrition status of pregnant adolescents and describes programs providing services for these women. Significant Findings Studies vary in these findings but many have found inadequate dietary and biochemical measures of calcium, iron, Vitamins A and C, pantothenic acid and folic acid in pregnant ado- lescents. Also, it was not uncommon for these women not to use prescribed vitamin/mineral supplements even though they were provided free of charge. A variety of multidisciplinary pro- grams are available for pregnant teenagers that continue their high school education and provide prenatal care and counseling. However, these programs need to be evaluated in order that more and better services are provided to these women. Evaluation This article provides a good summary of studies on the nutrition status of pregnant teen- agers. However, a broader look is needed at the effects of low socioeconomic status and the high-risk complications of teenage pregnancies. Further, no mention is made of the W.I.C. program as another means of providing nutrition care to the pregnant adolescent. Applicability to Planning Agencies Pregnancy in the adolescent years is a critical concern for health care providers. The young woman is still growing herself and yet needs to consume sufficient nutrients for herself and the growing fetus. Teenage pregnancy is a high-risk one that threatens the health of both the mother and the infant. The W.I.C. Program provides food and nutrition education for the high-risk pregnant woman and is beginning to improve maternal anemia and dietary intake, and birth weights of the subsequent infants. Although W.I.C. programs are growing in numbers and caseloads, there are still not enough clinics across the country to meet the demand and need. 8839 Marinoff SC, Schonholz DH: Adolescent pregnancy. Pediat Clin N Am 19:795-802, 1972 Geographical Area National implications. Study Design This article explains the components of an adolescent pregnancy that make it high-risk. Significant Findings Pre-eclampsia and eclampsia frequently occur in the pregnant adolescent due to inadequate prenatal care and low dietary intake of nutrients. Many teenagers fail to seek early prenatal care because they are afraid to admit they are pregnant or in order to exclude the possibility of abortion. Iron deficiency anemia is also commonly seen. Teenage mothers have higher inci- dences of delivering premature infants due to inadequate weight gain and insufficient nutrient intake. Some complications in delivery are possible. Health education is needed during the pregnancy in addition to regular schooling. Also each patient must be advised on contraceptive methods after delivery. Evaluation This article provides an excellent review of the complications in adolescent pregnancy. One omission is the failure of the authors to include a nutritionist/dietitian in the interdisciplin- ary health care team. Applicability to Planning Agencies Clearly adolescent pregnancy is a critical event which should concern health workers in the area of pregnancy. Facilities and programs are needed to reach these high-risk young women. Teams consisting of physicians, nurses, social workers, nutritionists, and psychologists are needed. AO Working Group on Nutrition and Pregnancy in Adolescence: Relation of nutrition to pregnancy in adolescence. Clin Obst Gynec 14:367-392, 1971 Geographical Area National implications. Study Design This article discussed the problems surrounding pregnancy and childbirth in adolescent girls. Significant Findings The number of infants born to teenage girls is increasing. The incidence of low birth weight, and neonatal and perinatal mortality is higher in pregnant teenagers. Because adoles- cents are still growing, the onset of pregnancy with its increased nutrient demands may adversely affect the girl's adult stature. Pregnancy adds to the many psychological hurdles present in the adolescent. Increased incidences of toxemia and iron deficiency anemia are commonly seen in pregnant teenagers. Because many adolescent girls have poor diets, the increased demands of pregnancy make the quality of their diets even poorer. The outcome of an adolescent pregnancy is highly dependent upon her nutrition status prior to pregnancy. Nutrition services and educa- tion must be provided for these young women. Also, prenatal care and counseling must be readily available. Finally, education must be provided to prevent repeated pregnancies. ■ Evaluation This paper presents a good summary of the problems surrounding adolescent pregnancy. 89Applicability to Planning Agencies The pregnant adolescent is a primary concern for the health care provider. Nutrition coun- seling is especially crucial, given past eating habits, failure to understand the impact of nutrition on the outcome of pregnancy, and the psychological burdens of the pregnancy. All teen- age mothers should receive nutrition counseling as part of their regular prenatal care. This counseling can be provided by a nutritionist, or a nurse or physician who is trained by a nutritionist. Mature Pregnancy 41 Pitkin RM: Nutritional influences during pregnancy. Med Clin N Am 61:3-15, 1977 Geographical Area General. Study Design This paper presents the most recent knowledge in the area of nutrition in pregnancy. Significant Findings Energy needs (in calories) are increased because of increased maternal metabolism and fetal growth. Pre-pregnancy weight and the rate of weight gain have the greatest effect on birth weight. High-risk pregnancies include those mothers who are underweight prior to pregnancy, have either too low or too high a rate of weight gain, and who are obese. Caloric restrictions in the obese pregnant woman may harm the fetus. Increased needs for protein, iron, folate, calcium and Vitamin D, and other vitamins and minerals also occur during pregnancy. Sodium restrictions and use of diuretics are harmful in that they could reduce uterine blood flow and cause complications in the newborn. Iron and perhaps folate are the only nutrients that cannot be obtained in sufficient amounts from the diet that meets pregnancy needs. Therefore, supple- mentation of these nutrients is needed. Evaluation This article provides an excellent explanation of the most current information on nutrient needs in pregnancy. Applicability to Planning Agencies Articles such as this one are important for physicians to read because they receive little training in nutrition and because maternal nutrition has the strongest impact on pregnancy out- come. Literature reviews supplemented by frequent contacts with nutritionists and/or dietitians can fill this gap in medical training. 42 Tokuhata GK, Colflesh VG, Smith MW, et al: Prenatal Care and Pregnancy Outcome. Harrisburg, Pa., Bureau of Health Research, Pennsylvania Department of Health, 1976 Geographical Area South Central Pennsylvania, HEW Region III. Study Design A cross-sectional sample of 6,504 pregnant women from south central Pennsylvania was selected. The purpose of this study was to determine the effect of prenatal care on pregnancy outcome. Care was examined according to provider characteristics, trimester of first medical visit, frequency of medical visits, average examination time and kinds of services rendered. 90Significant Findings Fetal and neonatal mortality as well as incidence of prematurity and immaturity was highest for those women attending the hospital clinics. Congenital anomalies occurred less in those treated by obstetricians and osteopaths and more in those treated by general practitioners or a medical center and hospital clinics. Occurrences of prematurity, immaturity, congenital anomalies and low Apgar score increased significantly the later prenatal care was initiated. Generally, the incidence of these four variables decreased when 11 to 13 medical visits were made. It appeared that prematurity, immaturity, congenital anomalies and low Apgar scores increased as average visit examination times increased. Hormones increased the risk of fetal mortality, hor- mones and tranquilizers increased the risk of prematurity, sleeping pills and iron supplements, increased the risk of congenital anomalies, and hormones, tranquilizers, iron supplements, anta- cids and vitamins were significantly related to low Apgar scores. Special procedures such as maternal blood transfusions, ultrasonography, and metabolic tests increased the occurrence of these problems. Women who received prenatal care instruction experienced lower incidences of prematurity and immaturity but higher incidences of congenital anomalies and low Apgar scores. Evaluation This study brings to light many interesting findings. As expected, prenatal care by ob- stetricians and the frequency of prenatal care has a positive effect on pregnancy outcomes. However, the increase in problems seen with lengthier examinations and prenatal health care in- struction seems unusual. Information about the mother's health condition and the quality of the instruction needs to be determined. Also, the kinds of pregnant patients visiting the medical center and hospital clinics must be examined. No consideration is made of the effects of maternal weight gain and the quality of diet on pregnancy outcome. Applicability to Planning Agencies Serious consideration should be given to the quality and quantity of prenatal care. It is important to reconsider the effects of the kind of provider, the methods of health instruc- tion, medications and special tests prescribed on pregnancy outcome. 43 Bowering J, Morrison MA, Lowenberg RL, et al: Role of EFNEP aides in improving diets of pregnant women. J Nutr Ed 8:111-117, 1976 Geographical Area Study conducted in East Harlem, New York City, HEW Region II. Study Design The purpose of this study was to compare dietary changes in low-income, minority women who received prenatal counseling in the clinic and home visits by an EFNEP aide with those who received only prenatal counseling in the clinic. 119 high-risk women attending a Maternal and Infant Care clinic in a Harlem hospital were examined. Three 24-hour recalls were obtained on the average: one at the first clinic visit, another during the third trimester and a final time after delivery. Significant Findings Both study and control groups increased their calcium intakes. The Puerto Ricans in the study group had the highest increase in calcium during pregnancy that persisted into the post- partum period. This same study sub-group consumed greater amounts of ascorbic acid. Only 60% of all the women consumed two-thirds of the RDA for Vitamins A and C. Post-partum 24-hour re- calls revealed that although intakes of nutrients decreased, they were higher than their intakes prior to nutrition counseling. Counseling by the nutritionist and visits by the EFNEP aides produced a greater impact on dietary intake at the second and postpartum visits. Evaluation This is one of the first studies to evaluate the effect of EFNEP aides on changing dietary habits. While recognizing the difficulty of such a task, more studies of this kind should be conducted to learn what aspect(s) of the aides' work affected the change(s) noted. 91Applicability to Planning Agencies This study brings up an important area, namely, the use of paraprofessionals in the delivery of nutrition services. Given the limited number of nutritionists in this country, parapro- fessionals, properly trained, are vital in providing nutrition care to groups of people. 44 Jacob M, Hunt IF, Dirige 0, et al: Biochemical assessment of the nutritional status of low- income pregnant women of Mexican descent. Am J Clin Nutr 29:650-656, 1976 Geographical Area Los Angeles County, California, HEW Region IX. Study Design The purpose of this study was to determine the effect of low income on pregnant women. This paper looks at hemoglobin, total protein, iron, Vitamin C, carotene and folic acid and Vitamin B-^ levels in the blood in these women in the first or second of pregnancy. Thiamine, riboflavin and pyridoxine adequacy also were examined. The studied 301 women attending two county health centers. Significant Findings Most women had normal blood levels of hemoglobin, total protein, iron, Vitamin C, Vitamin B^2> and pyridoxine. According to their blood assays, deficiency levels were detected for serum folic acid (70% of the women), riboflavin (30%), and thiamine (22%). However, these blood levels were not, in all cases, followed by a concomitant decrease in urinary excretion. Out of 216 women who received at least seven of these biochemical tests, 15% were deficient in three or more nutrients, usually in B-complex vitamins. Women taking vitamin supplements had significantly fewer incidences of folic acid deficiencies. Low dietary intakes of these nutrients, disregard- ing vitamin supplementation based on 24-hour recalls, were found but did not correlate with bio- chemical findings. Including the use of vitamin supplements showed better dietary intakes. Evaluation Mexican Vitamin A, trimester author It is always difficult to correlate biochemical findings with nutrition intakes. Although low intakes in the diets may be found, usually they are not reflected in biochemical measures because changes in the latter measures usually reflect prolonged dietary insufficiency. Earliest changes occur in serum folic acid levels but not necessarily in other measures such as red blood cell folates or change in red or white blood cell structure. Lowered folic acid levels are commonly seen in pregnancy but whether this truly reflects a deficiency state is unknown. 'Applicability to Planning Agencies Pregnancy is another period in the life cycle where nutrition plays a significant role. A mother's nutrition pattern not only affects her health but it also affects the growth and development of the fetus and the infant's birth weight. When pregnancy is coupled with low income, the pregnancy might be high-risk. Adequate prenatal care is essential for such women and must include nutrition counseling and education, food, appropriate vitamin and mineral supplements and follow-up. 45 Committee on Maternal Nutrition/Food and Nutrition Board. National Research Council, Maternal Nutrition and the Course of Pregnancy: Summary Report. U.S. Government Printing Office, Washington, DC 20402. Geographical Area National implications. 92Study Design This is a short summary booklet of the larger volume entitled Material Nutrition and the Course of Pregnancy highlighting the major areas of the original document. Significant Findings Despite the affluence of the U.S., infant mortality rates are unnecessarily high, thus prompting the writing of this book. Physiological adjustments to pregnancy made by the mother and complications such as anemia, toxemia, and adolescent pregnancies are discussed. Further, the booklet has a strong presentation on the effect of nutrition on pregnancy outcome. Nutrition management includes proper weight gain, adequate caloric intake (especially for those previously poorly nourished), use of vitamin/mineral supplements only when recommended, and no use of caloric and sodium restrictions or diuretics for preventing pre-eclampsia. Several recommendations are given; many deal with increasing the knowledge of health providers working in the realm of pregnancy. Evaluation Although this document was issued originally in 1970, it still provides excellent information on nutrition needs during pregnancy. Unfortunately, many of the Committee's recommendations and suggested areas for research have not been investigated. It is strongly recommended that health professionals familiarize themselves with the original document. Applicability to Planning Agencies Maternal health is still an important concern today. However, we no longer can look at just a woman's health status during pregnancy. Preventive care must be provided for those children at-risk whether it is because of mental or physical disorders, family income, education, or whatever. Thus, women, infants, and children are important targets for nutrition planning and nutrition programs. 46 Massachusetts Department of Public Health: Maternal nutrition—what price? N Engl J Med 292:308-309, 1975 Geographical Area Area surrounding Boston, Massachusetts, HEW Region I. Study Design This paper discussed the impact of nutrition on pregnancy outcome. Significant Findings A brief discussion is given of the effect of maternal socioeconomic status, race, and protein intake on infant birth weight, maturity, and neonatal deaths. Some programs, including W.I.C., provide food supplementation to women with high-risk pregnancies. However, in order to increase and expand such programs, evaluations of the cost-effectiveness must be made. Evaluation This brief article highlights the factors adversely affecting pregnancy outcome. Applicability to Planning Agencies , Evaluation of nutrition programs is an important and necessary task which is being done in varying degrees across the country. Evaluation must include the effect of the program on health outcome and also must examine the benefits produced according to the amount of time and labor invested by health personnel. 9347 Pitkin RM, Chesley LC, Chez RA, et al: Nutrition in Maternal Health Care. Chicago, American College of Obstetricians and Gynecologists, 1974 Geographical Area National implications. Study Design This pamphlet is designed for the physician and other health care providers who work with pregnant women. Significant Findings This booklet explains the importance of nutrition and its effect on the health of the infant and mother. Energy, protein, iron, folate and sodium intakes are discussed. The authors state the impact of preconceptual nutrition, and economic and social factors on pregnancy outcome. Factors causing high-risk pregnancies are related as well as the necessary components of nutri- tion care. A table of 1974 RDA values, standard weights and heights, and a prenatal weight gain guide are included. Evaluation This is an excellent document that can be used by physicians for increasing their awareness of nutrition needs during pregnancy. It is concise and well written and should be made avail- able to all obstetricians and gynecologists. However, more stress should be given to using well qualified nutritionists and dietitians for consultation purposes. Applicability to Planning Agencies One of many tasks of the nutritionist is that of training health professionals, especially physicians, in various areas of nutrition. Therefore, planning should include not only providing nutrition services to at-risk populations, but also training those health providers dealing with these at-risk groups. Because nutrition has a significant impact on pregnancy outcome, passing critical nutrition information from the provider to the pregnant woman may assist in reducing infant mortality and developmental problems. 48 Pitkin RM, Kaminetzky HA, Newton M, et al: Maternal nutrition: a selective review of clinical topics. J Obst Gynec 40:773-785, 1972 Geographical Area National implications. Study Design This paper presents information on the areas of vitamin/mineral supplementation, calorie intake, and sodium metabolism during pregnancy. Significant Findings Nutrient needs for pregnant women are increased. However, most of these increased needs can be met by special attention to dietary intakes of food. Only supplements of iron and folic acid are needed. Optimal weight gain during pregnancy averages around 22 to 27 pounds. Weight gain due to maternal storage occurs throughout pregnancy whereas weight gain due to the products of conception occurs in the latter part of pregnancy. Restriction of weight gain reduces birth weight of the infant. Therefore, weight reduction in an obese woman is ill-advised during preg- nancy. Sodium restriction prevents the necessary blood volume expansion and will not treat eclampsia or pre-eclampsia. Administration of diuretics to the eclampic patient is dangerous. Evaluation Although this paper was written in 1972, its information is still excellent and covers crucial areas in maternal nutrition. 94Applicability to Planning Agencies Even though this information has been available for a few years, many physicians are still prescribing caloric and sodium restrictions, in addition to the use of diuretics as a means of preventing or treating pre-eclampsia or eclampsia. Training is needed for physicians and health care personnel concerning the ill-advisability of these restrictions. 49 Latchford LM, Milne H, Vaughan M, et al: Food intake study of expectant mothers attending prenatal classes in metropolitan Toronto. Can J Pub Health 61:525-533, 1970 Geographical Area International implications. Study Design The objectives of this study were: to examine food group intakes and nutrient intakes prior to attendance at prenatal classes; to collect data on specific factors which could influence the selection of food by the subjects; and based on the information obtained above, to apply the information from the survey to the nutrition teaching in prenatal classes. The sample population consisted of 981 expectant mothers who registered for any of the mothers or parents prenatal classes conducted by the Social Planning Council of Metropolitan Toronto during the twelve-month period from September 1, 1968 to August 31, 1969. Each received a three-day food intake record booklet. Records were kept for one weekend day and two week days. Questions concerning age, weight before pregnancy, weight gain, height, number of months preg- nant, number of pregnancies, occupation, education, and change in food habits were included. The values of the average daily intake of calories, protein, calcium, iron, Vitamin A, thiamine, riboflavin, niacin, and Vitamin C were calculated for each mother and compared to the Canadian Dietary Standard table for Recommended Daily Nutrient Intakes in Pregnancy. Significant Findings Eighty-three percent of the 981 participants were between 20 and 29 years and 83% were in their second trimester of pregnancy. Eighty-nine percent were expecting their first child. Seventy-three percent of the subjects had completed at least secondary school and 38% had com- pleted post-secondary education. Sixty-eight percent of the mothers were presently employed. A change in food habits since the onset of pregnancy was reported by 57% (562) subjects. Thirty-eight percent replied that salt restriction, weight control, loss of appetite or food intolerance were reasons for the change. Half of those who changed food habits did so by their own decision while 25% did so because of doctor's recommendations or a combination of the two factors. Milk and dairy products was the food group where consumption increased the most, followed by increases in fruits and vegetables. Almost one-third of the subjects reported a drop in empty calorie foods. Forty-two percent of the subjects still consumed less than half of the recommended amount of milk products according to Canada's Food Guide. Seventy-three percent of the mothers con- sumed the recommended amount of citrus fruits. Only 11% of the subjects had even one slice of whole grain bread or fortified cereal and almost 50% had none at all. Ninety-five percent had adequate intakes of meat and alternates. Only 15% of either those who did or did not complete high school consumed 75% or more of the recommended quantities of nutrients. The nutrient intakes, however, do not include vitamin or mineral supplements. Eighty-six percent of the subjects were taking supplements and of these, 75% of the participants took supplements which supplied both types of nutrients. Twenty-five percent of the mothers had intakes of calories, calcium, iron and Vitamin A below the recommended quantity of calories. Nevertheless, weight gains in the 4th, 5th, and 6th months of pregnancy were normal. Evaluation The study was comprised of a good sample size and many useful insights were reported. The study would have been more valuable if biochemical and/or clinical examinations were incorporated. Accurate assessment of an individual's nutrition status is impossible without this data. The fact that so many women were deficient in several nutrients may or may not have been offset by the fact that 89% of them were taking nutrient supplements. This is a question only biochemical evaluation could resolve. 95The findings of the study must be carefully evaluated by Americans who follow a different set of Recommended Dietary Allowance values. While the findings are quite alarming in terms of Canadian norms, they are even more significant using American standards. The standards used in this study represent only 66% of the standard for Vitamin C in the U.S., 64% of the protein value, 72% of the iron, and 84% of the Vitamin A. It is improper to apply the RDA's to an indi- vidual, but use of a value of 66% of the RDA has been generally recognized as being the lower end of the safety margin. The fact that the standards used in this study are in that range and that the deficiencies are still noted, suggests that significant inadequacies are present. Additional importance is lent to the findings since the sample population was comprised of women who registered for the prenatal classes. These women may well have been more highly moti- vated in regard to health than the mothers who did not register and were not represented in this study. Applicability to Planning Agencies The study suggests that noteworthy nutrition deficiencies exist in pregnant women in the Toronto area. In light of the fact that this has implications for both mothers and infants, it behooves public health workers to step up nutrition education programs. Many of the mothers were motivated to change food habits (75%) and this interest must be used to its best advantage. As has been done in Toronto, the findings from studies such as this should be incorporated into the education program, so that attention may be focused on the most significant problems. It is difficult to determine what effect the prenatal classes had; however, a significant number of women increased their consumption of milk and dairy products and decreased their intake of empty calorie foods once in the course. An association between the two facts is tempting; how- ever, further testing would be necessary to confirm the theory. If this association is valid, the value of prenatal education courses would be confirmed. Nutrition Status of Adults 50 Inano M, Pringle DJ, Little L: Dietary survey of low-income, rural families in Iowa and North Carolina. JADA 66:356-360, 1975 Geographical Area Calhoun and Pocahontas Counties in Iowa and Duplin County in North Carolina. HEW Regions VII and IV, respectively. Study Design This paper is the first in a series of three in the dietary survey of low-income, rural residents of the above three counties. The survey was part of an experimental program on nega- tive income tax conducted by O.E.O. A stratified sample of 809 families was selected, 501 from North Carolina and 308 from Iowa. More were selected from the southern state because rural poverty occurs in much higher frequency. A modified version of the 24-hour recall was used to determine the family (not individual) food intake. Nutrient intake was examined, also, according to annual and per capita income. Significant Findings A discussion is presented in support of the use of the 24-hour recall in determining dietary patterns for groups of people. Problems in interpreting the meaning of nutrient intake below RDA values also are presented. Evaluation This article is clear and explicit about methodologies used in the study. Applicability to Planning Agencies There are advantages and disadvantages for every kind of dietary intake investigation. Although family food intakes do reflect individual food intake, care must be taken to avoid using such data as indicators of individual nutrient intake. 9651 Inano M, Pringle DJ: Dietary survey of low-income, rural families in Iowa and North Carolina. JADA 66:361-365, 1975 Geographical Area Rural Iowa and North Carolina, HEW Regions VII and IV. Study Design Families were grouped into four categories according to annual income. Intakes of protein, calcium, iron, Vitamin A, ascorbic acid, thiamine and riboflavin were evaluated as being "good," "fair," or "poor," using the 1974 RDA and a family nutrient standard derived from the 1968 RDA that was used in the Ten-State Nutrition Survey. The diets then were evaluated according to per capita income. Out of the original 809 families, 668 participated. Significant Findings Comparison of results obtained from the two dietary evaluation methods is difficult because allowances changed between 1968 and 1974. More families in North Carolina had poorer nutrient intakes than families in Iowa. Protein and thiamine intakes most often were labeled "good" for families in North Carolina whereas ascorbic acid and calcium intakes most frequently were "good" in the Iowa families. As income increased, the number of families with poor diets decreased but at the highest income level, the numbers with good diets decreased. Annual income was a better indication of family nutrient intake than per capital income. However, by either method, the North Carolina group had a greater incidence of "poor" intakes. Evaluation The percent participation rate in this study is good and the methodology is used exactly as stated in the previous paper. Applicability to Planning Agencies The use of income as a means of categorizing nutrient intakes is a method that displays a great deal of information on the effect of income on food consumption. 52 Gray S: Nutrition and population: a family planning project. J Nutr Ed 2:25-26, 1970 Geographical Area Solano County Health Department, Vallejo, California, HEW Region IX. Study Design The author reports about the nutrition component of a family planning clinic in Vallejo, California. Significant Findings In this study members consist of women with children who want tc limit their family size. Topics discussed include economical shopping, weight control, and meal planning. Individuals go through interviews and receive nutrition counseling. Clients are given follow-up care at homes by visiting nurses. The nutritionist can expand family planning activities to areas outside the health clinic, e.g., in schools. Evaluation The author has taken an important step by providing nutrition services in a family planning clinic. Her belief in the importance of nutrition in the preconceptual and inter-conceptual periods is an excellent example of one of the roles of nutrition in preventive health. In order to assess the impact of her services, the author should perform some kind of evaluation of the program. 97Applicability to Planning Agencies Although this article was written in 1970, nutrition still is not a component of a large number of family planning clinics across the country. Given that nutrition services provided in this setting are preventive in nature, health care providers across the country should in- clude nutrition in family planning programs. Nutrition Status of the Elderly 53 Gershoff SN, Brusis 0A, Nino HV, et al: Studies of the elderly in Boston: the effects of iron fortification on moderately anemic people. Am J Clin Nutr 30:226-234, 1977 Geographical Area Boston, Massachusetts, HEW Region I. Study Design The objective of this study was to provide information on the biochemical and clinical status of generally healthy, institutionalized and free-living people over 60 years of age living in the Boston area and to determine the effects of an iron fortification program in the free-living popu- lation considered, to be moderately anemic (Hb=9-12.9 g/dl of blood). The sample included 779 people of 60 or more years of age. Of this group, 520 lived in eight Boston public housing projects or in private housing near a Jewish Community Center. Only 259 lived in retirement homes. There were 276 females and 203 males; 675 whites and 104 Blacks; 218 were between 60 and 69 years of age, 325 were 70 to 79, and 236 were over 80. Medical histories were collected on all subjects. The following tests and examinations were performed: in-bed resting electrocardiogram, sitting blood pressures, height and weight deter- minations. The urine was sampled by stick test for blood, sugar, protein and pH. The blood was sampled for hemoglobin, hematocrit, total iron-binding capacity, B-^, folic acid, albumin, cho- lesterol, BUN, creatinine, uric acid and, in some cases, Vitamin E. The intervention consisted of giving two-thirds of the subjects iron fortified wheat-based foods while the other one-third received the same foods without supplemental iron. Significant Findings 250 free-living people had hemoglobin values between 9 and 12.9 g/dl and of these, 221 agreed to participate in the intervention study; 160 finished the study. Race Few statistically significant differences were observed between white and Black subjects. As a group, Black women had lower Hb and HGT levels than white and were heavier with higher serum protein levels. Sex Men showed significantly higher Hb and HGT values and lower serum cholesterol and systolic blood pressure. They also had higher transferrin saturation, serum protein and serum uric acid values and lower total iron-binding capacity. Free-Living vs. Institutionalized Differences were small, but free-living persons had somewhat higher mean hemoglobin, albumin globulin ratios and weights. Serum folacin and transferrin saturation tended to be higher in institutionalized subjects. With increasing age, there appeared to be trends toward lower hemoglobin values, weights, albumin/globulin ratios, diastolic blood pressure, cholesterol, higher serum folacin and uric acid. 98Control vs. No Control Control women gained more weight than experimental groups of females. Both groups showed significantly elevated hemoglobin levels. There was little change in HGT values. Both diastolic and systolic blood pressures dropped for both groups. The experimental group lost a small, but significant amount of weight. The group placed on FeSO^ for an additional three months showed no significant change in hemoglobin levels and only a small rise in HGT values. Evaluation The provision of supplemental iron either in the foods or as FeSO^ was not effective in raising the hemoglobin levels of the elderly volunteers. It must be borne in mind, however, that this study started with a population not significantly (if at all) iron deficient. Other studies have shown that Fe absorption and utilization are dependent on existing body iron levels. It must also be considered that Blacks represent about one-seventh of the sample population. Other studies have found that Blacks typically have lower hemoglobin and HGT levels than whites while they are not necessarily deficient. Thus, the presence of Blacks in the sample would tend to minimize any observed benefits from the intervention. These findings are not in total agreement with the findings of other surveys like the Ten- State Nutrition Survey. Examination of the two reveals differences in the baseline population biochemical values. Also, different laboratories were used for sample evaluation so, possible variations may be due to experimental error. Applicability to Planning Agencies The findings for this survey are somewhat nebulous. The authors suggest the rise in hemo- globin levels was due to the intervention itself and not the supplement. They argued that the study was perceived as a major event in the lives of these people. The laboratory tests were analyzed and findings were reported and explained to them. This may have led to an enhanced interest in taking care of their health. Interview records during the intervention study re- vealed that 75 subjects out of 160 altered their diets. This is significant, particularly in an elderly population. Studies on this group (perhaps more than other sub-groups of the population) must consider psychological as well as physical variables. This suggests that potential value can be derived from corrective programs not using elab- orate interventions or expensive care. Simply identifying a study group, explaining their health needs and possible corrections, and showing considerable attention to them will lead to success- ful results. 54 Grills NJ: Nutritional needs of elderly women. Clin Obst Gynec 20:137-143, 1977 Geographical Area National implications. Study Design This paper enumerated the nutrition needs prevalent among elderly women in hope that guide- lines for planning nutritionally adequate diets may be established. Findings were drawn from a number of studies and methodologies which were not presented. Significant Findings Studies of free-living and institutionalized relatively disease-free elderly women have found that diets are most commonly low in calories or one or more of the following nutrients: quality protein, iron, calcium, magnesium, ascorbic acid, folic acid, riboflavin and Vitamins A and D. Environmental factors implicated were: degree of isolation, dentition, food preferences, energy available for food shopping and preparation, availability of food stores or facilities, and degree of physical or mental disability. The common degenerative and debilitating diseases in the elderly woman, osteoporosis, hypertension, diabetes, obesity, coronary heart disease, arthritis, and the various anemias, can be partially controlled or the degree of debility decreased by dietary manipulations. 99Evaluation The author has drawn upon numerous studies to support the contention that elderly women are at nutrition risk. The statistical validity of the reported findings cannot be assessed because the methodologies were not presented. The paper itself is clearly written and effectively states its position. Applicability to Planning Agencies In planning an adequate diet for a woman over 50 years of age, one must consider her psycho- logic, social and economic needs. The author proposes four principles to be followed when planning modifications in a subject's diet: the change should have measurable and meaningful results; the person who is going to be most affected by the change should be highly involved in the planning; the diet should not sacrifice or compromise any essential nutrient; the diet should necessitate little change from the person's past eating habits and style of eating. It is best to start nutrition education and appropriate habits early in life. 55 Harper JM, Hansen GR, Shigetome CT, et al: Menu planning in the nutrition program for the elderly. JADA 68:529-534, 1976 Geographical Area National implications. Study Design The stated objectives of this study were': To design a simple system for planning menus for nutrition programs for the elderly which meet a specific nutrient standard based on one-third of the Recommended Dietary Allowances; To design a simple system for monitoring meals in nutrition programs for the elderly provided by third party contractors. To the greatest possible extent, the monitoring system should use the methods and materials developed for menu planning; and To evaluate the feasibility of the menu planning/monitoring system by studying the ability of ten nutrition project representatives to plan satisfactory menus and to monitor accurately contractor-provided meals using the system. The nutrient standard selected was based on one-third of the 1974 RDA and consisted of nine indicator nutrients and calories. An adaptation of the NSM (nutrient standard menu), which was developed for the National School Lunch Program, was used. The monitoring method used for third party meals involved selecting in the NSM manual the menu item closest in description to the third party item and then calculating the ratio between serving sizes. The test involved ten menu evaluators who were selected by the Administration on Aging and had been given formal instruction. Statistical analysis was based on the evaluation of questionnaires. Significant Findings Site managers who were younger, who had more educational experience, and who planned menus, showed greater comprehension and ability in both the menu planning and monitoring techniques. However, managers with average skills and no sound training could master both planning and monitoring skills. Of the evaluators 84% planned menus successfully and 75% monitored them successfully. 100Evaluation This study revealed the potential value of the proposed method of menu planning but, further testing and refining seem to be necessary. First, only ten menu evaluators were used. This is a small sample to use when one wants to make assumptions about a much larger population. Be- cause the evaluation of this method was relatively subjective (based on questionnaires), the participants' comments must be considered. One of their beliefs was that the concept of serving 3/4 portions to women as compared to full portions to men would be difficult to put into prac- tice. This point seems valid and should be tested. Participants also felt the practice of find- ing a nutritionally similar menu item for all third-party contractor items would be a potential difficulty which could lead to inaccuracies. This too should be studied further. On the positive side, participants did believe the use of the NSM method would be superior to the four food group approach. No problems were seen in incorporating donated or unusual foods into the menus. They felt the method would allow more variety in the menus. Applicability to Planning Agencies The author stated, without offering details, that several modifications have been made in the method. Therefore, a judgment on the NSM program's applicability cannot be made. The method could be an effective tool in nutrition education programs on the food sites. It could also be used in master menu planning by state administrative supervisors and supervising dietitians to monitor menus, both when prepared "on-site" or when purchased from a third-party contractor. 56 Bozian MW: Nutrition for the aged or aged nutrition? Nurs Clin N Am 11:169-177, 1976 Geographical Area National implications. Study Design The purpose of this paper was to discuss the role of the nurse in nutrition counseling of the elderly. No study was performed. Significant Findings Most older people do not utilize essential nutrients efficiently. Despite reduced energy needs and the absence of growth, the dietary levels of nutrients should remain approximately the same as in younger age groups with the exception of caloric requirements. Quick nutrition assessments can be made based on physical evaluation and comprehensive eval- uation of food consumption and activity. Elderly persons often suffer from poor dentition, reduced income and little social contact. This often results in the consumption of easily prepared, inexpensive, easily masticated, high caloric foods which lead to the development of obesity. This is further complicated by reduced energy needs and the use of appetite-stimulating psychotropic drugs. The relatively high prevalence of chronic disease in the elderly places them in a nutrition- ally high-risk category. Emphasis should be placed on social activities to stimulate the interests of the elderly patient. Simple preliminary measures to control weight gain, weight loss, fatigue, gas and consti- pation are presented. Evaluation The article offers no new data and briefly skims over a few common concerns. The value of the paper lies in its message that nutrition plays a major role in the health and comfort of the elderly. Simple alterations in a patient's diet can immeasurably enhance the quality of the patient's life. An oversight in the article is its failure to emphasize the importance of the relationship between the nurse and the dietitian. The better the communication between health workers, the higher the quality of service which can be offered. To plan a good diet for a patient, a nurse's input can be very valuable. Many variables must be considered when planning a diet such as drug-nutrient interactions. For this reason alone, any modification of a patient's diet should involve consulting a dietitian knowledgable in the field of elderly nutrition. 101Applicability to Planning Agencies The article highlights the unique nutrition position of the elderly patient. The message is of significance to health planners, nurses and other health workers involved with the elderly. 57 Rawson IG, Weinberg EX, Herold JA, et al: Nutrition of rural elderly in Southwestern Pennsylvania. (Unpublished) Geographical Area and Study Design Pennsylvania, HEW Region III. This survey assessed the nutrition deficiencies among a sample of elderly residents of the service area and integrated the findings in the Area Agency on Aging's regional plan. The survey was conducted during the summer of 1975 in three counties of Southwestern Pennsylvania. A geographically stratified 10% sub-sample of 28 respondents from a larger survey of health status and services utilization by the elderly was interviewed for a standard 24-hour recall diet record. Significant Findings Based on an assessment of the 24-hour diet recall, intakes of protein, iron, niacin and Vitamin C were rated above adequate; riboflavin, thiamine and Vitamin A were determined to be close to adequate levels (88-90%); while calories (71%) and calcium (66%) were reported consumed at significantly deficient levels. Males were more deficient in calories and Vitamin A, while females on the average were lacking in calcium. More than two-thirds of the females were de- ficient in iron and Vitamin C. Use of private garden plots, hot weather, income, transportation and information were believed to influence consumption patterns. Evaluation This survey suffered from several significant problems. First, the sample population in- cluded only 28 persons. It is difficult to extrapolate the findings from such a small sample to a general population. Second, the assessment technique was the use of only a 24-hour dietary recall. While the author recognizes the limitations of such a method, he maintains it is the most practical instrument for field-level evaluation. This may be true; however, the data it generates are still of questionable value. This is particularly true in a geriatric population where daily fluctuations in diet may be more pronounced than in other sub-groups of the popula- tion. The paper does include a good literature review on the problems of elderly nutrition. Many significant direct (i.e. consumption patterns) and indirect (transportation problems) factors are elucidated. There is also a valuable discussion on the application of research findings to program planning. Applicability to Planning Agencies The findings from the Southwestern Pennsylvania study suggest that the rural elderly have specific nutrition needs. In this study poor milk consumption was noted. The Area Agency on Aging's nutrition program staff used this data in planning programs. They altered menus to include more dairy products and allowed the elderly participants to make suggestions on the types of dairy products to be used to increase acceptance of the foods. The staff also stressed educa- tional material concerning milk products during teaching programs. In addition, innovative approaches to education were used to stimulate participation in education programs. Finally, the findings resulted in an expansion and/or development of Congregate Meal Pro- grams in several rural and semi-rural communities. This study demonstrates how data can be used to improve the services offered to a population. The example used in the paper has applicability in many situations in all sub-groups of the population. 10258 Corales SM, Madden SP, Riddick HA: Health-related findings from a survey of the elderly. Sci Ag, Summer 1975 Geographical Area National implications. Study Design The purpose of this survey was to evaluate the Congregate Meals Program (CMP) in terms of participation and participant characteristics. During the spring of 1974, 644 non-institutionalized persons in five Pennsylvania counties were interviewed. Two-thirds of the group were CMP participants. Significant Findings Only 17.5% of the sample rated their health as "poor" or "very poor," and of these, a large proportion of non-CMP participants (21.6%) felt this way compared to CMP participants (15.3%). Program participants were slightly more likely to have restricted their activities due to illness, disease or injury in the six-month period. They were also slightly more often inca- pacitated than non-participants. Participants, more than non-participants, were more likely to have a health condition re- quiring the regular attention of a physician or constant medication. Over three-fourths of the respondents had annual incomes below $4,000. CMP participants reported a higher prevalence of high blood pressure; back, spine and hip trouble; and stomach and bowel trouble. The non-participants reported a higher prevalence of arthritis and rheumatism; attacks of sinus trouble, hay fever and allergies; and heart trouble. Evaluaion This survey offers a basic, simple assessment of the health status of the population. Be- cause data are based simply on an interview, the criteria for what constitutes a problem to the participant is nebulous. Clinical and biochemical data would be necessary to correct this shortcoming. Since these data are intended only for comparison purpsoes, it can be useful as an indication of the Congregate Meals Program's impact. Whether the program alters the physical indices of the participant's health or just improves the person’s perception of his or her health, the value of the Congregate Meals Program will be significant. Applicability to Planning Agencies This survey was simply designed to obtain a baseline feel for the health status of the elderly population. Its value will become apparent only after it is compared to the re-survey performed one year later. The results of the comparison will be of value to health planners in general and the administrators of the Congregate Meals Program specifically. The data will allow the determination of the program's cost-effectiveness. This data can then be used to justify the program's existence or termination. 59 Gibbons FJ: Haematological problems in the older patient. Practitioner 215:606-611, 1975 Geographical Area National implications. Study Design The prevalence of and difficulty in diagnosing anemia are presented. The numerous types, causes, and treatments for various anemias are discussed. Significant Findings The following types of anemias are discussed: hypochromic microcytic, gastrointestinal conditions causing blood loss, macrocytic, malabsorption, folate deficiency, normocytic, leucoerythroblastic, leukemias, and multiple myelomatosis. 103Evaluation The paper clearly and concisely presents its material. Techniques for detecting and methods for treating anemias are well covered. To enhance the effectiveness of the paper, the preva- lence and significance of anemia in the elderly population should be discussed. Applicability to Planning Agencies This paper would be most useful to health planners attempting to set up anemia screening or treatment programs. Many of the problems with detection and methods of treatment are presented for the planner to evaluate and apply to his or her program. 60 Brown KS, Forbes WF: A mathematical model of aging processes III. J Gerontol 30:513-525, 1975 Geographical Area International implications. Study Design The paper examined the changes with age in the distributions of blood pressure and serum cholesterol levels using data from a Montreal population. Blood pressure and serum cholesterol measurements were used from a randomly selected popula- tion of male municipal employees in the city of Montreal. Significant Findings With each parameter, there was no pronounced increase in skewing the distribution curve with increasing age. The distribution of systolic blood pressure showed increased variance with age while the distribution of serum cholesterol remained similar with increasing age. Evaluation The author states, "Based on the changes in the distributions of the two studied parameters with age, the suggestion that increases in cholesterol levels represent a more important risk factor than systolic blood pressure increases, may imply that the factors controlling blood pressure deteriorate with age without leading to death, whereas those controlling cholesterol levels maintain their critical importance. That is, there may be mechanisms which allow an indi- vidual to tolerate slight increases in blood pressure in the course of his life span, which are not present for serum cholesterol levels." The authors suggest several other explanations, however, one being that there is a day-to-day variation in a person's blood pressure which, unlike cholesterol levels, increases in magnitude with age. Other theories are that cholesterol is not a risk factor or is one only until the age of 40 years. Neither of these last two seem plausible. Applicability to Planning Agencies The finding that if the serum cholesterol value of an individual changes, the individual will be placed at a substantially greater risk than if changes occur for blood pressure levels holds significant implications for health planners. At a time when budgets are small and funding is difficult to obtain, one is forced to set priorities. The mathematical model proposed can be a useful tool for prioritizing one's actions. The data suggest that changes in certain parameters may be of great significance, thus emphasizing the need for appropriate longitudinal studies or the review of presently available data to check the hypotheses offered by this study. 61 Planning and Organization of Geriatric Services. WHO Tech Rep Series No 548:1-46, 1974 Geographical Area National implications. 104Study Design The purpose of this report was to: Define the problems related to the aging and the aged. Assess their magnitude and their interrelationships. Identify priority areas. Examine possible ways of fitting geriatric services into different health and social systems. Review different approaches to the planning, organization, and administration of the financing of geriatric services. Elaborate guidelines for the further development of WHO's program in this field and for coordination with other United Nations agencies and non-government organization. Significant Findings This report dealt with a multiplicity of factors related to the health and well being of the elderly. Specific findings were reported for each. This evaluation focused only on the nutrition parameters involved. The FAO/WHO committees that studied the prevalence of subclinical malnutrition in the elderly felt that nutrition requirements for the elderly do not increase with age. The committee stated that in developed countries, where the diet contains protein of both animal and plant origin, a man weighing 65 kg should consume not less than 46 gm of protein per day and a woman of 55 kg, 36 gm/day. No distinction between the protein requirement of adults and old people was made. Except for energy requirements, the nutrition needs of the elderly are not decreased, and there is a special need for adequate amounts of vitamins, especially C and D, as well as minerals such as calcium, potassium, and iron. Adequate exercise and an element of roughage are essential in order to maintain the tone of the intestinal tract. Obesity is a factor which almost certainly shortens life and is a particular problem in developed countries. Certain groups of the elderly were considered to be at a higher nutrition risk: Those living alone, especially the housebound; Those with physical disease that makes shopping or cooking difficult; The mentally ill; The recently bereaved; and Those in old peoples' homes. Factors found to influence the diet of elderly persons include: taste diminution; poor dentition; lack of interest in food; lack of social activities; insufficient means to cover the purchase of appetizing, or even adequate, foods; difficulties in shopping, resulting from impaired mobility; and possibly poor intestinal absorption. Evaluation This report presents an excellent summary of the factors affecting the health and well being of the elderly. Attention is given to both the developed and the developing countries. Numerous recommendations are made on a variety of issues. The section on nutrition offers a sound intro- duction to the state of geriatric nutrition. Applicability to Planning Agencies The findings reported in the nutrition section are not substantiated in the text. If one wanted to design a program for the elderly, this report would be ah excellent place to initially acquire a feel for the numerous factors involved. For program development, review of more detailed studies would be necessary. 10562 Eddy TP: Nutritional needs of the old. Nurs Times 70:1499-1500, 1974 Geographical Area International implications. Study Design This paper outlined the nutrition needs of the geriatric population and discussed many fac- tors which contribute to poor dietary habits in this population. Findings were reported from two papers: (1) Recommended Intakes of Nutrients for the United Kingdom; and (2) A Nutrition Survey of the Elderly. The methodologies used and population descriptions were not presented. Significant Findings Factors Contributing to Poor Dietary Practices The elderly have food habits developed long ago and are resistant to change. Living conditions affect nutrition needs. Energy expenditures in the elderly are significantly greater in colder homes. Total food ingested tends to drop with age; yet the same relative proportions are consumed, thus placing the elderly in a higher risk category for specific nutrient deficiencies. Bedridden, disabled and/or housebound elderly are at higher nutrition risk for certain nutrients (i.e. without exposure to sunlight, levels of Vitamin D may be inadequate). Many elderly do not consume regularly prepared meals because they are either unable to make them or are simply uninterested. This again reduces the margin of error for an adequate nutrient intake. Repeated incidents of slight Vitamin C deficiency may have cumulative deleterious effects. Many elderly have undergone some form of surgery involving the gut. This results in impaired function of the gut which can lead to the development of pernicious anemia, vitamin deficiency and other diseases of malabsorption. Cancer and degenerative diseases are more prevalent in the elderly and can negatively affect nutrition. Statistical Findings A decline in physique accompanies aging and is the result of a reduction of the number of living cells, or lean body mass. This leads to a reduction in energy expenditure and requirements. Energy requirements for men over 75 in the United Kingdom were estimated to be about 2,350 kcal which is a reduction of about 400 calories from a young man's needs. For women, the recommendations are 2,050 kcal at 55 to 75 years and 1900 for women over 75 years. A Nutrition Survey of the Elderly revealed that energy intakes of women over 65 years was 13 to 14% below recommended levels. Geriatricians report an incidence of 10% in osteomalacia in elderly British women. The condition is partly attributable to diet. Evaluation The present paper serves as a general overview of the nutrition problems facing the elderly. Little data were presented to support the generalizations made. Several nutrients were singled out for examination; however, many additional problems were not explored. Taken as a general indication of the unique position in which the elderly find themselves, in terms of nutrition, this article presents several thought-provoking ideas. Applicability to Planning Agencies Because this paper simply presented a number of situations and nutrients in which the diets of the elderly may be comprised, the applicability of this paper is limited to use as a general topic introduction. Methods of treatment for the correction of the problem presented, as well as the evaluation of additional relevant factors, will require further research. 3,0663 Cohen C: Social and economic factors in the nutrition of the elderly. Proc Nutr Soc 33:51- 57, 1974 Geographical Area National implications. Study Design This paper summarizes numerous studies concerning the nutrition status of the geriatric population between the 1830's and 1974. Many specific concerns are highlighted such as: budgetary restrictions, masticatory difficulties, and mobility limitations. Significant Findings There is little evidence that elderly people suffer primary sub-nutrition because of a lack of funds. Sub-nutrition in the elderly is usually one facet of the multiple pathology which char- acterizes the elderly patient. Those who have minimum incomes have to rely on cheaper foods which may result in a monoto- nous diet. They are also more vulnerable to rapid increases in food prices. Poverty may occur if there is undue pride or ignorance of the financial help available. Food fads and inherited faulty dietary advice may lead to poor nutrition. Men over the age of 75 who live alone are the most likely to have poorer nutrition. A poor state of dentition may not be related to poor nutrition but the diet is likely to be monotonous. Relatives play an important part in caring for the elderly at home. The ability of elderly people to maintain adequate standards of nutrition may be threatened by a drop in income at the time of retirement and if they outlive their savings. Evaluation This paper has presented numerous studies which were not described in detail. It, therefore, is not possible to comment on the validity of the findings except to state that they may be indicative of general trends in geriatric nutrition. Applicability to Planning Agencies The findings presented in this paper suggest that planners must consider all aspects of an elderly person's life before designing any program to improve the existing situation. In terms of already existing programs, the number of "preparation for retirement" courses should be increased, as should meals-on-wheels services and lunch clubs. More extensive use should also be made of dietitians, health visitors and social workers as members of community health teams, alongside general practitioners. 64 Furbank M: Improved meals for geriatric patients. Nurs Times 70:1501-1503, 1974 Geographical Area National implications. Study Design This paper described new improved menus used at a geriatric hospital and the positive reactions they received. A long-stay geriatric hospital was the site of the trial. Menus with a choice of meals were introduced in July 1970 to provide a wider variety of food, eliminate wastage, provide a more balanced diet, and improve the standard of catering. Significant Findings The new menus did not significantly increase the cost to the hospital. 107At the time of this article, 70% of the patients were capable of making choices on the menu. Improvements in health had been noticed in a lower incidence of chest infection, pressure sores, and coughs and colds during the winter. Patients were more alert and interested in their surroundings. Constipation was less prevalent. Food wastage was reduced to a minimum. Evaluation Little statistical data supported the findings. The program was reported more as an idea than as a study proving its feasibility or actual value. Applicability to Planning Agencies The approach adopted at this hospital may find application in any situation where meals must be.planned and prepared for a group of people. The relative costs and benefits must be weighed in each situation. The benefits of improved mental and physical health and reduced costs due to less wastage can be significant and worth studying. 65 Schlenker ED, Feurig JS, Stone HL, et al: Nutrition and health of older people. Am J Clin Nutr 26:1111-1119, 1973 Geographical Area National implications. Study Design This study pointed out the existing nutrition problems in the geriatric population. Numerous studies were cited in the paper with no details of methodologies. Significant Findings Significant findings were reported in the following areas among others: Relationship between nutrition adequacy early in life to health and well being in later life. Poor absorption of Vitamin A. Vitamin B12 deficiency. Problems of low nutrient intake. Osteoporosis. Sex differences. Obesity. Longevity. Physical activity. Dietary fat intake and cardiovascular disease. Dietary carbohydrate intake and morbidity and mortality. Fiber. Thiamine deficiency. Evaluation This paper briefly covers many nutrition problems observable in the geriatric population. Little time is spent evaluating the various studies presented and no new data are offered. The paper does point out clearly that nutrition problems do occur commonly in the elderly. Applicability to Planning Agencies This paper may be used in conjunction with other findings by planners as a basis for developing programs or studies to improve the nutrition status of the geriatric population. 10866 Thomas JH: Anemia in the elderly. Br Med J 2:288-290, 1973 Geographical Area International implications. This article discusses the causes, types, symptoms, treatment and prevention of anemia in the elderly. It offers practical and useful suggestions for dealing with anemia. Significant Findings The causes contributing to anemia are: occult bleeding from the gastrointestinal tract, insufficient intake of nutrients, diminished absorption, and disease. There are two types of anemia: hemolytic and nutrient deficient. The treatment of nutrient deficient anemia is oral supplementation of the non-contributory nutrients and whole blood transfusions. Prevention can be achieved through insurance of adequate nutrient intake and early detection and treatment of disease. Evaluation The article clearly and concisely presented the various parameters of the problem of anemia in the elderly population. Stronger emphasis on the severity of the problem and its implications would have been beneficial. The discussion on hemolytic and marrow anemia may have been some- what technical and incomplete. The author relies heavily on laboratory tests and patient histories. The home management and prevention therapy aspects were not as directive. Applicability to Planning Agencies The author points out the problem of anemia in the geriatric population. He describes the various types and causes and suggests methods for handling the problem. Planners would find this paper useful when exploring the feasibility of correcting the problem. 67 Elwood PD, Burr ML, Hole D: Nutritional state of elderly Asian and English subjects in Coventry. Lancet 1:1224-1227, 1972 Geographical Area International implications. Study Design In 308 elderly people, aged 65 or more, from Coventry, medical doctors made determinations for height, weight, triceps skinfold thickness, mid-arm circumference, dental state, Hb and red-blood-cell values, serum Vitamin B]^2» serum and red blood cell folate and serum ascorbic acid, protein, calcium and cholesterol. The sample included English, Scots, Irish, Welsh and Asians. All but the Asians were considered English. Significant Findings Anthropometric measurements were quite similar among all the subjects; 62% of the Asians and 90% of the English were edentulous. The mean DMF (decayed, missing or filled) index in the English was 19+1.0 and in the Asians 16±0.6. The mean Hb and HGT values were similar although there is a greater scattering of values among Asian males. The mean cell volumes of the Asians are significantly greater than for the English. Serum Vitamin B^2 levels are lower for the Asians. The serum and red blood cell folate levels, as well as ascorbic acid levels, are lowest among the Asians. Evaluation Malnutrition is not an important problem in the elderly in the United Kingdom. The author believes that the study gives little encouragement for population screening for anemia. While the study has some shortcomings, i.e., 30% of the English population refused to participate in the study, while 98% of the Asians participated, the overall findings are significant. They 109highlight the need for good objective studies before money and action are committed to the im- provement of a perceived problem which in reality does not exist. Applicability to Planning Agencies The present study is significant in that it points out the need for evaluation before planning, budgeting and implementation of programs. If nutritionists are to demonstrate the value of their profession, they must attack problems which are worthy of the effort. To prove effectiveness, problems which are confronted must be real and solvable or at least amenable to improvement. 68 Guthrie HA, Black K, Madden JP: Nutritional practices of elderly citizens in rural Pennsyl- vania. Gerontologist 12:330-335, 1972 Geographical Area Pennsylvania, HEW Region III. Study Design The objective of this paper was to determine if a relationship between health status and nutrition exists and to identify some of the social factors associated with dietary practices. The study was designed to evaluate the nutrition adequacy of two groups of elderly citizens in a predominantly rural, area and to compare their dietary practices. Group one included those who were eligible for food assistance programs. Group two was similar in all respects except that their income was sufficient to disqualify them for food assistance programs. The para- meters of age, educational level, income, medical restrictions, state of household, general dental health, and nutrient intake were studied. The heads of 70 households of one or two persons over 60 years old were interviewed. Group one consisted of 55 persons in 35 households. Group two consisted of 54 persons in 35 households. Information was gathered by interviews and 24-hour dietary recall on each subject. Food models were used. The findings were plugged into a computer for translation into the nutritive intake of each participant. These were compared to the RDA for each nutrient and related to the parameters already mentioned. Significant Findings Food Expenditures In one-person households, group one subjects spent an average of $4.80/week and $26.50/month on food. In group two the figures were $9.10/week and $36.10/month. The differences were sig- nificant. For the two-person households the comparable expenditures of $12.10 and $43.00 in group one did not differ significantly from expenditures of $13.70 and $53.00 in group two. Food expenditures represent 36% of the monthly income in group one and 16% for group two for one-person households and 32 and 20% respectively in two-person households. Dietary Intake The low-income group had diets somewhat less adequate than those with higher incomes. The differences were significant for protein, iron and riboflavin. The other social variables con- sidered in the analysis affected the intake of only one of the eight nutrients assessed. The Caloric intake of persons over 80 years of age fell below the RDA for a significantly greater percentage of subjects than for those 60 to 69 years of age. There were no comparable differ- ences for other nutrients so there were differences in the types of food selected. Group one subjects participating in the food stamp program had diets more often adequate in energy, pro- tein and iron. When the adequacy of intakes of subjects over 60 was compared to families of all ages in another county at the poverty level, the former group had significantly less adequate intakes of calories, protein, thiamine and riboflavin. lio.Nutritional Supplements In 44 subjects, 16 in group one and 28 in group two reported using nutrition supplements. Eighty percent did not know what was in the supplement. Only two subjects took supplements providing all the nutrients in which their diets were deficient. Food Frequency Group one consumed significantly less meat and fruits than group two. Evaluation To obtain a more significant assessment of nutrition adequacy, biochemical and/or clinical evaluation of the subjects should be performed. The present study relied on the 24-hour dietary recall method which, in this population, where day-to-day intakes vary perhaps more than in any other sub-group, is of limited value. The utilization of ingested nutrients is also affected by health which is influenced by age. The present study used a sample of relatively small size, 109 subjects, and would be more reliable if a larger sample could have been assembled. Nutritionists generally agree that one's life-long eating pattern is more important than a short-term sample. Many of the elderly in this study, who now have low incomes, had incomes relatively more adequate during their productive years. Unfortunately, as the author points out, the data presented do not provide an answer to the question of whether the dietary practices of elderly persons who have been poor throughout life are different from those of persons with a similarly low income who would not have been considered poor in their productive years. If the latter group have dietary practices similar to the more adequate practices of the higher income group, then one could postulate that the dietary practices were a function of a life-time of practices rather than of poverty after 65. Applicability to Planning Agencies The use of nutrition education may be unrealistic with the elderly whose food habits are deeply engrained in their social and cultural background. Instead, a program of modifying or enriching the foods traditionally eaten by this group to provide nutrients most likely to be lacking is recommended. It was found that the food assistance program available in the area was used by only 26% of the eligible elderly. Pride and transportation problems were the factors held responsible. Efforts to correct these factors could be effective in improving elderly nutriture. One method would be to modify the distribution system used. The study found significant nutrition differences between the groups using a value of two-thirds of the EDA for its criteria of adequacy. The fact that so many diets fell below the adequate levels and no significant incidence of manifest disease was found suggests, that either there is cause for concern over the diets of the population studied since problems may be subtle, or that the current dietary standards are unrealistically and unnecessarily high. 69 Lloyd EL: Serum iron levels and haematological status in the elderly. Gerontol Clin 13:245-255, 1971 Geographical Area International implications. Study Design The study was carried out to assess the incidence of sideropenia and the haematological status of patients admitted to the geriatric assessment unit of the Glasglow Royal Infirmary geriatric service. The sample population consisted of 100 patients. In each patient, the Hb, PCV (Packed Cell Volume), MCHC (mean corpuscular HB concentration), TIBC (Total Iron Binding Capacity), blood urea and serum iron values were determined. U1Significant Findings No significant differences between male and female Hb, MCHC, TIBC, and blood ureau levels were found. There was a significant decrease in Hb and PCV values with age. There was a signifi- cant sex difference for PCV and percent saturation values. Blood urea levels did rise signifi- cantly with age. Twenty percent of all patients were anemic. Twenty-five percent of the patients, male and female, had a serum iron below 50 pg/100 ml and 50% of males and 55% of females had TIBC values over A00 pg/100 ml. Evaluation The implications of the findings are difficult to evaluate because there is not agreement in the scientific community on what constitutes normal levels for such values as serum iron con- centration. The author states this and works well within this limitation by clearly stating the values he has chosen as normal. The extent of the problem reported by this study may be artificially high since the sample population consisted of institutionalized patients who have typically presented lower values. While nutritionists emphasize the necessity of clinical and biochemical data in determining incidence and severity of disease, general dietary intakes are also important in patient eval- uation. This parameter was not discussed. I Applicability to Planning Agencies The author discussed the problem of anemia in the geriatric population. This study found 25% of all patients had serum iron below 50 pg/100 ml and 50% of males and 55% of females had TIBC values over A00 pg/100 ml. These figures in conjunction with the results of some trials of iron therapy in sideropenic non-anemic women would suggest that all geriatric patients should have their iron status investigated and sideropenia treated. 70 Caird FI, Andrews GR, Gallie TB: The leucocyte count in old age. Age Aging 1:239-2AA, 1972 Geographical Area International implications. Study Design The sample was comprised of 50 "fit" people aged 65 or over who were living at home. They were chosen from Kilsyth (201), a small town and Northern Glasgow (300). Blood samples were taken. In A8 cases (96%) total leucocyte count was made by a manual method (361), and by coulter counter (119). A differential count was performed in A68 cases and absolute polymorph and lymphocyte counts were calculated. Significant Findings There were no significant differences between the total leucocyte counts, differential counts or absolute polymorph and lymphocyte counts by coulter counter or manual methods. There were no significant differences by sex or age in the absolute or differential counts. The mean total leucocyte count was 5280/mm^. Fourteen percent of these were under AOOO/mm^ and fewer than 1% over 10,000/mm^. Sixteen percent of the absolute polymorph counts were under 2500/mm^ and A7% of absolute lymphocyte counts were under 1500/mm3. Evaluation The study was of good sample size and excellent percent participation. Statistical analysis seems adequate. Considering the study was partly based on the belief that "fit" subjects were involved, the findings must be considered as indications of the existing situation as opposed to an absolute statement of fact. Applicability to Planning Agencies While there is lack of agreement on absolute standards for normal ranges of the total neuco- cyte count and its major components, the values obtained fall within the lower acceptable limits for total leucocyte and lymphocyte counts. Thus, there appears to be a slight tendency towards 112leucopenia and a more definite tendency to lymphopenia in the sample group. The fact that participants were determined to be "fit" suggests that a diagnosis of leucopenia should not be made in elderly person unless the total leucocyte count is below 300/mm . Conversely, findings of 8000 to 8500/mnr may suggest significant leucocytosis in contrast to the presently accepted critical range of 10,000-11,000/mm . 71 Fisher S, Hendricks, DG, Mahoney AW: Nutritional Assessment of Senior Rural Utahans by Biochemical and Physical Measurements. Logan, Utah, Nutrition and Food Science Department, Utah State University, n.d. Geographical Area National implications. Study Design The purpose of this study was to identify the specific nutrition conditions that existed in the rural population. The survey was conducted in the southwestern five-county region of Utah. In all, 187 older individuals from the area volunteered to participate in the study. Ages ranged from 41 to 91 years with a mean of 69 years. The participants did not represent a random sample but were believed to be typical of the area. A questionnaire seeking demographic, economic, health and food pattern information was completed by each participant. Blood and urine samples were collected and measurement of 15 parameters was performed. Blood pressure, height and weight were also recorded. Significant Findings No deficient levels were detected in hemoglobin, hematocrit, MCHC or serum iron tests. The mean levels for all minerals measured fell within acceptable ranges. Forty-eight percent of the women and 33% of the men had cholesterol levels above 250 mg/100 ml of blood. One-fourth of the men and 15% of the women had values less than 200 mg/100 ml of blood. Forty percent of the females had low levels of serum protein and 26% of this number were deficient. Only 13% of the men had low levels. Vitamin A status was acceptable for all persons. Urine analysis revealed one-fifth of the population with low riboflavin excretion levels. Fifty-eight percent of the men and 29% of the women excreted low levels of thiamine. An observable decrease in height and weight occurred as age increased. Approximately 50% of the women and 30% of the men were classified as obese based upon use of standard weight for height at 25 years. About one-fourth of both sexes had systolic and diastolic pressures above 160/95 mm Hg. Evaluation The value of this data is reduced by several statistical shortcomings. First, the sample population was comprised of only 187 participants. This is a relatively small sample and extrapolation of data from this sample to the general population is difficult. Second, the participants did not represent a random sample. This again detracts from the applicability of the data. The extent is uncertain since community workers believed the participants were typical of the area. The data were interpreted in terms of mean values. It would have been useful to know the frequency distribution of the biochemical indices. Large fluctuations have been noted, especially in the geriatric population. It should also be kept in mind that the participants volunteered for this study. The characteristics of a selected and volunteering population may vary. This study did not measure nutrient deficiencies per se, but observed health symptoms which are related to food selection. These symptoms include hypertension, overweight, and elevated serum cholesterol. Perhaps improper food selection, rather than inadequate food availability, could be the predominant causal factor in present health problems. The author will be pub- lishing an analysis of this population with 3-day dietary records. This information, in con- junction with the present data, will probably supply an answer to this hypothesis. 113Applicability to Planning Agencies The findings of this study suggest that there are nutrition problems existing in the elderly population. It is now the function of health planners to attempt to develop and implement programs to correct these problems. The use of the data from this paper, plus the data from the companion paper on dietary histories, should be used by planners in program development. Emphasis should be focused on problems of the greatest magnitude in terms of both health and numbers. 72 Monagle JE: Food habits of senior citizens. Can J Pub Health 58:504-506, 1967 Geographical Area International implications. Study Design This paper pointed out the lack of research on geriatric nutrition as well as the need for more study in the area of constructive action. Findings in this paper were obtained from several Canadian studies. The Winnipeg study was directed toward elderly home-bound individuals. In 74 subjects selected from public health and welfare agency lists, all lived under somewhat less than desirable circumstances and often depended on others for help in obtaining food assistance. The Nutrition Division Study in- cluded 780 subjects in eight centers across Canada. The study was based on a random sample from Old Age Security mailing lists and voluntary response by return of a card which was mailed with a letter inviting participation. Food records were obtained by 24-hour recall interview on four consecutive days and were rated against "Canada's Food Guide." Significant Findings The Winnipeg study revealed 67% of the subjects were consuming diets with caloric intake below Canadian Dietary Standards. Twenty percent received less than two-thirds of the recommended calories. Low intake of other nutrients was also found; Vitamin A (45%), iron (39%) and ascorbic acid (31%). In general, diets were low in animal protein, fruits and vege- tables. Twenty-five percent of the men and 12% of the women had below normal Hb levels. Plasma protein levels were low in 33% of the women and 29% of the men. Half of the men were low in ascorbic acid levels. Diets were monotonous and rigid. The Nutrition Division Study found 9% of the sample had "Good Diets," 41% "Fair," 42% "Borderline," and 6% "poor." Forty-eight percent were below minimum levels in three or more food groups. The most poorly represented foods were: cheese, whole grain cereals, citrus fruit, eggs, milk, vegetables, and fruit. Fourteen percent had low caloric intakes. Thirty- seven percent were below Canadian recommended levels for iron and calcium, 28% for Vitamin A and 23% for ascorbic acid. Males fared better than females as a rule except when living alone. Those living with a spouse had the highest numbers of "Good" diets. Higher income did not assure a "Good" diet and over one-third of those on lower incomes had reasonably good dietary intakes. Thirty percent of the subjects had hemoglobin levels below normal and 9% had levels indicative of deficiency. Twelve percent had low plasma protein levels and 5% were deficient. Five percent of both sexes were low in ascorbic acid levels. Based on a subjective health inquiry, the state of health and quality of diet were posi- tively correlated. Evaluation The paper suggests two areas of primary concern (1) prevention or retardation of the pro- cess of degeneration, and (2) facilitating or contributing to the enjoyment of the later years of life. The fact that physiologic and psychologic implications are considered means evalua- tion is very difficult using conventional statistical methods. Still, both areas are of critical importance and a lack of objective criteria for evaluation should not inhibit efforts to satisfy both needs. The Winnipeg study was based on only 74 subjects, a rather small sample; thus, findings must be used with caution. 114The Nutrition Division Study is difficult to evaluate because the lists used for sampling are strictly confidential. So, project workers had no knowledge of names until receipt of the returned cards. This meant there was no method for determining how representative the final sample was or how the 700 who returned the card differed from the 7,300 who did not. Use of the 24-hour recall method is of limited value. Actual nutrition status, which is dependent upon long-term eating patterns, requires more detailed clinical and biochemical inves- tigation as well. Neither study used clinical examinations. Applicability to Planning Agencies While the paper is now 10 years old and is based on studies with several significant short- comings, the general trends in geriatric nutrition are still relevant. The findings presented in this paper used in conjunction with other more recent studies can be used by planners as an indication of the needs of this sub-group of the population. NUTRITION THROUGHOUT THE LIFE CYCLE Studies of Specific Areas 73 Prothro J, Mickles M, Tolbert B: Nutritional status of a population sample in Macon County, Alabama. Am J Clin Nutr 29:94-104, 1976 Geographical Area Macon County, Alabama, HEW Region IV. Study Design This study conducted dietary, biochemical, and clinical assessment of nutrition status in 20 preschoolers, 27 adolescents and 55 adults living in Macon Conty. Complete blood and urinary analyses were conducted for the adults and adolescents. A smaller series of tests were per- formed for the preschoolers due to the small amounts of blood received. Significant Findings Participants came from rural and urban settings as well as low and moderate income back- grounds. Intakes of protein, Vitamins A and C were adequate for the entire sample. However, intake of calories and iron was low. On an age group basis, calcium and iron were low for the preschoolers; calcium, iron and calories were low for the adolescents; and calcium and calorie intakes were low for the adults. Serum calcium levels were high, thus, not correlating with dietary data. Serum folate deficiencies were common for all age groups. Cholesterol levels were elevated for the 19 to 55 year old males and 56 to 85 year old males and females. Compar- isons by race were difficult because of unequal subgroup sizes. However, adult non-Black females had greater niacin intakes than adult Black females and lower hemoglobin values than any other group. Although non-Black adolescents and adults had greater B12 intakes, their Black counter- parts had higher serum B^2 levels. Evaluation This is an excellent study of the nutrition status of residents from a smaller geographical area. Methodologies chosen were appropriate for investigating the research question. Applicability to Planning Agencies Information from local studies such as these can be extremely useful to local planners in determining nutrition needs of a community. 11574 Odland LM, Mason RL, Alexeff AI: Bone density and dietary findings of 409 Tennessee sub- jects. I. Bone density consideration. Am J Clin Nutr 25:905-907, 1972 Geograhical Area Tennessee, HEW Region IV. Study Design X-ray bone densitometry was used to determine calcium storage and mineralization of bone in 113 males and 296 females ages 3 to 90 years. Dietary intakes, physical examinations, labora- tory analysis of blood and urine, and calcium and fluoride content of water were also determined. Significant Findings Males achieved highest bone densities in adulthood whereas females gained their highest bone densities 10 years later. As a person gets older, skeletal growth slows down and densities increase. Evaluation This report demonstrates the utility of using x-ray bone densitometry as a means of assessing bone mineralization status in people of all ages. Applicability to Planning Agencies Given the difficulty of assessing an individual's calcium status through dietary and bio- chemical means, such a method could be a more useful tool. However, attention must be given to the possible harmful effects of the roentgenograms to the health of children and young adults. 75 Odland LM, Mason RL, Alexeff AI: Bone density and dietary findings of 409 Tennessee sub- jects. II. Dietary considerations. Am J Clin Nutr 25:908-911, 1972 Geographical Area Tennessee, HEW Region IV. Study Design This article reports dietary information from 386 out of the 409 subjects participating in the bone x-ray study. Significant Findings Intake of protein, thiamine, riboflavin, and niacin generally were adequate in all age groups for both males and females. Girls from the ages of 3 through 20 appeared to have diets most lacking in nutrients compared to the RDA values. Iron, Vitamins A and C, and calcium were most frequently consumed in amounts below two-thirds of the RDA. Diets more nearly reflected recommended levels for those ages 21 and above. However, many males in the 71 to 80 age group exhibited low intakes of Vitamin C and calcium. Evaluation Clear, concise information is presented on the dietary intake of a variety of nutrients according to age group. Applicability to Planning Agencies Because the data are broken down according to age, such information can easily demonstrate possible nutrient need in each sub-group. 116BLACK POPULATIONS 76 Schuck C, Tartt JB: Food consumption of low-income, rural Negro households in Mississippi. __ JADA 62:151-155, 1973 Geographical Area Bolivar, Leflore, and Tallahatchie Counties in Mississippi, HEW Region IV. Study Design Information on income, household size, educational levels, kinds of foods eaten and the cost of the foods is presented for 461 Black households from three counties in Mississippi. Significant Findings Low income due to under employment was quite prevalent. Educational levels achieved generally were no higher than the sixth grade. As household size increased, so did expenditures for food. Meats and grains provided the main sources of calories. Forty percent of the total calories came from fat, most of which was in the meat. Food stamps did not reduce food costs because few of the study members participated in the program. The authors recommend adult education classes, child care centers, increased home food production and use of food stamps, and greater utilization of Cooperative Extension Aides as means of increasing employment potential, income, and nutrient intake. Evaluation This is a good descriptive study demonstrating the kinds of foods eaten and the amounts of money spent on food by low-income Blacks in the rural South. Applicabiliy to Planning Agencies The provision of food and/or nutrition services to low-income groups may not be successful if consideration is not given to their economic and social conditions. Ideally, nutrition services should be part of a total package of services that allows these people to help them- selves through increased educational and occupational opportunities. 77 Bradfield RB, Coltrin D: Some characteristics of the health and nutritional status of California Negroes. Am J Clin Nutr 23:420-426, 1970 Geographical Area California, HEW Region IX. Study Design Health statistics on Blacks in California are presented. Because few studies on the nutrition status of California Blacks have been done, reviews of research on Black preschool children, conducted mainly in the South, are presented. Significant Findings Compared to whites, Califo'rnia Blacks have lower levels of education, occupational status, income and higher rates of unemployment. Also, they have high birth rates, prematurity, fetal and maternal death rates. Studies of the nutrition status of Black preschool children are too diverse in their findings, thus preventing any applicability to the California population. : i' ; Evaluation ' ;: • "1 i; :: : i . This article reflects the lack of information on the nutrition status of Blacks in California. 117Applicability to Planning Agencies In order to provide nutrition services to low socioeconomic status populations and/or minorities, research must be conducted to determine the nature, extent, and location of health problems. This data could assist planners in allocating funds for various programs. DISADVANTAGED GROUPS 78 Inano M, Pringle DJ: Dietary survey of low-income, rural families in Iowa and North Carolina. JADA 66:366-370, 1975 Geographical Area Iowa, HEW Region VII; North Carolina, HEW Region IV. Study Design This is the third and final article in this series. The percentage of protein, calcium, Vitamin C and Vitamin A derived from intake of meat, milk products, and fruits and vegetables, respectively, is compared to the total nutrient content of diets of 35 Iowa and 25 North Carolina families. Significant Findings Wide ranges of intakes in the four nutrients coming from their respective food groups were found in both the Iowa and North Carolina families. However, all these families were selected because their diets contained two-thirds or more of the RDA; the remainder of these nutrients were coming from different food sources. For instance, some families received all their protein from dairy products. Evaluation This article clearly demonstrates the limitations in using the Basic Four Food Groups as a means of assessing adequate nutrient intake in groups of people. Applicability to Planning Agencies Assessing nutrition adequacy in groups or in.individuals is a difficult task. The method that is chosen depends upon the kind of question one wants to answer. While the USDA Basic Four Food Groups may be useful in classifying foods, they should not be used as a means for evaluating the adequacy of individual or group dietary intake. JAPANESE POPULATION 79 Wenkam NS, Wolff RJ: A half century of changing food habits among Japanese in Hawaii. JADA 57:29-32, 1970 Geographical Area Hawaii, HEW Region IX. Study Design This paper reviews the social and dietary changes in Japanese people who moved to Hawaii. Significant Findings Traditionally, the Japanese diet was high in carbohydrates and low in animal protein. Upon moving to Hawaii, bread, crackers, and white flour replaced rice and more animal protein was con- sumed. The majority of Japanese in Hawaii have acquired American food preferences but have 118retained some of the traditional foods. Such changes have occurred because of a desire for increased status, a breakdown of the traditional Japanese family, exposure to other ethnic foods, and public education. As a result of these dietary changes, life expectancies and stature have increased and deaths from beriberi have decreased. However, this is accompanied by increased dental decay and coronary heart disease. Evaluation This article reflects a great sensitivity to the factors that have resulted in the current eating practices of the Japanese population in Hawaii. Applicability to Planning Agencies If problems in nutrition health are found in special population groups, an investigation of the forces causing these problems must be conducted prior to attempting any behavior change. Otherwise, intervention activities will be futile. MIGRANT POPULATION 80 Kaufman M, Lewis E, Hardy AV, et al: Families of the Fields. Their Food and Their Health. Jacksonville, Florida, Department of Health and Rehabilitative Services, State of Florida, 1973 Geographical Area Palm Beach and Lee Counties, Florida, HEW Region IV. Study Design This study had two objectives. The first was to examine the nutrition status and prevalence of nutrition disorders in migrant workers and their families. The second was to develop, con- duct and evaluate a nutrition program designed to correct the nutrition problems. The majority of the seasonal workers were Black, Mexican, or Puerto Rican. Clinical, biochemical, anthropo- metric, and dietary information was obtained. Significant Findings No advanced clinical cases of nutrient deficiencies were found. A few children had rickets and growth retardation was found in the Black and Spanish-speaking children. Obesity was especially common in the women. Poor oral hygiene was evident in most adults. Biochemically, deficiencies of iron and folate were apparent. Diets usually were low in iron, Vitamins A and C, and calcium. Families demonstrating biochemical nutrition deficiencies received nutrition counseling. After one year, modest improvements were found in all nutrient intakes. The authors recommend continued health education programs in the schools and communities to bring about greater change. Evaluation This study proves that well designed and informative studies of the nutrition status of local groups can be done. Also, this study is unique in that it includes the additional inves- tigation of the effects of a nutrition intervention program. Applicability to Planning Agencies Seasonal agricultural workers should receive all the benefits of categorical nutrition programs. In addition, they should be monitored to determine the impact of programs on populations. hi 119MEXICAN AMERICANS 81 Bradfield RB, Brun J: Nutritional status of California Mexican-Americans. Am J Clin Nutr 23:798-806, 1970 Geographical Area California, HEW Region IX. Study Design This article reviews the available socioeconomic and health information about Mexican- Americans in California. Significant Findings Most California Mexican-Americans live in urban areas. They are the largest minority in the state. They have low educational levels, are mainly employed in the agricultural sector and receive low incomes. Few studies have been made of the health and nutrition status of Cali- fornia Mexican-Americans of all ages. Although under- and over-nutrition and anemia are thought to be health problems, few studies document this. Screening to determine health problems and their magnitude, delivery of culturally appropriate services, and evaluation of the effectiveness of the programs must be conducted. Evaluation Clearly, there is a paucity of information on the health status of Mexican-Americans in California. However, there may be more welfare and health services such as Food Stamps, W.I.C., and Summer Feeding, that are now available to them than there were in 1970. Applicability to Planning Agencies The majority of articles examining the health status of minority groups in the U.S. conclude that insufficient information and health programs are available about and to them. While nutrition is just one component of the total care needed by these groups, it must be provided in the same manner as other health programs. That is, screenings that identify prob- lems must be followed by action programs. These programs, in turn, must provide education that is culturally acceptable and that allows these groups to have knowledge of how to improve nutrition health themselves, referral to other services, and evaluation of program effectiveness. NATIVE AMERICANS 82 Bass MA, Wakefield LM: Nutrient intake and food patterns of Indians in Standing Rock Reservation. JADA 64:36-41, 1974 Geographical Area Standing Rock Reservation, straddling North and South Dakota, HEW Region VIII. Study Design This paper investigated the nutrient intake, meal patterns, attitudes toward weight, health, food, food sources, and use of native foods in a sample of 94 women and their families living on the Standing Rock Reservation. Significant Findings Calcium intake in these women was quite low due to low milk and milk products intake. Low intake of calories, riboflavin, and ascorbic acid was also found. Obesity was common mainly due to the sedentary lives of these women. Meat was seen as an important and prestigious food. These Indians no longer relied on the land for their food; most of it came from commodity foods 120or the grocery store. Seventy-three percent of the families received commodities and all except bulgur were used. Traditional foods were seen as very important, but were used only for certain purposes and/or when they could fit into their current life style. Evaluation This is a good article that explains food intake patterns of Sioux Indians. It would have been interesting if additional questions on their health attitudes included more than percep- tions of being overweight. Applicability to Planning Agencies Studies such as these are important for supplying information that becomes the foundation of nutrition intervention programs. One needs to know the current practices and attitudes of a particular population in order to determine where one will intervene and what methods to use. NUTRITION-RELATED HEALTH PROBLEMS ANEMIA 83 O'Neal RM, Abrahams OG, Kohrs MB, et al: The incidence of anemia in residents of Missouri. Am J Clin Nutr 29:1158-1166, 1976 Geographical Area Missouri, HEW Region VII. Study Design This study examined the incidence of low hemoglobin, hematocrit, and serum iron in relation to dietary intake of iron in a state-wide sample of people living in housing units in Missouri. Blood analysis was obtained from 1,164 persons and dietary histories from 530 people. These data are taken from the findings of the 1973 Missouri Nutrition Survey. Significant Findings Thirty percent of the white males ages 0 through 9, and over 59, had low or deficient hemo- globin levels. Such levels were much lower in white females. Low serum iron levels were found in many white males ages 6 to 9, and over 59, and in white females ages 10 and over. Low iron measures were found regardless of income backgrounds. Males with low hemoglobin or serum iron generally had sufficient dietary iron intake whereas females with less than two-thirds the RDA had normal hemoglobin and serum iron levels. However, in many children low biochemical measures and low dietary intakes were found thus suggesting iron deficiency anemia. For most ages, Blacks had lower hemoglobin and serum iron. Evaluation This is a good study that investigates the occurrence of iron deficiency anemia. While other studies have shown that it is a common problem in young children and women of child- bearing ages, this study suggests tht males over age 59 also may be at-risk. Applicability to Planning Agencies Given the inconsistent associations between biochemical and dietary indicators of iron status, it is difficult to estimate the number of individuals with iron deficiency anemia from survey populations. 12184 Katzman R, Novack A, Pearson H: Nutritional anemia in an inner-city community: relationship to age and ethnic group. JAMA 222:670-673, 1972 Geographical Area New Haven, Connecticut, HEW Region I. Study Design This article reports the incidence of iron deficiency anemia in 1,789 children (less than 21 years old) attending the Hill Health Center. The population was 56% Black, 11% white, and 33% Spanish-speaking. Children suspected of severe anemia were given more elaborate tests and, if confirmed, were treated with iron. Significant Findings Based on hemoglobin, and to a lesser extent, hematocrit, anemia was found in 17.5% of those age 10 months to three years. Incidence of anemia peaked again for adolescent girls (32.7% were anemic). Anemia was especially high in Black girls, ages 14 to 21. No consistent differ- ences in hemoglobin or hematocrit according to age categories were found among the three ethnic groups. Evaluation This study provides a very basic examination of the occurrence of anemia in children and the findings parallel most studies on the topic, namely, that iron deficiency anemia is common in the one-and two-year-old child and in the adolescent girl. Further information could be obtained if variables such as income, maternal education and dietary intake were examined. Finally, the occurrence of anemia may be less than it appears to be in the Black adolescent girl, given that Blacks have consistently lower hemoglobin and hematocrit values than whites. Applicability to Planning Agencies Although anemia in early childhood is an important public health concern due to its possible adverse effect on growth and development, anemia in the teenage girl must not be neglected. Pre-conceptual nutrition status has an important effect on pregnancy and pregnancy outcome. If a young woman enters pregnancy slightly anemic, the condition may worsen as the pregnancy progresses, thus causing potential harm to mother and child. CORONARY HEART DISEASE 85 Brown HB: Current Focus on Fat in the Diet. Chicago, American Dietetic Association, 1977 Geographical Area National implications. Study Design This booklet discusses the role of fat in the health and disease of Americans of all ages. Significant Findings Chapters include information on the need for and characteristics of fats, how they are metabolized, the relationships between lipids and atherosclerosis, and nutrition management in the prevention or treatment of atherosclerosis. The latter also can be applied to problems with hypertension, obesity, and diabetes mellitus. Recommendations on fat consumption and an excellent selected bibliography are presented at the end. 122.Evaluation This represents the most current comprehensive explanation of the role of fat and its association with disease that has been published. It is an excellent source book for physicians and nurses as well as dietitians and nutritionists because it has integrated the current available information. Applicability to Planning Agencies Coronary heart disease is a major killer of Americans. Given the association between nutrition factors and atherosclerosis, it is imperative that Americans of all ages begin taking measures that will aid in preventing, as much as possible, the further elaboration of this disease. 86 Walker WJ: Changing United States lifestyle and declining vascular mortality: cause or coincidence? N Engl J Med 297:163-165, 1977 Geographical Area National implications. Study Design This paper discussed the role of changes in life style and eating habits in causing the reduced vascular mortality in the U.S. Significant Findings The author noted declines in deaths from coronary heart disease after the warning on smoking by the Surgeon General and the recommendations on diet changes by the American Heart Association. Cerebrovascular mortality has decreased because of better treatment of hypertensive patients. Deaths from these vascular causes have declined at a faster rate than deaths from non-vascular causes. Coronary mortality decreases have paralleled a decrease in per capita consumption of animal fats, smoking, butter, whole milk, cream, and eggs. Evaluation This article provides a refreshing viewpoint. Declines in mortality from coronary and vascular diseases have been paralleled by changes in diet and smoking habits. However, the population data used to determine these trends did not deal with changed life style habits in those at-risk. Rather, coronary and cerebrovascular mortality data were separate from con- sumption data so whether the decreased deaths were due to changes in eating and smoking is unknown. Applicability to Planning Agencies It is important to know whether these population trends of changes in diet and smoking are actually preventing vascular mortality in those who might have been at-risk. If such a re- lationship is found, then changing people's habits in order to prevent ill-health is not hopeless, but rather, a significant endeavor. 87 Mayer J (ed): Nutrition and heart disease: National Commission's report. Postgrad Med 19:257-259, 1971 Geographical Area National. Study Design This article reviewed the recommendations made by the Inter-Society Commission for Heart Disease Resources on diet and heart and arteriosclerotic diseases and criticisms of their report.Significant Findings Evidence is cited for the role of saturated fats and cholesterol in mortality caused by coronary heart disease. The Commission requested a national study on the effects of dietary changes in reducing the risk of death from heart disease. However, if such recommendations are made, they will be opposed by those in the cattle and dairy industries. The Commission did not examine other risk factors such as genetics, smoking, lack of exercise, and hypertension. The v^«'role of the family physician in providing preventive care to patients is stressed. Evaluation This article presents good information that was available in 1971. However, now it is known that hypertension, cigarette smoking, and elevated cholesterol levels are considered risk fac- tors in the morbidity and mortality from coronary heart disease. Applicability to Planning Agencies The recommendations made by the Commission in 1970 (reduced total fat, saturated fat, and cholesterol consumption, increased polyunsaturated consumption) are identical to the recommenda- tions made by Senator McGovern, seven years later, in his Dietary Goals for the United States. Federal acceptance followed by federal monies filtered to state and then local agencies will provide the resources needed to systematically attack the problem of coronary heart disease and atherosclerosis through prevention programs. 88 Moore MC, Moore EM, Beasley CdeH, et al: Dietary atherosclerosis study on deceased persons: methodology. JADA 56:13-22, 1970 Geographical Area New Orleans, Lousiana, HEW Region VI. Study Design This paper reports the entire process that was followed to develop a questionnaire on food practices that could be completed by a wife in order to ascertain the dietary practices of her husband who died of atherosclerosis. Significant Findings After much pre-testing and training, wives of living husbands were able to give accurate information on their husband's time of eating, number of meals and snacks eaten away from home, and kinds and amounts of foods they consumed. Eating meals away from home did not change the accuracy of the determination of dietary patterns. Evaluation Clearly the questionnaire on food practices that was developed was based upon extremely thorough and comprehensive pre-testing. Applicability to Planning Agencies Data on the dietary patterns of people who died from atherosclerosis may help explain the association between diet and the progression and end-point of the disease. 89 Moore MC, Moore EM, Beasley CdeH: Dietary-atherosclerosis study of deceased persons: eating habits of 208 deceased males in a biracial community. JADA 56: 23-28, 1970 Geographical Area New Orleans, Louisiana, HEW Region VI. 124Study Design This study investigated possible relationships between food intake, atherosclerosis, and racial differences in 208 autopsied males. The food intake data were based upon the question- naire discussed in the previous paper. The sample was 46% white and 54% non-white. The majority of the deceased males fell into the 45 to 55 year age group and the next highest represented age category included those 35 to 44 or 46 or over. Significant Findings White subjects consumed more coffee than non-white subjects; however, the latter consumed more carbonated beverages. Wheat, dairy and animal protein products were eaten in greater quantitites by the white men. Rice and corn starch products, pork, dried beans, and eggs were more frequently eaten by the non-white population. Furthermore, this latter group consumed more beef fat, pork fat, and visible fats. Evaluation The task of obtaining dietary data of deceased individuals is quite difficult. However, it is possible to examine the association between diet and atherosclerosis in persons with the disease who are not deceased. This facilitates obtaining dietary intakes. Future studies of intake should focus specifically on the frequency of consumption of specific "at-risk" foods. Applicability to Planning Agencies This study raises the possibility that there may be a racial element in the incidence and severity of atherosclerosis. Whether this is due to differences in diet needs to be further investigated. OBESITY 90 Weil WB: Current controversies in childhood obesity. J Pediat 91:175-187, 1977 Geographical Area National implications. Study Design This article reviewed the literature on the definition and measurement of obesity, its natural history, the cause of obesity and its adverse effects and the treatment of this condi- tion. Significant Findings Definition and Measurement: Obesity refers to excessive body fat but attempts to measure it have been difficult. Weight alone is a poor index of fatness especially in young children and adolescents. A reliable measure must account for age, height, sex, and body build. Calipers measuring fatfold thickness is the best measurement of fatness that can be used clinically. Natural History: Those who are obese as children have a high probability of being obese as adults. But most of the obesity in adulthood is not a result of childhood obesity. Etiology: Reduced physical activity modified by biological, social, and psychological forces currently is seen as the major cause of obesity. Significance: Positive correlations between obesity and hypertension, cerebrovascular accidents and diabetes mellitus have been found. However, the psychologic and social effects of obesity are more hazardous in children. 125Treatment: The author recommends dietary restrictions in conjunction with treatment of the psychosocial forces as the first step in the treatment of obesity. If that fails, techniques such as behavior modification should be used. Evaluation This article provides a good review of the literature on obesity. The bibliography is ex- tensive and is in itself an excellent resource. Dietary recommendations such as the elimination of "carbohydrate snack foods" (does this include fruits, vegetables, and crackers?) need clarification. Although the psychological effects of obesity are important, greater emphasis should be placed on the adverse health effects of obesity. Applicability to Planning Agencies Obesity is a common disease in Americans of all age groups. Because of its association with coronary heart disease, stroke, hypertension, and diabetes mellitus, it is a major problem and should be the priority of public health programs. Preventive activities must be aimed at people of all ages and include treatment of the environmental conditions that lead to the development of this condition. 91 Mayer J: Obesity during childhood, in Childhood Obesity. Winick M (ed). New York, John Wiley, 1975, pp 73-80 Geographical Area National implications. Study Design Various mechanisms of food regulation and causes of obesity are described. Significant Findings Obesity results from small excesses in caloric intake which, over a long period of time, results in several extra pounds of body weight stored as fat. Individuals are "programmed" for the number of calories that are needed and if one over- or under-eats for a while, one's regulatory mechanism will compensate at a later date. There are 12 to 15 kinds of obesity. Some kinds depend upon body types, feelings of satiety, regulation of food intake in keeping with activity levels, genetic inheritance, socioeconomic status, and activity levels. The obese child is treated as an outcast and this rejection further lowers his/her self-image leading to reduced activity and greater obesity. Evaluation This article provides a good introduction to the causes of obesity in childhood. Applicability to Planning Agencies This article is placed under the disease category of this life cycle section instead of under the childhood category to demonstrate one point. That is, obesity in adulthood is close to impossible to reverse. If obesity can be prevented in early childhood then the number of obese adults will be reduced. Because obesity is a major health problem for its primary and secondary complications, it must be stopped or prevented in early life. nx 126DIABETES MELLITUS 92 West KM: Prevention and therapy of diabetes mellitus. Nutr Rev 33:193-198, 1975 Geographical Area National implications. Study Design This paper reviewed the nutrition-related causes of diabetes, the effect of diet on the disorders associated with the diabetes, and the role of diet therapy in treatment. Significant Findings Obesity and total caloric intake, regardless of food source, are the most important dietary factors in the cause of diabetes. Complications secondary to the diabetes include coronary disease, gangrene, atherosclerosis, small vessel disease and ketosis. Diet therapy for the obese maturity-onset diabetic includes weight reduction through diet and/or exercise. However, for the lean adult diabetic, adequate calories and meals taken at regular times are important. Restric- tion of carbohydrate intake is no longer emphasized because insulin needs depend upon total energy ingested. Evaluation This article is an excellent review of the current information on the dietary causes of diabetes and dietary treatments for the disease. It is especially important that health care practitioners realize that carbohydrate restrictions are no longer severe. Little information is given about the juvenile-onset diabetic, however. Applicability to Planning Agencies Diabetes mellitus is a disease of major proportions in the U.S. Because of its association with other major diseases, such as obesity, coronary heart disease, atherosclerosis, kidney, and eye disease, it should be the concern of public health programs. Such programs must include a nutrition component given the importance of nutrition in preventing or controlling diabetes. 93 Tokuhata GK, Miller W, Digon E, et al: Diabetes mellitus: an underestimated public health problem. J Chron Dis 28:23-35, 1975 Geographical Area Pennsylvania, HEW Region III. Study Design This study investigated the total number of deaths from diabetes in Pennsylvania whether or not it was stated as a contributory or underlying cause on the death certificate. Significant Findings Careful investigation showed that instead of 2,639 diabetic deaths, 18,970 Pennsylvanians had diabetes at the time of death from 1968-1969. Therefore, examining underlying, contribu- tory and not reported causes, could make diabetes the third leading cause of death in the U.S. From the Pennsylvania data, diabetes as an underlying cause of death was being replaced by the classification "heart disease." A comparison of other complications of diabetes showed that obesity, hypertension, heart disease, retinopathy, and cerebrovascular disease were more preva- lent in diabetic patients than in non-diabetic patients. Evaluation This is an illuminating article that demonstrates that diabetes mellitus may be underestima- ted in its importance as a cause of death in the U.S. Proper testing of live individuals and better reporting on death certificates will show a truer indication of its significance. 127Applicability to Planning Agencies Clearly, diabetes constitutes a major public health problem. Primary prevention, including regular screening and proper weight control, will assist in decreasing the number of new cases occurring. Continual monitoring and therapy can assist in controlling the severity of the disease. Federal funding for research and health programs should reflect the importance of this disease. DENTAL DISEASES 94 Frequency of eating and dental caries prevalence. Nutr Rev 32:139-141, 1974 Geographical Area National implications. Study Design This paper reviewed articles on the effect of the frequency of eating on the occurrence of decayed, missing, and filled teeth in people of all ages. Significant Findings In a Hawaii study, those children who brushed their teeth frequently and ate more breads, buns, and rolls as opposed to candy and gum, had a reduced prevalence of dental caries. Another study showed a negative correlation between dental caries occurrence and consumption of milk, meat and vegetables and a positive correlation with the consumption of candy, desserts, and snacks. Consumption of pre-sweetened cereals on an elective basis by children in another cited study did not cause an increased incidence of decayed, missing, and filled teeth. Conflicting evidence is available on the effect of race, sex, and age on caries prevention. Evaluation There are too many population variables and problems in study design that interfere in these studies, thus preventing a clear explanation of the effect of feeding frequency on the prevalence of dental caries. Applicability to Planning Agencies Although a demonstrated correlation between frequency of feeding on general and dental caries occurrence is not found, consumption of specific foods high in plaque-forming carbohy- drates (usually refined sugars), compounded by a low frequency of toothbrushing will aid in the development of dental caries in people of all ages. Thus, nutrition education can play an important role in dental health by promoting the consumption of fruits and vegetables instead of pastries and candy, as well as frequent brushing and fluoride treatments. Consumption of non-cariogenic foods may have other long-range benefits such as the prevention of obesity and the associated secondary complications. 95 Mayer J (ed): Diet and periodontal disease. Postgrad Med 49:249-251, 1971 Geographical Area National implications. Study Design This article explains the importance of nutrition in the prevention and treatment of periodontal disease. 128Significant Findings Excessive carbohydrate and Vitamin D, and inadequate protein, calcium, phosphorus, fluoride, Vitamin A, and Vitamin B complex intakes all can have some detrimental effect on periodontal tissue leading to various types of periodontal diseases. "Resistance," "sparingly used," and "susceptibility" foods refer to the range of foods that are beneficial, not too harmful, and harmful, respectively, to the periodontal patient. Evaluation This is a highly technical article that is best understood by the periodontist and other workers in the dental field. Applicability to Planning Agencies This is another example of the role of nutrition in the dental health field. Care must be taken to insure that the diet given to the periodontal patient does not conflict with any other therapeutic diet the patient might have. Nutrition consultation with the periodontist will assist in providing foods which will supplement any nutrient deficiencies that may have caused the disease. CANCER 96 Mayer J (ed): Clinical nutrition: Nutrition and cancer. Postgrad Med 50:65-67 (Oct); 57-59 (Nov), 1971 Geographical Area National implications. Study Design These two articles discuss many of the nutrition disturbances caused by cancer or by the methods used to control the cancer. Significant Findings Anorexia, increased basal metabolic rates, and negative nitrogen balances are commonly found in cancer patients. Other frequently seen problems are the malabsorption of different nutrients due to tumorous obstructions or lesions in the gastrointestinal tract. Hyperalimen- tation probably does not relieve any of these problems. While nutrition therapy cannot cure the cancer patient, it could make him/her more comfortable. Chemotherapy, radiotherapy, and surgery, the common methods used in cancer treatment, all cause a variety of malabsorption problems. However, because cancer treatment takes highest priority, nutrition status must be monitored on an on-going basis to prevent these secondary problems. Evaluation This is a good review of the nutrition problems that are caused by career or cancer therapy. Applicability to Planning Agencies Nutrition monitoring is especially crucial for the outpatient cancer patient who is not in a hospital setting where he/she has ready access to such monitoring. Although nutrition therapy cannot cure the various forms of cancer, it does play an important role in decreasing the patient's discomfort and secondary problems from cancer and cancer treatment. 129DIETARY FIBER 97 Burkitt DP, Walker ARP, Painter NS: Dietary fiber and disease. JAMA 229:1068-1074, 1974 Geographical Area International. Study Design This article, using epidemiological data, examined the possibility that decreased fiber intake causes a variety of gastrointestinal diseases common to the Western world. Significant Findings Diseases such as appendicitis, diverticular disease, gallstones, varicose veins, deep vein thrombosis, hiatus hernias, hemorrhoids, cancer of the colon and rectum, and obesity, are relatively new chronic diseases that have spread to affluent, urbanized countries. Changes in eating habits such as decreased consumption of fiber, and increased sugar and fat consumption were paralleled by an increased prevalence of these diseases. Fiber in the diet decreases the time the stool is stored in the colon and therefore decreases the time available for bacterial proliferation. A lack of fiber can cause the above-mentioned diseases. Evaluation This is an interesting article that implicates changes in the Western diet, specifically decreased fiber intake, in order to lessen the incidence of a variety of chronic diseases of the gastrointestinal tract. Applicability to Planning Agencies While fiber is lacking in Americans' diets, it is important not to ascribe too many bene- ficial traits to this dietary component without having more controlled prospective studies. ORAL CONTRACEPTIVES 98 Brown JE, Cairns K: Nutrition related health risks associated with oral contraceptive use. Minneapolis, University of Minnesota, School of Public Health (unpublished report), 1977 Geographical Area Minneapolis and St. Paul, Minnesota, HEW Region V. Study Design This is a retrospective study that examined 556 medical records from one Planned Parenthood and two Family Planning Clinics in the Twin Cities area. The effect of oral contraceptive use on health was investigated to determine the need for nutrition services in these clinics. Significant Findings A significant increase in weight was found in women using the Pill for 6 to 12 months. Mean systolic blood pressures also were higher in these women as well as occurrences of protein in their urine. Other possible oral-contraceptive linked problems not examined here include Vitamin Bg and folic acid deficiency, hypertension and abnormal glucose tolerance. The promo- tion of good nutrition in family planning clinics not only could promote health in the inter- conceptual and conceptual periods, but could also reduce the potential adverse effects of oral contraceptive agents. 130Evaluation This is a good example of the kinds of studies that could be conducted on a local basis. However, larger population studies have not shown that the problems apparent here are typical problems that occur with oral contraceptive use. Applicability to Planning Agencies Again, nutrition education plays an important role in the family planning clinic. For the healthy client, it can insure good nutrition health that will aid in the success of future pregnancy outcomes. For those women with biochemically and clinically demonstrated nutrition problems, related or unrelated to oral contraceptive use, nutrition counseling and therapy can reduce and/or eliminate the problems and restore health to the client. 99 Committee on Nutrition of the Mother and Preschool Child: Oral Contraceptives and Nutrition. Washington, DC, National Academy of Sciences, 1975 Geographical Area National implications. Study Design This article examines the effect of oral contraceptives on various vitamin levels. Significant Findings With respect to Vitamin and B^., some methods of analysis demonstrate an increased need for these vitamins with oral contraceptive use whereas other methods demonstrate no change in need. Reduced serum or erythrocyte folate levels have been found in some studies of oral con- traceptive users, and Vitamin C needs are increased. Use of oral contraceptives reduces the need for Vitamin A, iron and copper. Despite these biochemical effects, few changes have been seen clinically. The Committee concluded that nutrition assessment and counseling should be provided in family planning clinics and that more research should be conducted on the biochemical and clinical effects of oral contraceptive agents. Evaluation This brief paper provides current information on the biochemical effects of oral contracep- tives. Applicability to Planning Agencies In planning nutrition components for family planning programs, attention must be given to general aspects of nutrition, as well as to the effects of different methods of contraception on nutrition status. 131CHAPTER II, DELIVERY OF NUTRITION SERVICES INFORMATION FROM STATE NUTRITION PROGRAMS WITH TWO MODELS To determine the kinds of nutrition services currently available throughout the country, information was sought from the Association of State and Territorial Public Health Nutrition Directors and Graduate Faculties in Public Health Nutrition. Twenty-seven states reponded to this request. The literature received provides examples of programs that have been successful in some states which could be implemented in others. These examples, by no means, provide an exhaustive list of services in each state but they do indicate some of the ongoing programs to meet nutri- tion needs. Two states, Arizona, in Region IX, page 159, and Oregon, in Region X, page 163, are particularly important to study. In each of these states, a variety of well coordinated nutrition services are provided and emphasis is on the preventive as well as the curative aspect of nutrition and health. Both Arizona and Oregon have complete plans for nutrition ser- vices. They formulate objectives on the basis of identified needs. Services are planned so that outcomes can be measured in quantifiable terms. This allows for ongoing evaluation and provides data that are useful in planning future programs. The information is a resource that enables planners to review the nutrition activities occurring in their respective states. DHEW Regions were used as the format for this presentation of information. Also included is the name and address of the nutritionist in each state who provided the information. Table 3 is a directory of members of the State and Territorial Public Health Nutrition Directors throughout the country. Planners should utilize the public health nutrition director as a major source of nutrition information for plans being prepared by HSA's. The literature received was reviewed in terms of the following characteristics. Nutrition needs identified by the state. Nutrition objectives formulated at the state level. Services offered by the state. Provisions made for evaluating services. 132Table 3 Directory of Members of the Association of State and Territorial Public Health Nutrition Directors ALABAMA Nutrition Services Administrator Bureau of Maternal & Child Health Alabama Dep't. of Public Health State Office Building Montgomery, Alabama 36103 (205) 832-6525 ALASKA Sandra K. Graham Chief Nutritionist State of Alaska Division of Health & Social Services McKay Building, Room 222 338 Dinali Street, Anchorage, Alaska (907) 465-3110 ARIZONA Morissa J. White Acting Chief, Bureau of Nutrition Arizona Dep't. of Health Services 1740 West Adams Street Phoenix, Arizona 85007 (602) 271-3478 ARKANSAS Carol Fowler Nutritionist Supervisor Arkansas Dep't. of Health 4815 West Markham Street Little Rock, Arkansas 72201 (505) 661-2242 CALIFORNIA Patricia E. Jensen Nutrition Consultant California Department of Health 714 "P" Street Sacramento, California 95814 (916) 322-2950 COLORADO Judy L. Ross Nutrition Consultant Colorado Dep't. of Health 4210 E. 11th Avenue Denver, Colorado 80220 (303) 388-6111 Ext. 259 1977 CONNECTICUT Elolse K. Eckler Chief, Nutrition Section Community Health Division Connecticut State Dep't. of Health 79 Elm Street Hartford, Connecticut 06115 (203) 566-2520 DELAWARE Mayton Zickefoose Nutritionist III Division of Public Health Dep't. of Health & Social Serv. Jesse Cooper Building Dover, Delaware 19901 (302) 678-4725 DISTRICT OF COLUMBIA Lois B. Earl Chief Nutritionist Department of Human Resources Munsey Building, Room 319 1329 "E" Street, N.W. Washington, D.C. 20014 (202) 724-8818 FLORIDA Mildred Kaufman Nutrition Program Supervisor Florida Dep't. of Health and Rehabilitative Services 1323 Winewood Blvd. Tallahassee, Florida 32301 (904) 487-1075 GEORGIA Frances R. Hanks Chief Nutritionist Division of Physical Health Georgia Dep't. of Human Resources 47 Trinity Ave., S.W., Rm. 516-H Atlanta, Georgia 30334 (404) 656-4667 133GUAM KENTUCKY Jeanne Sterling Peggy S. Kidd Chief Nutritionist Advisor for Nutrition Dep't. of Public Health & Social Services Bureau for Health Services P. 0. Box 2816 Agana, Guam 96910 734-9904, Ext. 201 HAWAII Flora L. Thong Chief, Nutrition Branch Hawaii State Dep't. of Health P. 0. Box 3378 Honolulu, Hawaii 95801 (808) 548-6552 IDAHO Jane DeBuse Chief Nutritionist M&I Care Project Idaho Dep't. of Health & Welfare State House Boise, Idaho 83720 (208) 384-3471 ILLINOIS Genevieve Anthony Dietary Service Consultant Illinois Dep't. of Public Health 535 West Jefferson Street Springfield, Illinois 62761 (217) 782-6698 INDIANA Lois A. Gumper Nutrition Consultant Indiana State Board of Health 1330 West Michigan Street Indianapolis, Indiana 46206 (317) 633-4610 IOWA Anna Katherine Jernigan Director, Nutrition & Dietary Management Section Iowa State Dep't. of Health Lucas State Office Building Des Moines, Iowa 50319 (515) 281-4120 KANSAS Rebecca E. Rowe Nutritionist Bureau of MCH Kansas Dep't. of Health and Environment Forbes Air Force Base, Bldg. 740 Topeka, Kansas 66620 (913) 296-3506 Kentucky Dep't. for Human Resources 275 East Main Street Frankfort, Kentucky 40601 (502) 564-4740 LOUISIANA Rose Ann Langham, Ph.D. Administrator, Nutrition Program Lousiana Health and Human Resources Administration Division of Health P. 0. Box 60630 New Orleans, Louisiana 70160 (504) 568-5065 MAINE William Carney Deputy Commissioner Department of Human Services State House Augusta, Maine 04333 (207) 289-2546 MARYLAND Clare Forbes Chief, Division of Nutrition Maryland Dep't. of Health and Mental Hygiene 201 West Preston Street Baltimore, Maryland 21201 (301) 383-3494 MASSACHUSETTS Joel M. Hollis Public Health Nutritionist Mass. Department of Public Health 600 Washington Street Boston, Massachusetts 02111 (617) 727-2642 MICHIGAN Molly A. Graber Chief Nutritionist Bureau of Personal Health Serv. Michigan Dep't. of Public Health 3500 North Logan Street Lansing, Michigan 48906 (517) 374-9500 13AMINNESOTA F. Eileen Reardon Supervisor of Nutritionists Minnesota Dep't. of Health 717 Delaware Street, S.E. Minneapolis, Minnesota 55440 (612) 296-5280 MISSISSIPPI Vonda A. Webb Director of Nutrition Services Miss. State Board of Health P. 0. Box 1700 Jackson, Miss. 39205 (601) 354-6680 MISSOURI Amy Anderson Director, Bureau of Nutriton Division of Health Missouri Dep't. of Social Serv. P. 0. Box 570 Jefferson City, Missouri 65101 (314) 751-3751 MONTANA Helen Magnuson-Gerig Nutrition Consultant Maternal & Child Health Bureau State Dep't. of Health and Environmental Sciences Cogswell Building Helena, Montana 59601 (406) 449-2554 NEBRASKA Kathleen Hanna Director, Nutrition Division Nebraska Dep't. of Health P. 0. Box 95007 Lincoln, Nebraska 68509 (402) 471-2781 NEVADA Kathleen A. McBurney Nutrition Consultant Nevada Division of Health Capitol Complex, Kinkead Bldg. 505 East King Street Carson City, Nevada 89710 (702) 885-4800 NEW HAMPSHIRE Dona H. White Director, Public Health Nutrition Services New Hampshire Div. of Public Health 61 South Spring Street Concord, New Hampshire 03301 (603) 271-2776 NEW JERSEY Margaret P. Zealand Nutrition Consultant New Jersey State Dep't. of Health John Fitch Way, Box 1540 Trenton, New Jersey 08615 (609) 292-8106 NEW MEXICO Marjorie Townsend Chief, Office of Food, Nutrition and Health State Health Agency HSSD 113 Washington Street State Securities Building Santa Fe, New Mexico 87503 (505) 827-2914 NEW YORK John H. Browe, M.D. Director, Bureau of Nutrition N.Y. State Dep't. of Health Empire State Plaza Albany, New York 12237 (518) 474-4374 NORTH CAROLINA Barbara Ann Hughes Head, Nutrition & Dietary Services Branch Division of Health Services N.C. Dep't. of Human Resources P. 0. Box 2091 Raleigh, North Carolina 27602 (919) 733-2351 NORTH DAKOTA Joan Tracy, Dietitian Division of Maternal & Child Health N.D. State Health Department State Capitol Building Bismarck, North Dakota 58505 (701) 224-2493 OHIO Joyce Kline, Ph.D. Chief, Nutrition Division Ohio Department of Health 450 East Town Street, Box 118 Columbus, Ohio 43216 (614) 466-4110 135OKLAHOMA Elizabeth B. Hensler Director, Nutrition Division Okla. State Dep't. of Health N.E. 10th Street & Stonewall Oklahoma City, Oklahoma 73105 (AOS) 271-4676 OREGON Chedwah Stein Manager, Nutrition Unit Oregon State Division of Health P. 0. Box 231 Portland, Oregon 97222 (502) 229-5593 PENNSYLVANIA Billye June Eichelberger Director, Division of Nutrition Penn. Department of Health 604 Health & Welfare Building Harrisburg, Pennsylvania 17120 (717) 787-5376 PUERTO RICO Maria Virginia Cruz de Lara Director, Nutrition Program Puerto Rico Dep't. of Health San Juan, Puerto Rico 00908 (809) 763-8890 RHODE ISLAND M. Constance McCarthy Chief, Public Health Nutrition Service R. I. Department of Health 75 Davis Street Providence, R.I. 02908 (401) 277-3093 SOUTH CAROLINA Director, Division of Nutriton S. C. Dep't. of Health & Environmental Control 2600 Bull Street Columbia, S.C. 29201 (803) 758-5647 SOUTH DAKOTA Judy Davis Nutritionist/MCH Program S.D. Dep't. of Health Pierre, S.D. 57501 (605) 734-6639 TENNESSEE H. Lee Fleshood, Ph.D. Director, Division of Nutrition Services R.S. Gass State Office Building Room 312 Ben Allen Road Nashville, Tennessee 37219 (615) 741-7218 TEXAS Helen B. Campbell, Ph.D. Special Project Director Health Maintenance Texas Dep't. of Health Resources 1100 West 59th Street Austin, Texas 78756 (312) 458-7352 T.T.P.I. Director of Health Services Trust Territory of Pacific Islands Saipan, Mariana Islands 96950 2192-2155 UTAH Blanche Z. Rappleye Maternal & Child Health Nutrition Consultant State Division of Health 44 Medical Drive Salt Lake City, Utah 84113 (801) 533-6181 VERMONT Ellen B. Thompson Chief, Nutrition Services Vermont Dep't. of Health 115 Colchester Avenue Burlington, Vermont 05401 (802) 862-5701 VIRGINIA Juliet Milk Nutrition Services Supervisor State Dep't. of Health 109 Governor Street Richmond, Virginia 23219 (804) 786-7367 VIRGIN ISLANDS Julia T. Wallace Director, Nutrition Services Virgin Islands Dep't. of Health Box 7309, Charlotte Amalie St. Thomas, Virgin Islands 00801 (809) 774-7775 136WASHINGTON WISCONSIN J. June Stein Senior Nutrition Consultant Health Services Division Washington State Dep't. of Social & Health Services P. 0. Box 1788 M.S. 3-3 Olympia, Washington 98504 (206) 753-5849 WEST VIRGINIA Margaret E. Ferguson Director, Bureau of Nutrition West Virginia Dep't. of Health 1800 Washington Street, East Charleston, W.V. 25305 (304) 348-2985 Martha S. Kjentvet Chief, Section of Nutrition Wisconsin State Division of Health P. 0. Box 309 Madison, Wisconsin 53701 (608) 266-2661 WYOMING Edith M. Constantine Registered Dietitian Div. of Health & Medical Services Wyoming Dep't. of Health & Social Services Cheyenne, Wyoming 82002 (307) 777-7278 137Directory of Members Faculties of Graduate Programs in Public Health Nutrition 1977 Institutions presently (1977) giving master's programs in public health nutrition and their directors are listed below. Further information may be obtained by writing the program directors. UNIVERSITY OF CALIFORNIA, BERKELEY HARVARD SCHOOL OF PUBLIC HEALTH Attn: Dr. Eileen Peck Assistant Professor of Public Health Nutrition School of Public Health University of California Berkeley, California 94720 Phone: (415) 642-4327 UNIVERSITY OF CALIFORNIA, LOS ANGELES Dr. Robert A. Mah, Head of ENS Division Professor of Environmental Sciences School of Public Health UCLA Los Angeles, California 90024 Phone: (213) 825-5157 CASE WESTERN RESERVE UNIVERSITY Dr. Janice Neville Chairman, Department of Nutrition Case Western Reserve University 2121 Abington Road, Room 218A Cleveland, Ohio 44106 Phone: (216) 368-2440 COLUMBIA UNIVERSITY, TEACHERS COLLEGE Dr. Joan D. Gussow Chairman, Program in Nutrition Teachers College Columbia University Box 137 New York, New York 10027 Phone: (212) 970-4477 CORNELL UNIVERSITY Dr. Malden Nesheim, Director Intercollege Division of Nutritional Sciences Savage Hall Cornell University Ithaca, New York 14850 Phone: (607) 256-5436 Attn: Dr. Daphne Roe Dr. Fredrick J. Stare Head, Department of Nutrition Harvard School of Public Health 665 Huntington Avenue Boston, Massachusetts 02115 Phone: (617) 734-3300 UNIVERSITY OF HAWAII Dr. Jean Hankin Professor of Public Health Department of Public Health Services School of Public Health University of Hawaii 1960 East-West Road Honolulu, Hawaii 96822 Phone: (808) 948-8577 LOMA LINDA UNIVERSITY Dr. U.D. Register Chairman, Department of Nutrition School of Public Health Loma Linda University Loma Linda, California 92354 MASSACHUSETTS INSTITUTE OF TECHNOLOGY Dr. Nevin S. Scrimshaw Head, Department of Nutrition and Food Science Massachusetts Institute of Technology Cambridge, Massachusetts 02139 Phone: (617) 253-5101 UNIVERSITY OF MICHIGAN George Owen, M.D. Director, Human Nutrition Program Department of Community Health Services School of Public Health University of Michigan 1420 Washington Heights Ann Arbor, Michigan 48109 Phone: (313) 764-3277 138UNIVERSITY OF MINNESOTA Dr. Judith Brown Acting Director Nutrition Program School of Public Health University of Minnesota 1342 May Memorial Minneapolis, Minnesota 55455 Phone: (612) 373-8112 UNIVERSITY OF NORTH CAROLINA Dr. Joseph C. Edozien Professor of Public Health Nutrition Department of Nutrition School of Public Health University of North Carolina Chapel Hill, North Carolina 27514 Phone: (919) 966-1078 PENNSYLVANIA STATE UNIVERSITY Dr. Laura S. Sims, Assistant Professor of Nutrition in Public Health College of Human Development 114-C Human Development Building The Pennsylvania State University University Park, Pennsylvania 16802 Phone: (814) 856-3447 UNIVERSITY OF PUERTO RICO Dr. Elizabeth Sanchez Head, Department of Biochemistry and Nutrition University of Puerto Rico San Juan, Puerto Rico 00905 UNIVERSITY OF TENNESSEE Dr. Roy E. Beauchene Acting Head and Professor Department of Food Science, Nutrition and Food Systems Administration College of Home Economics University of Tennessee Knoxville, Tennessee 3^916 Phone: (615) 974-3491 Programs UNIVERSITY OF TORONTO Mrs. Ann Bodley Assistant Professor and Program Director Department of Nutrition and Food Science Faculty of Medicine, Fitzgerald Building University of Toronto Toronto, Ontario, Canada M5S 1A1 Phone: (416) 928-2134 TULANE UNIVERSITY Mrs. Ann Metzinger, Assistant Professor of Nutrition Tulane University School of Public Health and Tropical Medicine 1430 Tulane Avenue New Orleans, Louisiana 70112 Phone: (504) 588-5397 TUSKEGEE INSTITUTE J. King Acting Head, Department of Home Economics and Food Administration Tuskegee Institute Tuskegee Institute, Alabama 36088 VIRGINIA POLYTECHNIC INSTITUTE AND STATE UNIVERSITY Dr. Ryland Webb Head, Department of Human Nutrition and Foods Virginia Polytechnic Institute Blacksburg, Virginia 24601 Phone: (703) 951-6783 Attn: Jane Wentworth, Ph.D., Coordinator Organization UNIVERSITY OF CONNECTICUT HEALTH CENTER Dr. Simone Adams University of Connecticut Health Center Farmington, Connecticut 06032 UNIVERSITY OF CONNECTICUT Dr. Kirvan Knox Division of Nutritional Science University of Connecticut Storrs, Connecticut 06268 WASHINGTON UNIVERSITY Dr. Ruth Brennan Professor of Nutrition Department of Preventive Medicine School of Medicine St. Louis, Missouri 63110 139Region I: Massachusetts, Rhode Island Massachusetts Submitted by: Joel M. Hollis, M.S., R.D., Nutritionist, Massachusetts Department of Public Health, 600 Washington Street, Boston, Mass. 02111 (617) 727-2642 v The Status of Nutrition and Nutritional Services: A Report of the Massachusetts Nutrition Board (July 6, 1977). The following information is represented in this report. I. Organization goals of the Massachusetts Nutrition Board II. Nutrition Assessment of Massachusetts Residents A. Elderly 1. Elderly least likely to meet calorie requirements of all age groups. 2. Nutrition problems often identified are low iron and low folate. 3. Social, cultural, environmental and economic determinants of nutrition problems should be examined carefully. B. Pregnant Women and Infants 1. Large variation in infant mortality rate and prematurity and low birth weight rates found among various locales. 2. Nutrition data are inadequate. C. Preschool Children Nutrition problems often identified are poor or stunted growth, obesity, and anemia. D. School Age Children Nutrition problems often identified are obesity, dental caries, poor and erratic eating habits. E. Low-income Families Income is found as most sensitive index of nutritional risk. F. Incidences of major nutrition-related diseases. III. Inventory of Food and Nutrition Programs in Massachusetts Abstract of each program provides information on objectives, target population, budget, sources of funding, personnel, major activities, problem areas, and projected plans. There are 38 separate nutrition programs administered by 19 different State agencies, with more than $277 million budget (90% Federal). IV. Significant Findings and Recommendations A. Organization of Food and Nutrition Programs Findings: 1. Nutrition Board is only state-wide coordinating body, but has no funds. 2. There is no mechanism for incorporating priorities and needs of individual programs into state plans. 3. Many programs lack experienced and trained nutritionists. 4. "Fragmented responsibilities", "inadequate funding", and "lack of coordin- ation" common problems. Recommendations: 1. Designate and fund Nutrition Board to develop statewide Nutrition Plan every two years. 2. Designate Nutrition Board to review annual department budgets with regard to Nutrition Plan. 3. The Nutrition Board should act as nutrition program information clearinghouse and liaison between HEW and program directors. 140.Massachusetts (Con't.) 4. The Nutrition Board should help departments in planning and managing nutrition-related programs. B. Personnel Findings: 1. State pay scale for nutritionists and dietitians inadequate to attract qualified professionals. 2. Some nutrition-related programs have inadequate budgeting for needed nutrition components. Recommendations: 1. Governor's Office should revise Civil Service classifications and pay scales for nutrition and dietitian positions. 2. The Human Services Officer should require public institutions to hire adequate numbers of qualified professional nutritionists and dietitians. C. Nutritional Status and Health Findings: 1. Many people are at health risk because of poor eating habits or socioeconomic status. In addition, Federal financial constraints prevent many eligible individuals from participating in the WIC program. 2. There is no mechanism in Massachusetts for continually monitoring nutrition status. Recommendations: 1. Nutritional status evaluation should be built into all Federal food programs. 2. The Nutrition Board should be designated to be responsible for nutrition in development of health programs and State Health Plan. 3. Third party payors should develop programs to provide therapeutic nutrition services to high-risk individuals. 4. Educational programs to promote good lifestyle habits should be developed. D. Nutrition Education Findings: 1. The Food Stamp Program is providing no nutrition education component. 2. Third party payors, with exception of the Department of Public Welfare, reimburse no nutrition counseling services. 3. Nutrition education is not required in medical schools or teacher training institutions. 4. Only four of ten authorized positions for nutrition educators in Bureau of Nutrition Education and School Food Services are funded. Recommendations: 1. The Governor should encourage reimbursement for nutrition counseling services and support allocation of funds for the six vacant positions in the Bureau of Nutrition Education and School Food Service. 2. The Secretary of Human Services and the Governor should encourage the Depart- ment of Public Welfare and the Department of Public Health to develop nutrition education programs within their on-going nutrition programs. 3. The Nutrition Board should encourage integration of nutrition education into curricula'of medical schools, teaching training colleges, and allied health personnel training centers. 141Region I (Con't.) Rhode Island Submitted by: M. Constance McCarthy, R.D., Chief, Public Health Nutrition Service, Rhode Island Department of Health, 75 Davis Street, Providence, Rhode Island 02908 (401) 277-3093 Needs Information submitted by the Public Health Nutrition Service to the Division of Budget, Department of Administration indicated the need for an organized system for identifying the nu- tritional needs of the population. This was defined as the essential first step; the development of regulations, laws, and educational programs designed to improve the population's health would follow. A proposal for the provision of such a service was included. Major Weaknesses of the Community Nutrition Services Delivery System Major weaknesses of the community nutrition services delivery system were outlined and recommendations were made for improvement. The weaknesses included: a serious shortage of therapeutic nutrition counseling services for non-hospitalized patients, a lack of a nutrition component in family planning services, a lack of data on which to base future planning of pre- ventive health programs, inadequate funding for WIC programs, insufficient training, technical assistance, coordination, and direction for staff in Community Action Programs, Health Centers, Community Food and Nutrition Programs, day care centers, and food stamp programs. d; c tone : . DIV j n d t. i j : 1 i ' : >' • ' 'i . i: !: : it ti . mi « :: ,.>;)> t \ : j J :: i i ’r«s ;n- ?:■ n m h k , ,«■11ret ; I; »i i: | >• " I : l! • ! '"f !t iii: ; I: 1 •' ” «<•» ' ;;1,: ■ . ii.r. t.„ ■ h.it u Si,., tt -. t.> . . i: it'. : ■.■ti . i . h •) 1 nlstlti ic : :•« hvj.ir > tit. j: t.t 181Evaluation The importance of economic and social policy as major influences on the nutrition status of children was recognized, but the article dealt mainly with the provision of nutrition educa- tion through maternal and child health programs. This factor was judged equally important in combatting malnutrition in children. Applicability to Planning Agencies Nutrition education is an important program component, but in order for it to be effective, community resources must be utilized and cooperative work with other community agencies is required. Effectiveness must be measured in terms of the improvement achieved in food habits. This requires the definition of goals, baseline data, and objective criteria; data on obesity, dental caries, and iron-deficiency anemia might be collected as examples of major public health problems. 119 Egan MC: Working together in community nutrition. JADA 45:355-358, 1964 Geographical Area National implications. Study Design The traditional role of the dietitian concerned mainly with the management of food service and the care of the sick was contrasted with the community nutritionist who can provide valuable services in health care systems. Significant Findings The importance of knowing about the community to be served was stressed. This requires familiarity with the age of the residents, their occupations and incomes. Leading causes of mortality and morbidity should be known and sources of available health care, particularly prenatal care should be identified. Other information that is important to the nutritionist concerns the number of teenage marriages and parents in the community, the number of working mothers, and the kinds of child care services that are available. Community trends were iden- tified. With more women working, more men take the responsibility for the selection and pre- paration of food. A more mobile society means that people have a wider range of food exper- iences. More people are found in the older and younger age groups than in the middle-aged group. Chronic disease, rather than communicable disease, is a pressing health problem. Scientific and technological advances result in the discovery of new diseases and new drugs; both are of interest to the nutritionist. Legislative changes have made money available and have mandated the creation of health care facilities and feeding programs that require the ser- vices of a nutritionist. The services of nutrition workers were defined. Nutrition specialists have considerable training and function as consultants and advisers to those who serve the people directly. Professional workers can often integrate nutrition concepts into their services. Auxiliary workers have some short-term training; they serve the community directly. Five main areas in which nutritionists could make valuable contributions to the community are identified: Community nutritionists can work with hospital dietitians to provide more complete patient education that will be of use in the home as well as in the hospital; nutrition information should be presented to other professionals, physicians, nurses, social workers, teachers, home economists, dentists; nutritionists should prepare educational materials cooperatively; dietitians and public health nutritionists should participate in a constant exchange of information; and nutrition standards for group care facilities must be set. 182Evaluation An excellent definition of the role of public health nutritionists and others who provide nutrition services was supplied with a description of the increasing need for nutrition ser- vices in the community. Considerations for community planning were defined; the orientation for the provision of services was toward the young. Applicability to Planning Agencies It is important to define the components of the community to be served and to recognize changes that are taking place within the community. Distinctions must be made among the various types of nutrition personnel available and their services must be used appropriately. Integra- tion of nutrition services with those of other health professionals is desirable to better serve the community. NUTRITION AS A COMPONENT OF HEALTH CARE SYSTEMS 120 Treacy H: The nutritionist in a comprehensive health care plan. JADA 68:253-254, 1976 Geographical Area New York, HEW REgion H. Study Design The role of the nutritionist in the Genesee Valley Group Health Association in Rochester, New York, was described. It was developed and financed by Blue Cross and Blue Shield and had 20,000 enrollees plus up to 6,000 fee-for-service patients. Significant Findings Staffing in the medical group was about 50% physicians and 50% other professionals. Job descriptions were not created, but there was a philosophy of directing the patient to the appropriate professional. A record of yearly visits showed that 35% of services ordinarily provided by physicians were being provided by other professionals. The nutritionist performed services that complemented those of the physician. She worked on a one-to-one basis with patients and conducted group activities particularly related to obesity, heart disease, hypertension, diabetes, and prenatal nutrition. Evaluation The article spoke only of the success of the program. A clear picture was offered of how a nutritionist works in a comprehensive health care plan and of the advantages in terms of money saved since the services of the physician are required less often. Hospital costs are reduced because preventive treatment reduces the need for hospitalization. Applicability to Planning Agencies The presence of the nutritionist in a comprehensive health care system can be appreciated in terms of the services provided and because these services result in lessening the demand on the physician's time and in lowering medical costs. 121 East D, Harger V: Oregon dietitians respond to call for health care planning data. JADA 69:400-404, 1976 Geographical Area Oregon, HEW Region X. 183Study Design In response to a request by the chief planner of the Oregon State Health Division, the Oregon and Willamette Dietetic Associations provided information concerning the types of ser- vices that could be supplied in the area served by their Health Systems Agency. Significant Findings The nutritionist/dietitian was defined in terms of the Position Paper of the American Dietetic Association. A list of facilities involved in health care resources planning was compiled. It included hospitals, health resource centers that served the community but provided less than the full range of primary level services, out-patient clinics, state institutions, government programs, schools, colleges, and universities. Professional services that can be provided by nutrition- ists and dietitians in health planning programs were described. These included the administra- tion of food service departments in institutions, the assessment of food practices and nutrition status of individuals and groups, nutrition counseling, and education for the public and for other professionals. Standards were formulated for the number of nutritionists and dietitians needed to provide the services described. They were service and institution specific. Evaluation A general description of services that the nutritionist can provide in the health care system was provided. The development of standards to estimate personnel numbers was useful. Applicability to Planning Agencies This information could guide planners in other states to determine how nutrition services will fit into their services. 122 Spodnik JP: Nutrition in the health maintenance organization. JADA 61:163-165, 1972 Geographical Area National implications. Study Design The article defined Health Maintenance Organizations and discussed the place of the nutritionist in the organization. Significant Findings HMO's have five basic principles: preventive medical care, group practice, prepayment, voluntary enrollment, and integrated medical facilities. They are hospital based. All of these factors favor the participation of nutritionists. In HMO's nutritionists are valuable resource persons because they can reach the entire family unit and because their services are important throughout the entire life cycle. Evaluation The primary purpose of the article was to describe the principles of HMO's. Consistency of nutrition information for clients was suggested and is appropriate for continuity of care. Consideration must be given to demographic as well as cultural differences in the population. Applicability to Planning Agencies The goal of keeping patients healthy through preventive medical care is important and when incorporated in a health care system, requires the services of qualified personnel including the nutritionist. 184123 American Dietetic Association Position Paper on Nutrition Services in Health Maintenance Organizations, JADA 60:317-319, 1972 Geographical Area National implications. Study Design Position Paper approved by the Executive Board of the American Dietetic Association, February 12, 1972. .Significant Findings The ADA proposed that nutrition care be identified clearly as a basic service of every HMO program. Nutrition care was defined in terms of certain essential services that should be combined and coordinated to meet individual and family needs: assessment of food practices and dietary status, nutrition education and counseling to meet normal and'therapeutic needs, provision of, or referral to, resources for appropriate food service, special feeding equipment, and/or supplemental food assistance. Nutrition care should be available at every phase of HMO operation. The important role of the nutritionist as a member of the HMO planning team was described. In the initial planning stages and during the operation, criteria must be established for the identification of the subscribers most likely to need services. The subscriber population, as a whole, must be analyzed in terms of food and nutrition needs. Other nutrition resources available to the community must be identified. Priorities for implementation of a nutrition care program must be determined, and staffing patterns and job descriptions written. Evaluation of the efficiency and effectiveness of the program must be included. Recommendations were made for appropriate staffing. The term "deititian/nutritionist" was defined as a person qualified for registration by the American Dietetic Association. In addition to that qualification, a knowledge of and experience in community organizations, health services and resources were recommended. The nutritionist should be able not only to manage that particular component, but also to coordinate nutrition with other care components. Supportive personnel could be used to extend services, but it was required that they be properly trained by the nutritionist. It was stressed that the improvement of nutrition status is important in preventive medicine. The emphasis in an HMO is on prevention. Documentation of the interrelationships among food, nutrition status, and health throughout the life cycle supports the inclusion of nutrition services in HMO's. This will help to avoid the need for more costly therapeutic care while improving the quality of medical care provided. Evaluation This is an important paper for planners. The need for nutrition service as part of a health care organization is clearly demonstrated and an outline for implementation is pre- sented. Applicability to Planning Agencies Nutrition may be such an integral part of living that the mention of nutrition services in program planning is overlooked; this results in poor quality and inadequate services. Nutri- tion care must be clearly defined as a basic component of the system. The recommendations presented in this position paper can be easily adapted to HSA's. 124 American Dietetic Association Position Paper on the Nutrition Component of Health Delivery ^ Systems. JADA 58:538-540, 1971 Geographical Area National implications. 185Study Design The ADA proposed that nutrition services be a component of all health and health-related programs, that they be designed to reach the total population and that nutritionally vulnerable groups, such as infants, children, youth in the growing years, women in the childbearing years, and the older population be given priority. Significant Findings The need for a review and evaluation of the present health care delivery system was ex- pressed. Increasing costs of medical care and inadequate resources to meet public demand for health care services indicated this need. Inclusion of nutrition as a component of health care will significantly reduce the number of people requiring sick care service. This would relieve the strain on the present health care system, decrease costs, and increase the well being of the public. Recommendations to improve the level of health through the inclusion of nutrition services in health services delivery systems were made. Nutrition care was defined as the application of nutrition science to the health care of people and it was recommended that it be available to all people, in a preventive as well as a remedial context in order to achieve maximum health benefits. It was stipulated that nutrition services be under the direction of persons professionally educated in the field, that these people function at the planning and policy-making level of federal, regional, state, and local comprehensive health planning bodies, and that steps be taken to assure a supply-of dietitians. Comprehensive health care plans should include staffing patterns and qualifications for personnel, identification of nutrition problems, standards for nutrition services and care, methods to be used for delivery of services, and evaluation. Adequate funding to support nutrition services was required, particularly in existing pro- grams. An appraisal of the economic benefits of nutrition care in a comprehensive medical care system should be made and future health care legislation should include dietary counseling services in third party payment plans. Evaluation Not only did this paper demonstrate the need for nutrition services in health services delivery systems and the benefits that can be derived from them, but also, it provided a clear set of recommendations for establishing these services. Applicability to Planning Agencies Every recommendation presented deserves careful examination by health planners. NUTRITION SERVICES IN SPECIFIC PROGRAMS 125 Yanochik-Owen A, White M: Nutritional surveillance in Arizona: selected anthropometric and laboratory observations among Mexican-American children. Am J Pub Health 67:151-154, 1977 Geographical Area Arizona, HEW Region IX. Study Design A surveillance system in Arizona collected data as part of the health care system. The data were analyzed to identify a target population, the Mexican-Americans. Of the 13,000 people assessed for nutrition status in county health department clinics in 1974, 47.8% were Mexican- Americans. Of this population (which was not selected randomly so it should not be applied to all Mexican-Americans in Arizona), 90% were under six years old. There was an equal distri- bution of boys and girls. The initial screening at the county health department clinic in- cluded height, weight, head circumference, hemoglobin, hematocrit, and serum cholesterol. Secondary screening included blood pressure measurement; information on cardiovascular disease risk factors and socioeconomic status was gathered and a 24-hour dietary recall was done. After screening, an individualized patient-care plan was devised, reevaluation of data was scheduled, appropriate referrals were made, and WIC vouchers were provided for eligible clients. 186Significant Findings Data for the Mexican-American children were compared to data for other children, except American Indians, seen in clinics in Arizona. There was an abundance of short stature Mexican-American children, but the difference between the two population groups was not statistically significant. Low weight-for-height was not a problem in either group, but 13.3% of the Mexican-Americans were overweight compared to 8.9% in the other group. Anemia was a significant problem in both populations. In 2 to 5 year olds, 20.8% of the Mexican-American group had hemoglobin readings below 11 gm/100 ml. Serum cholesterol levels were high in both groups with 56.1% of the Mexican-Americans hav- ing a reading greater than 160 mg/100 ml and 12.2% having a reading over 200 mg/100 ml. Serum cholesterol levels were slightly higher in the other groups. Evaluation A surveillance system to provide data for patient care and program planning in existing health care facilities was useful in this system. Applicability to Planning Agencies The results were area-specific. The importance of incorporating a nutrition program into the health delivery system is stressed because it leads to continuity of nutrition care. 126 Barnett SE, Eden W, Chase HP: The Case of the Migrant Farmworker: A Demonstration of Unmet Need for Nutritional Surveillance. Testimony for the Committee on Science and Technology, Subcommittee on Domestic and International Scientific Planning, 1977 (out of print). Geographical Area Colorado, HEW Region VIII. Study Design This testimony draws mainly upon information from Dr. Chase's survey from the University of Colorado Medical Center on the Student Health Program for Migrant Farmworkers and Rural Poor. Interdisciplinary teams of students in the health fields provided health services to migrants in Colorado. Resources were obtained from a variety of agencies. Strong use was made of cate- gorical nutrition programs such as WIC, Food Stamps, and Food Commodity. Significant Findings As determined from nutrition surveillance, there was a decrease in the number of children with growth measurements below the third percentile for height, weight, and head circumference. Funds from the Colorado Migrant Council were used for a study of Vitamin A status, and Vitamin A deficiency was reduced also. More nutrition surveillance data are needed to determine whether this team approach can treat malnutrition. Evaluation This testimony provides insight into the use of students in multidisciplinary health teams for providing health care. It also demonstrates the importance of using a wide variety of agencies for funding special programs. Applicability to Planning Agencies This testimony gives an excellent example of how nutrition surveillance can be applied. However, it also points out the problems due to lack of continued funding that hamper the effectiveness of the system. In order to continually monitor the impact of nutrition interven- tion programs, monies must be made available to support nutrition surveillance. 187127 Jensen P, Cunningham GC: Developing a Partnership to Provide Nutrition Services and Information. California Department of Health, Maternal and Child Health Branch, 1977 Geographical Area California, HEW Region IX. Significant Findings A discussion of the areas in which the Maternal and Child Health Branch of the California Department of Health has been working to improve the nutrition status of an identified high-risk population: mothers and infants. The areas include: training of health providers in maternal and pediatric nutrition; establishment of guidelines for nutrition services in MCH at state and local levels; development of professional and consumer education materials; expansion of nutrition services into local programs by assisting in funding and recruitment of appropriate personnel; and defining and implementing uniform nutrition assessment and surveillance of the women and children receiving service. Evaluation The authors attempt to demonstrate how the California Department of Health works to ensure quality and availability of services for women and children. Applicability to Planning Agencies Planners will find the germ of a useful idea—that it is not always necessary to start nutrition programs de novo. Often, a segment of providers in the public and private sector could begin to meet the nutrition needs of a population if additional staff, funding and training are provided. 128 Yanochik A, Eichelberger C, Dandoy S: The comprehensive nutrition action program in Arizona. JADA 69:37-43, 1976 Geographical Area Arizona, HEW Region IX. Study Design The Comprehensive Nutrition Action Program (CNAP) was developed in Arizona. Three counties with a good urban-rural mix and a diversity of cultural groups were chosen to participate in the development. Three populations were identified. Population A (4,899 people) was the original group; 90% of the people were under five-years old and 10% were other children and adults. The group monitored, Population B (1,311 people), represented those people found to be at-risk by at least one index. Additional data were gathered on children under five years of age (Popula- tion C [116 children]). A nutrition team serviced each county. In County I, the team consisted of a nutritionist, a home economist and two community nutrition workers. A nutritionist and two home economists worked in County II. County III was staffed by one community nutrition worker who received supervision from the County II team. Each nutrition team was responsible for screening, referrals, and monitoring. The screen- ing for Population A included hemoglobin and/or hematocrit determination and height and weight. Population B was also screened for physical appearance, food intake, and socioeconomic status. Measurements of serum Vitamin A, beta-carotene, protein, and albumin were done for Population C. A referral system made use of contacts with community agencies. Those with established nutrition components were contacted first, then those with aide or community workers, and finally, agencies which dealt in areas which might influence nutrition status. The monitoring system consisted of intervention with the components of counseling, educa- tion, referral, rescreening, and case review. Attempts were made to relate all aspects of the project to existing sociocultural patterns. 188Significant Findings The community nutrition workers were extremely effective. Being familiar with the customs, life style and language of the communities, they were able to establish good rapport with the families. In Population B, 87% of the heads of households were employed in non-skilled occupations and 22% were receiving welfare assistance. Average family size was five persons. Mexican- Americans were the largest cultural group represented. In Population A, 25% were identified as having anemia, while 55% in Population B were anemic. Other major problems identified in Population B were economic, infant and child feeding, and obesity. Excessive milk consumption was noted and portion size was three to four times what is conventionally considered average. The referral system also functioned as a communications network among community agencies, with approximately 800 referrals made to the CNAP project and 1,800 referrals made by the CNAP project to those same agencies. After monitoring, the prevalence of anemia was reduced by 72%. Improvement, defined as "acceptance of information and education demonstrated by behavioral change, subjectively noted by the community nutrition worker on the nutrition care plan," was demonstrated in over 50% of the families followed. Excessive milk intake was decreased. Evaluation In addition to recommending the adaptation of the defined project components, certain specific positive aspects were stressed. The operation and the construction of the system were not separate projects. This made it immediately useful and allowed for flexibility so that changes can accompany growth. The use of existing facilities and the integration of community services not only made them more effective, but also lessened the possibility of an overlap of services. The establishment of an on-going surveillance allowed for simultaneous data collec- tion and delivery of care. The role of community nutrition workers was extremely important. Because they were able to relate to the clients they could effect behavioral changes. Clients were treated as individuals; the family environment, existing food patterns and available facilities were considered in formulating care plans. Applicability to Planning Agencies Any description of a working model of a successful community nutrition program is valuable. In this one, the description is explicit and complete. Essential components of the project are well defined. The elements of the design are stated: identification of nutrition problems, development of a mechanism for the delivery of nutrition services, and evaluation of the effec- tiveness of the system. Implementation, using four subsystems, is outlined. The organized framework is well illustrated with pertinent examples and data tables. 129 Karp J, Nuchpakdee M, Fairorth J, et al: The school health service as a means of entry into the inner city family for the identification of malnourished children. Am J Clin Nutr 29:216- 218, 1976 Geographical Area The study was conducted in Philadelphia but has national implications. Pennsylvania, HEW Region III. Study Design An evaluation was performed with 143 of the 168 children who were newly entered into a public elementary school. Initial measurements consisted of height, weight and triceps fatfolds (TFF). Children below the tenth percentile for height and weight by age and sex (as defined by Stuart) or below 70% of standard for TFF (as defined by Hammond) were considered "at-risk." Chilren below these standards in both categories were evaluated clinically. Measurements of red blood cell indices from the at-risk group were compared with measurements from the group which was at-risk in neither category. 189Significant Findings Fourteen (10%) of the children evaluated were deficient in both categories. Seventy-seven children (62%) were deficient in either one or two measurements. Fifty-two children (28%) were above the minimum standards in both categories. The mean hemoglobin concentration among the at-risk population was less than that of the well nourished group. The mean age of the at-risk population was greater than that of the well nourished group. The association of short sta- ture and decreased body weight for age and sex with reduced hemoglobin concentration suggests that environmental factors may be responsible for short stature in some individuals. Screening programs which employ these tests may help identify children who are undernourished; identifi- cation is the first step towards intervention at the family level. By investigating the families of those children who were at-risk in both categories, at least one family with undernourishment was identified. Evaluation Assuming that height, weight, hemoglobin concentration, and triceps fatfold measurements are routinely made on children entering school, it seems appropriate to evaluate this data to identify children who are environmentally at-risk. Use of the association between height, weight and TFF with hemoglobin concentration pigeon-holes a smaller group of at-risk children than any of the measurements would if performed individually. School personnel can then focus school community resources on the problems of the most needy. Still, the sensitivity of the screen is open to question. Only one child of the fourteen was evaluated as environmentally at-risk. In a,large school district home visits to the families of all potentially at-risk children might be beyond the resources of school personnel. More sensitive indices of at-risk potential would be helpful. Applicability to Planning Agencies Until more sensitive indices are developed, planners could include the height, weight, TFF and hemoglobin concentration measurements as a regular part of school medical screening programs. As a result the limited nutrition services available in some communities would be utilized in a more efficient manner. 130 Dillon HL: Improvement of the quality of life through a food and nutrition project. JADA 67:129-131, 1975 Geographical Area Illinois, HEW Region V. Study Design A one-year nutrition program was initiated in the Daniel Hale Williams Neighborhood Health Center on the South Side of Chicago. The purposes of the program were to help meet the nutritional needs of the community, to demonstrate the value of a health center nutrition out-reach service in the hope that funding would become available, and to demonstrate to appropriate medical organizations that it was possible to organize programs of this nature. The community had a population of approximately 101,000. The mean average income in 1973 was $4,250; in 1970, 70% of the people received public aid. Twelve people were chosen from the neighborhood to become family health workers. They received intensive training in nutrition from a staff nutritionist and health orientation from the Division of Nursing. Each worked with individual patients during the week at the center or in the home. They used a nutrition interview form to determine dietary intake, medical status, and life style. They took blood pressure measurements and checked for edema, tempera- tures, and the amount of medication remaining before the next clinic appointment. They also conducted group sessions and nutrition programs in the public schools. 190-Significant Findings An analysis of 350 interview forms showed that 98% of the patients had a desire to learn more about planning better diets. Half of the patients had previously received modified diets (diabetic, low-salt, low-fat, and weight control) but without adequate instruction. Meals tended to be high in fats and carbohydrates. In 75% of the diets foods high in iron, ascorbic acid, Vitamin A, and calcium were lacking. Of the 12 family health workers recruited, five have enrolled in paramedical college courses. In addition to their prescribed duties, they served as an out-reach force for health programs in the community. Evaluation The need for this type of program and the desire on the part of the participants to have nutrition information available are clearly demonstrated. Applicability to Planning Agencies The fact that workers were chosen from the community is important as well as the fact that they underwent intensive training by responsible personnel who were also available to provide supervision. 131 Hinkle M, Fessler E: A decade of Dial-A-Dietitian in Columbus, Ohio. JADA 66:48-50, 1975 Geographical Area Ohio, HEW Region V. Study Design A description of the "Dial-A-Dietitian" program in Columbus and Franklin Counties from November 1961 through October 1972. During this time 8,072 citizens participated. The program was staffed by volunteer dietitians who answered questions recorded by an answering service. Significant Findings Approximately 40 to 60 inquiries were received per month; the number was directly influ- enced by advertising efforts. Questions during the first year (1961) related mostly to heart disease, diabetes mellitus, and general dietary modification. In 1971 more questions concerned food values, nutrient composition and caloric content of foods. Evaluation The program met the public need for access to information in the area of normal nutrition and pointed to the need for a community diet counseling service. Applicability to Planning Agencies This article points out the need for sound nutrition information to the public and the public interest in normal as well as therapeutic nutrition. 132 Spencer A: Storefront converted to health education center. Hospitals 49:57-59, 1975 Geographical Area New York, HEW Region II.Significant Findings Through the use of a hospital's community relations department and trained volunteers, cen- ters for the distribution of preventive medical information can be established. Health screening and local community need assessment can be provided simultaneously in an atmosphere designed to attract neighborhood individuals and groups. Evaluation This article is descriptive with only marginal information about specific health problems of the neighborhood and the ways in which those problems are handled. More information on the impact of the storefront neighborhood health center is required. Applicability to Planning Agencies The storefront concept is a useful model for the provision of highly personalized services tailored to the needs of a neighborhood. 133 Langham A: A state health department assesses undernutrition. JADA 65:18-23, 1974 Geographical Area Louisiana, HEW Region VI. Study Design This article focuses on surveillance activities with infants, children and adolescents, although in some cases adults and the elderly are reported. Information is collected on the sample in three ways- Severe undernutrition is a reportable disease. In order to quantify the term undernutrition, several severe deficiency states were defined and made reportable. This required epidemiological investigation. Clinical or laboratory testing can be used to identity these states. Death certificates were reviewed to identify those deaths whose primary or secondary cause was malnutrition. A Nutrition Surveillance System was developed utilizing data from the EPSDT program. Data on age, race, sex, height, weight and hemoglobin or hematocrit were collected. Definitions of low hemoglobin/hematocrit are taken from the Ten-State Nutrition Survey. Height and weight data are plotted against the Stuart- Meredith growth figures. Significant Findings No deaths due to lack of availability of food have been reported. Anemia continues to be a problem in Louisiana. In a sample of 6,202 infants and preschool children, 20% had low hemoglobin levels. Of a sample of 785 white children and 5,413 Black children under nine years of age, the rate of anemia in the Black group is more than double that of the white group. A wide range of incidence exists for metropolitan areas, from 6.5% in Jefferson Parish, to 27% in Rapides Parish. Anemia appears to be more prevalent in rural populations. Height and weight data for white and Black boys and girls under the age of nine suggest that more white boys and girls are below standard than Black boys and girls. Evaluation The Division of Health Maintenance and Ambulatory Patient Services of the Lousiana Health and Social and Rehabilitation Services Administration has wisely begun to use existing data collection techniques to sample population deficiencies in order to evaluate the nutrition needs of Louisiana citizens. To expand the program additional biochemical tests could be routinely run and additional population groups could be added to provide an expanded and more detailed picture of the population. 192Applicability to Planning Agencies Louisiana Division of Health found surveillance to be less expensive in terms of money and personnel. Planning intervention and preventive care programs can be based on the information generated by surveillance but additional research must be carried out to determine which techniques are most effective in changing dietary habits. Surveillance activities can provide data on the effectiveness of intervention programs provided that those who participate in the programs are not re-entered into the screening population immediately. Additional fund- ing is required to expand surveillance activities. 134 Cairns S, Caggiula A: Evaluation of the attitudes of recipients of home-delivered meals. JADA 65:560-562, 1974 Geographical Area Pennsylvania, HEW Region III. Study Design An evaluation was made of the services provided by five home-delivered meal programs which service 290 elderly people in the Pittsburgh area. A questionnaire consisting of 15 statements for which scale values had been computed was delivered to the program participants with their meals. They rated the statements and returned the forms by mail. Significant Findings Most of the recipients were pleased with the service. Some problems, such as portion size and lack of flavor were detected by comparing the responses of participants of the different programs. The most common problems recognized were keeping foods hot and cold. Evaluation The evaluation was useful mostly in terms of providing a scale to compare existing programs with one another or over time. Applicability to Planning Agencies The general conclusion that people are satisfied with existing programs does not help the planner, because the operations of the programs are not described. 135 Frankie RT, Christakis GM: Community nutrition teams. Hospitals 47:56-57,60, 16 Dec 1973 Geographical Area New York, HEW REgion II. Study Design The project was designed to increase the emphasis on the hospital as a resource for commu- nity care as well as for individual patients. The institutions involved were the Mount Sinai School of Medicine in New York City and three community agencies in East Harlem: the Little Sisters of the Assumption, a family health care agency; the Exodus House Drug Rehabilitation Center; and the Stanley Isaacs Neighborhood Center, which serves the aged. Community nutrition teams consisting of a medical nutritionist, a pediatrician, a dietitian, a medical student, and a staff member, either a public health nurse or a social worker, were formed to work with the agencies' clients. Home visits were made and storefront nutrition and health clinics were established. The resources of Mount Sinai hospital nutrition labora- tory and clinic were available. Clients received appropriate medical care and follow-up. 193Significant Findings The nutrition status of more than four hundred drug addicts was assessed. Many patients exhibited a craving for carbohydrates, some demonstrated low folate and Vitamin levels or unusual adipose tissue fatty acid patterns. Nearly 50% of the patients had abnormal enzyme levels. Laboratory tests performed for the clients indicated a need to screen for indicators of coronary heart disease. It was recommended that all patients be screened. Evaluation The beneficial relationship between a community agency and a hospital-based medical school, for providing nutrition and health care was clearly demonstrated. Documentation of the project in terms of the numbers of participants for each agency and the kind of care that they re- quired was given. Applicability to Planning Agencies The focus on nutrition as a major part of the health care team is important as is a patient- oriented, rather than a disease-oriented approach. The integration of existing facilities, medical in the hospital and social in the community agencies, is important. 136 Williams L: Experience in systematic training in a rural program for elderly Mississippians. Am J Clin Nutr 26:1138-1142, 1973 Geographical Area Mississippi, HEW Region IV. Study Design Some characteristics of four meal programs in the rural area of north central Mississippi are discussed. Program participants are predominantly Black and have an average income of $650 to $800 per year. Most do not live alone. Significant Findings Solely providing meals for the elderly does not ensure participation. Consistent and fre- quent out-reach efforts were instituted using 20 program participants as community nutrition aides. Aides were assigned territories and instructed in methods of nutrition education. Aides also reported back to regular staff about the problems and situations they encountered. Additional recreational and service activities were added to the meal programs. Nutrition education presentations were tailored to the needs of the slightly educated population. The rural setting presented some transportation problems but provided the benefit of home gardens for many individuals. Social Security coverage was unavailable to many program participants because of the nature of the work they had performed during their working years. Evaluation An informal presentation of some of the problems encountered and services provided in a rural feeding program for the elderly. Little evaluative data are provided. Applicability to Planning Agencies Suggests to planners that comprehensive health and welfare services need to be tailored to the specific needs of the group served. 137 Gemple N, Hogue J: A nutrition and social service program for older people: an urban model. Am J Clin Nutr 26:1098-1105, 1973 Geographical Area California, HEW Region IX.Study Design The model described was designed for use in an urban setting and was tested in San Francisco. Significant Findings Initial efforts must be directed towards the development of program objectives; objectives should be based on the surveyed needs of the population to be served. Objectives should be stated in measurable terms to allow for short and long-term evaluations. Some objectives include: An increase in the nutrition or social status of participants; A reduction in social isolation; Creation of an increased level of community awareness with regard to the problems of the elderly; and Promotion of linkages among existing and potential communitv resources. Project facilities should be located near the population they intend to serve. Suggested activities and services are: Daily meals; Counseling in preventive health and social welfare; Referral services; Recreation and social activities; Out-reach activities; Transportation or escort services to and from a project facility; and Staff development, perhaps utilizing project participants. Health and nutrition education should be conducted in a manner and setting appropriately designed for the elderly. Adequate staff are needed to provide service in a comprehensive fashion. A typical staff might consist of a project director, social worker, secretary/bookkeeper, dietary consultant, cook, dishwasher/janitor, out-reach workers, volunteers, supplementary staff and resource people. A multi-faceted out-reach effort will be necessary to reach those most in need. The effectiveness of a program is measurable to the extent that the original objectives were stated in quantifiable terms and that appropriate methods for the collection and analysis of data are employed. Availability, accessibility, and suitability of the program's services are one measure of success. Cost-efficiency and the quality and continuity of the services pro- vided are other measures. The degree to which a nutrition program dovetails its activities with other community services and the degree to which program participants utilize other services also reflect a program's success. Evaluation Although the model was designed for an urban setting, the suggestions put forth for program design are applicable to rural settings. Limited descriptive material about the San Francisco project is provided. Applicability to Planning Agencies Planners will find a concise presentation of the major components of a nutrition and social service program for the elderly. 138 Holmes D: Nutrition and health screening services for the elderly. JADA 60:301-305, 1972 Geographical Area New York, HEW Region II. 195Study Design The operation of a demonstration feeding program for the elderly was analyzed using the hypothesis that providing meals and nutrition education would improve the eating habits and patterns of participants. Also predicted was an increase in the extent and nature of inter- personal activities, health care and general life satisfaction. The hypothesis was tested by collecting comprehensive information from each participant on two occasions, at enrollment and one year later. Complete data were collected from 150 individuals. Significant Findings Catered meals were less expensive than center-prepared meals. Although a sliding scale was established to allow participants to pay for meals on the basis of need (ceiling of fifty cents) few participants applied for lower meal cost. Various table arrangements were tried in order to find one which encouraged interaction between participants. Round tables, seating ten persons, were most effective. Interaction was also encouraged by the appointment of a table captain. The captain kept a record of those individuals who attended meals and relayed information about his table's com- plaints or suggestions to program staff. Special tables, with highly social captains, were created to ease new program participants into the program. Committees composed of program participants helped staff with meal planning and out-reach. Different tables were assigned responsibility for menu planning on a rotating basis and table members justified menu selec- tions. This served an important nutrition education function. The traditional lecture format for presenting nutrition information met with little success. A nearby hospital provided free initial medical screening of participants. No single technique of out-reach was most effective. An increasing number of individuals attended the program as community awareness of the program grew. Evaluation of the program revealed an impact on participants' eating habits, nutrition know- ledge, interpersonal relationships, and morale. No change in health status was observed. Evaluation This article provided an honest, refreshing look at the structure and process of one nutrition project. The lessons learned here would be applicable to other projects. Especially important is the effort made to give responsibility to program participants for those aspects of the program which affect them most. The constant evaluation of program components resulted in a structure which proved effective in meeting many program goals and participant needs. Applicability to Planning Agencies Nutrition programs provided fringe benefits for the elderly, especially where the nutrition .or food service aspect is only one component of a more comprehensive project. 139 King W: Mothercraft Centers combine nutrition and social sciences. J Nutr Ed 3:9-11, 1971 Geographical Area International implications. Study Design The concept of Mothercraft Centers and the ways in which they function were discussed. Concern with malnutrition on an international scale led to the observation that the most severe forms were seen among preschool children. Since it was recognized that the mother controlled the children's food, an educational program geared to poor, illiterate, tradition-bound mothers has been developed. Centers were established where mothers could bring their poorly nourished children and then participate in the rehabilitation of the children. The facilities were designed to be similar to the mothers' homes; this included the foods, equipment and funds used. In some cases limitations of local resources were so severe that adaptive research was required. Children were screened and 30 to 35 of the most malnourished were picked as participants. Their mothers took them to the centers six days a week for three to four months and each mother stayed one day per week to work with the supervisor. Supervisors were girls with high school education or less who had been specially prepared for their jobs. 196Significant Findings When the programs began, evaluation consisted of testing the mothers' mastery. Later operational evaluation was introduced. It included a record of the growth response of the children and a report prepared by an unannounced visitor from the central office. Long-range evaluation was based on periodic dietary surveys, post-discharge growth rates of children, and growth performance of younger siblings of the children admitted. Evaluation results showed that 50 to 60% of the children continue to improve in percent standard weight after discharge; about 25% continue to hold the gains they made in the center. Reasons for failures were usually health problems not correctable by diet or extremely desperate economic situations. Evaluation The article presents an example of the practical application of nutrition education. The concern is not with presenting the vague benefits of nutrition education; rather, an effective working program with a workable evaluation component is well described. Applicability to Planning Agencies Mothercraft Centers are adaptable to a variety of cultures, economic situations, and organizational schemes. Although they were created to meet the needs of people in developing countries, the principles can easily be applied to poorly nourished people in the United States provided that the specific characteristics and needs of the people are understood and accommodated. 140 Barnett SE, Eden W: The Clinical Nutritionist's Role on a Rural Primary Health Care Team. Denver, Colorado, University of Colorado, 1971 Geographical Area Colorado, HEW Region VIII. Study Design The Student Health Program for Migrant Farmworkers and Rural Poor (SHP) was started in 1971 at the University of Colorado Medical Center to serve the needs of seasonal workers who have limited access to health care. The program placed a great deal of emphasis on nutrition. Significant Findings SHP goals were stated: to increase the number and quality of health services to the target population, to provide health science students with experience in rural community health and stimulate further interest in careers in that area, and to offer interdisciplinary team experience. The nutritionist's role expanded as the program progressed. Several reasons were given for this. Many of the medical problems of the farmworkers were closely realted to nutrition and many of the health professionals were not sufficiently knowledgable to deal with them or did not have enough time to devote to them. With the nutritionist working at the community level, the nutrition awareness of the other health team members and of many community organiza- tions was increased. Six major role classifications were defined for the working nutritionist: manager, to identify goals, objectives, priorities and to plan and coordinate activities; educator/consultant, to plan in-service programs, provide group instruction for clients, develop methods and materials, and serve as a resource expert; diet therpist/counselor; appraiser/guide, to assess physical, biochemical and dietary status and make appropriate medical referrals; interdisciplinary team members; and recorder, to document nutrition intervention. 197Evaluation The importance of including the clinical nutritionist in the interdisciplinary primary health care team was well documented. Provision of nutrition services benefits the other mem- bers of the health care team as well as the clients. Applicability to Planning Agencies Health care teams must reach the individual, the family and the community in order to be successful. The inclusion of nutrition can be instrumental in accomplishing this in a health care program because it can be geared to all segments of the population, providing a liaison and supplementing the services of the other health care professionals. 141 Joering E: Nutrient contribution of a meals program for senior citizens. JADA 59:129-132, 1971 Geographical Area Ohio, HEW Region V. Study Design In 397 people from four senior citizen centers for ambulatory persons and one home delivered meal program, the average age was 72 with an age range of 45 to 90. The sample was multi-racial, of both sexes, with 80% of the incomes below poverty level. In 185, 24-hour food intake recalls from 135 women and 50 men, dietary records were analyzed for intake of calories, protein, calcium, iron, thiamine, riboflavin, niacin, Vitamin A and ascorbic acid. Significant Findings There was little or no meal preparation at participants' homes. The average daily intake of nutrients was greater for all study groups for all nutrients when a center prepared meal was included. Home delivered meals provided participants with only half the average nutritive in- take of those who had meals at the center. The poorest nutritive intake was in the home-bound group with no meal provided. Men had a higher caloric and nutrient intake with the exception of Vitamin A and ascorbic acid. Vitamin A intake was drastically increased in those who had center prepared meals. Increased Vitamin C intake resulted from a diet which included ascorbic acid rich juices and fresh fruits rather than canned foods. Evaluation The hazards of the recall method are many. The statistics most likely to be affected are those from the home-bound who have little peer support to help them remember the components of their meals. The sample size is limited and self-selected, with a large range of ages although it is multi-racial. Study groups were chosen from a range of neighborhoods. No biochemical tests measured serum levels of nutrients. Applicability to Planning Agencies The value of some form of food assistance program for the older person is illustrated. The advantages of the center-provided meal over the home-delivered meal in providing greater dietary intake of the selected nutrients are established for this sample. Careful selection of the nutritive components of a program to supply increased dietary nutrients is warranted.142 Hirsch IB: Feeding the poor. Hospitals 44:97-100, 1970 Geographical Area New York, HEW Region II. Study Design Community members and participants in a prenatal clinic at St. Joseph's Hospital, Catholic Medical Center of Brooklyn and Queens were involved in this project. Significant Findings Upon discovering that severely malnourished individuals lived in the immediate area surround- ing the hospital, hospital dietetic staff worked with an existing surplus food program to provide educational material and food preparation demonstrations to interest community residents in the surplus food program. The program originally held demonstrations at other community sites as well as at the prenatal clinic, but the clinic setting was more successful. Transportation, baby sitting and lack of follow-up demonstrations curtailed participation at off-hospital sites while prenatal clinic participants returned weekly. Recipes, menus and nutrition information using available surplus food were developed in Spanish and English to meet traditional ethnic eat- ing patterns. Information about eligibility for surplus food packages was provided. Some diffi- culties of the program included obtaining packages for demonstration purposes, the remote location of the food distribution center which made access for eligible community members difficult, and user dissatisfaction with previous food distribution programs. Attempts were made to set up a second, local distribution center without success due to the difficulty in finding sufficient numbers of people willing to subscribe to the program. The hospital plans to expand its own program to other clinics. Evaluation This hospital program points out the opportunities which exist if one is willing to adapt traditional structures to meet contemporary needs. Although this program exists in a local area, there is need for similar programs elsewhere. Outpatient hospital clinics are ideally suited for nutrition education programs because of the special needs of particular clinic populations. Applicability to Planning Agencies The use of hospital facilities and staff to provide nutrition education suggests that there are other community institutions which may be able to provide similar services. The expansion of existing facilities to meet the nutrition needs of a more diverse population may be a less costly alternative to the creation of an entirely new structure. NUTRITION EDUCATION 143 Martin ED: Systems in Transition—Health Delivery Systems-Implications for Nutrition Education. Presented at the Annual Meeting of the Society for Nutrition Education, Washington DC, July 12, 1972. Geographical Area National implications. Study Design The relationship between nutrition education and the health care system is explored. Significant Findings Health care systems vary with regard to their organizational setting and source of support, their emphasis on acute versus preventive medicine and the range of services which they offer. The current system has a number of attributes including a focus on crisis intervention, 199skyrocketing costs, little emphasis on what a patient is able to do for himself, and an uneven distribution of services. Also characteristic of the system are inadequate planning and a lag between technologic developments and their application. Several recent legislative changes have begun to shift priorities in the health care delivery system. Implementation of the National Health Planning and Resources Development Act of 1974 establishes a network of planning agencies and provides an opportunity for consumer involvement in planning. There is an increase in financial and manpower support for the development of increased levels of services in inadequately served areas. Greater emphasis is placed on the promotion of preventive health care and is exemplified by the Health Information and Health Promotion Act of 1976. Issues of cost containment are addressed through pending legislation to control rising hospital costs, establish national health insurance and expand home health care programs. Nutrition educators will have to redefine their role and evaluate current practice in response to these changes. How effective is nutrition education? Who is best qualified to pre- sent it? How can nutrition education be included in preventive health schemes? Evaluation Nutrition educators must assess the effectiveness of their current practice in order to determine which components are most suitable for a preventive health care format. They must also act assertively to ensure that these components are included in comprehensive health care plans. Applicability to Planning Agencies Nutrition education is an important preventive health care service which needs to be in- cluded in any health care plan. 144 Fusillo AE, Belarian AM: Consumer nutrition knowledge and self reported food shopping behavior. Am J Pub Health 67:846-850, 1977 Geographical Area and Study Design National implications. 1,664 American adults who were responsible for at least one-half of their household food shopping duties were surveyed for knowledge about food and nutrition in order to explore the association between knowledge, beliefs and food shopping practice. The questionnaire covered five areas of knowledge: (1) the availability of nutrients; (2) the need for daily intake of certain nutrients; (3) what foods contain nutrients; (4) what benefits certain foods provide; and (5) which foods serve as substitutes for other foods; it also contained groups of questions de- signed to elicit information about food shopping benefits and behavior. Survey questions were pretested for reliability. Sample data were weighed to match the population distribution of American adult food shoppers. Survey results were analyzed to identify groups where nutrition knowledge was low, medium and high and shoppers whose food beliefs were either well informed or not well informed so that cross tabulation between the two indices could be drawn. Food shopping behavior was indexed to identify "careful" shoppers. Significant Findings The level of consumer knowledge was low in the areas of nutrient availability, nutrient storage and benefits of food. Results varied in the source of nutrient category but indicated a generally high level of knowledge in the food distribution category. As the age of a respon- dent increased and his level of education decreased, the level of nutrition knowledge decreased; the lowest levels of nutrition knowledge were found among men who had less than a high school education and were over 50 years of age. Nutrition knowledge displayed a positive and linear association with "well informed" status and "careful food shopper" status. Evaluation According to the authors, the results of this survey depict an unfortunate state of affairs: portions of the American population lack the knowledge to help themselves purchase adequate nutrition. In their discussion the authors suggest that consumer nutrition education be aug- mented to allow people to take advantage of nutrition labeling and therefore make their food 200shopping more effective. But lacking what the surveyors determine to be necessary nutrition in- formation may not mean that a group is poorly nourished or lacking the capacity to feed them- selves adequately. An established cultural feeding pattern may provide a proper nutritive base despite the fact that it does not explicitly consider "nutrient" content. An additional survey component which considered what foods were actually purchased would have supplemented the find- ings. Applicability to Planning Agencies Few survey participants (33%) made use of nutrition labeling; only 41% made use of unit pricing. Both of these measures are part of a recent legislative package designed to aid the consumer in some areas of the country. The reasons for the underutilization of this information should be explored by planners in order to determine whether these are useful "household" tools. Perhaps a national or regional menu planning scheme would be more effective. To improve know- ledge and awareness about nutrients, their effects and uses, a comprehensive, graded program including the practical aspects of home economics and nutrition science should be required in schools. 145 Edozien JC, Switzer BR, Bryan RB: Medical Evaluation of the Supplemental Food Program for Women, Infants and Children I, II, Summary. Department of Nutrition, School of Public Health, University of North Carolina, Chapel Hill, NC, June 1, 1976 Geographical Area and Study Design National implications. This study was conducted to assess benefits of the Special Supplemental Food Program for Women, Infants and Children (WIC). The WIC program provides food supplements to low-income pregnant and lactating women, infants and children up to four years of age who are at "nutri- tional risk." The program is administered by the Food and Nutrition Services of the U.S. Depart- ment of Agriculture through state health departments and local health clinics. Nineteen WIC projects located in fourteen states participated in the medical evaluation which was performed primarily to determine whether the WIC program improved nutrition status and health of program participants. Measurements taken before and after program participation were compared to provide an estimate of the impact of the program. Of children participating, approximately 21% were white, 34% Black, 42% Spanish-American, and 3% American Indian. Assessment criteria for infants and children included measures of growth (height, weight and head circumference), dietary intake, and laboratory tests (hemoglo- bin, hematocrit, mean corpuscular hemoglobin concentration, including iron, transferrin (percent saturation of transferrin), complement 3, albumin, and total protein, chloesterol, and folacin in plasma). Criteria for evaluation of the women (of women participating, approximately 24.5% were white, 38.6% Black, 33.8% Spanish American, and 2.5% others) included vital statistics (abortion and miscarriage rate, stillbirth rate, prematurity rate, low birth rate, and infant mortality), medical complications of pregnancy, weight gain during pregnancy, birth weight of the baby, dietary intakes, and biochemical indices (hemoglobin, hematocrit, mean corpuscular hemoglobin concentration and iron, transferrin (percent saturation of transferrin), complement 3, albumin, total protein, cholesterol, Vitamin A, carotene, Vitamin C, and folacin in plasma). Socioeco- nomic data were collected for all participants. To overcome the fact that a concurrent control group was not included for comparative pur- poses and to account for changes in variables reflecting change in age and growth of infants and children, or progress of pregnancy, the following design study was employed. Clients entered the WIC programs at varying stages of pregnancy (women) and varying ages (infants and children) so results of their initial assessments were used as baseline data against which follow-up measurements after•program participation were compared. Significant Findings Infants and Children An increase in the rate of growth in weight and height in all age groups was associated with participation in the WIC program. The effect was least in six to eleven month old infants and greatest in thirty-six to forty-one month-old children. 201There was an increase in head circumference at the time of the six-month visit; this occurred primarily in infants enrolled within one month of birth. After six months in the program the incidence of anemia was cut by about 40% in all age groups. Participation in the program was consistently associated with an increase in mean corpuscular hemoglobin concentration values and a fall in plasma concentration of complement 3. Women The initial diets of the pregnant women provided them with less energy, protein, calcium, iron, Vitamin A, thiamine, riboflavin and niacin than is recommended for pregnant women. Participation in the WIC program increased their consumption of protein, calcium, phosphorus, iron, Vitamin A, thiamine, riboflavin, niacin, ascorbic acid and folacin, but not of energy. Pregnant women who participated in the WIC program gained more weight during pregnancy than women in the initial population. An increase in the mean birth weight of babies was associated with participation in the WIC program; the impact of the program was greater on Black and Spanish American babies than on white babies. Of the women who participated, the prevalence of anemia was reduced in women who were in their third trimester and in postpartum women but not in others. Evaluation Because concurrent control groups of infants and children were not available, rather cumbersome statistical ipanipulations were required to detect changes in growth. By the tech- niques used, there did appear to be consistent trends towards increase in rate of gain in weight and height in all ages studied. The increases in weight gain (observed gains-expected gains) were noted principally during the first six months of participation while the apparent effects on gain in height were detectable through eleven month follow-up. The effects on rate of gain of weight and height were least among infants and most among 36- to 41-month old child- ren. This probably reflects the fact that among older children, there were some individuals who had some degree of growth retardation when entering the program. In contrast, the infants com- prised an essentially normal population to begin with and would be unlikely to manifest any growth benefits from participation in the program. The average increased rates of growth during eleven months participation amounted to 113 gm, 0.56 cm and 0.02 cm, respectively, for weight, height and head circumference. For the average two-year-old child the differences in head circumferences are negligible wherever changes in weight and height gains represent 0.5 to 1.0 percent increments. It is difficult to ascribe the approximate 0.4 gm/dl increase in mean hemoglobin concen- trations among 12- to 47-month-old children to increased, or improved, iron intake because serum iron and percent saturation of transferrin declined somewhat with program participation. The investigators cited an increase in levels of mean corpuscular hemoglobin concentration (MCHC) as evidence of improved iron status in program participants. Most experts would argue that serum iron is a better indicator of iron status than is MCHC. As with evaluation of growth of infants and young children, it was necessary to use cumbersome statistical manipulations to examine the effect of program participation on weight gain during pregnancy and on birth weight. The number of maternal factors, such as pre-preg- nancy weight, height, weight gain during pregnancy, smoking, birth order, food intake, and so on, which influence weight of the infant at birth make it difficult to determine the importance of program participation on birth weight. Applicability to Planning Agencies Although the medical evaluation of the WIC program was "national" in scope, the findings are generally applicable locally to low-income pregnant or lactating women and to their infants and young children. 202146 Stern MP, Farquhar JW, Maccoby N, et al: Results of a two-year health education campaign on dietary behavior: the Stanford three community study. Circulation 54:826-833, 1976 Geographical Area and Study Plan California, HEW Region IX. A plan for reducing risk factors associated wih cardiovascular disease utilized a community based health education campaign. From each of three northern California communities a random sample of men and women aged 35 to 59 was selected and asked to participate in three surveys designed to disclose dietary change. High-risk individuals in each of the three samples were identified and in some cases offered intensive instruction in dietary management. Intensive instruction groups, whose purpose was to promote behavioral change, met for nine counseling sessions. Dietary change was measured by comparing the results of a dietary questionnaire and blood test after the first survey with the results from subsequent surveys. From January 1973 through the summer of 1975, a bilingual multi-media health education campaign consisting of direct mailing, newspaper columns, and radio and television spots was conducted in two of the three communities. The third community served as a control. This article discusses changes in the consumption of cholesterol and saturated fats as a result of the counseling and/or campaign. Significant Findings The greatest reduction in cholesterol and saturated fat consumption occurred in the group receiving intensive instruction, but the differences in fat consumption lost any statistical significance by the time th« third survey was conducted. Men showed greater change than women. Evaluation The authors question the validity of their own dietary questionnaire data although they do reach the conclusion that their results are sound. However, information was collected by a "self-reporting" technique which is subject to considerable bias. The effectiveness of intensive instruction is also open to question as a result of the recidivism experienced by the counseling group and the continued gains found in other groups. This may suggest that intensive instruc- tion is in fact detrimental; counselees may become dependent upon the counselor for support and fall to develop the independence and motivation required for continued dietary change. That some groups continued to make changes and experienced little recidivism may suggest that an individual's desire for a changed dietary lifestyle may be the single most important factor in predicting success. The degree to which other causative factors of change can be ruled out when participants are free to move within their natural environment is another source of error. Applicability to Planning Agencies The results of this study are inconclusive, and the degree to which they may be generalized to a larger population is questioned by the authors. 147 Sims L: Demographic and attitudinal correlates of nutrition knowledge. J Nutr Ed 8:122- 125, 1976 Geographical Area National implications. Study Design Demographic and attitudinal factors associated with the nutrition knowledge of mothers of preschool children were studied in an effort to determine whether attitudinal factors exert as consistent an influence on nutrition knowledge as demographic characteristics do. The sample studied consisted of 163 mothers of preschool children who attended a nursery school program or public health clinic in a midwestern city. Individual interviews were con- ducted and the mothers completed questionnaires. Three variables were measured. Nutrition knowledge was measured by using a test and by asking each mother to name the foods that she thought her child should have every day. The answers were then categorized in terms of the four food groups. The Socioeconomic Status Index 2Q3that was developed for Washington Heights Mental Health Survey was used to determine demo- graphic variables. Attitude variables were measured by using the Patent Attitude Research Instrument. Significant Findings Demographic variables that were highly positive when correlated with nutrition knowledge were socioeconomic status, the occupation-education scale of the parents, family income, the determined attitude that nutrition is important, and the determined attitude that children sometimes know things that parents do not. Variables which were negatively related were the stage in the family life cycle (older families were less knowledgable about nutrition), the amount of money spent for food (those spending more were less knowledgable), the number of per- sons in the household (larger families scored better). Authoritarian mothers were less know- ledgable as were mothers who felt less in control of their lives. Attitudes appeared to exert as consistent an influence on nutrition knowledge as did demo- graphic characteristics. Evaluation Although the article did not present suggestions for dealing with the different attitudes that may influence nutrition knowledge, it did identify them and confirm their importance. Applicability to Planning Agencies A primary goal of nutrition education programs should be the improvement of attitudes to accompany the presentation of nutrition facts and concepts. 148 Fuhrman R, McWilliams M: Consumer management program aims for total health education. Hospitals 50:86-89, 16 Aug 1976 Geographical Area California, HEW Region IX. Study Design The educational experience in consumer management and good nutrition offered by the Los Angeles County-University of Southern California Medical Center was described. Significant Findings The program used community resources to provide educational services to the medical center. Advanced dietetic and home economics students were recruited as instructors and supervised by the nursing director. Classes were held for staff members and volunteers. Direct patient education was initiated for individual families through the Medical Center's home care program. Individual patient instruction was also implemented in clinic waiting areas by means of mini-workshops. A "nutrition care" mobile teaching center was also developed for waiting areas. Evaluation was done on the basis of workshop attendance and subsequent requests for work- shops, student self-evaluations, and the informal reactions of participating agencies. Evaluation Program objectives were clearly stated and specific examples used to illustrate them. A formal evaluation of this method would be useful to determine its effectiveness and appli- cability to other health settings. Applicability to Planning Agencies The concept of presenting health information in a setting that is comfortable (the home) or convenient (the waiting room) is important. The "nutrition care" idea is an innovative one that takes advantage of the fact that the audience is already present. 204149 Kolasa K, Bass M: Participant-observation in nutrition education program development. J Nutr Ed 6:89-92, 1974 Geographical Area Tennessee, HEW Region IV. Study Design The paper described the initial steps taken to characterize the food behavior of the resi- dents of Hancock County, Tennessee, a poor rural area. Results were to be used as a basis for developing food and nutrition education materials. The county is located 75 miles northeast of Knoxville, but is geographically isolated by the Appalachian mountains. There are 7,000 residents; 96% are white. Complete interviews were obtained from 28 people. The philosophy behind the methodology was that the nutrition professionals who are planning a project must become participant-observers of food behavior in order to serve the community effectively. The practice of using local people to collect food behavior data was recognized as a valuable procedure, but not as a substitute for first-hand knowledge for the professional. Community contacts were made through the Expanded Food and Nutrition Education Program, through two anthropologists working in the area, a public health nurse, and Head Start personnel. Contacts were also made going door-to-door and at county stores. Twenty-four hour recalls that had been completed previously by EFNEP aides were examined and a thirty-one item food behavior questionnaire was developed. Significant Findings The two main food sources were home gardens and stores that stocked a small variety of staples and perishable items. Many of the garden items were canned, frozen, or dried. Wood stoves were still used although electric ranges were available. Prestige levels for food existed. Evaluation It was not possible to clearly outline effective steps for successfully approaching people in the community; however, they did stress the importance of the process. Both in conducting the project and in presenting it they used diversified approaches to gain a better understanding of the community with’ which they hoped to work. Applicability to Planning Agencies The variances due to geographic or cultural differences need to be recognized and con- sidered in the development of nutrition education materials and programs. 150 Position paper on nutrition education for the public. JADA 62:429-430, 1973 Geographical Area National implications. Study Design Nutrition education, the role of the dietitian, and methods for effecting behavior change were presented. Significant Findings A definition was presented: "Nutrition education is the process by which beliefs, atti- tudes, environmental influences, and understanding about food lead to practices that are scientifically sound, practical, and consistent with indivdiual needs and available food resources." 205Nutrition education should be available to all individuals and families and is needed by all, regardless of socioeconomic status. The focus was on the maintenance of health, rather than on crisis intervention, and the process was called continuing because it would incorporate new knowledge as it became available. The importance of the interaction among cultural, biological, and psychological factors in motivating eating behavior was discussed. Pragmatic suggestions included the identification of nutrition education as a part of every community health program, the encouragement of consumer participation, the reliance on qualified personnel to deliver nutrition education, and the inclusion of nutrition education in training programs for teachers, medical and dental professionals, and allied health personnel. Evaluation The organization's position was clearly stated. Applicability to Planning Agencies A definition and the elements of nutrition education were covered. Specifics for the implementations of the ideas presented were not provided. 151 Selph A: Focus on optimal development: improving child nutrition. J Nutr Ed 4:68-69, 1972 Geographical Area North Carolina, HEW Region IV Study Design The plan for a three-year demonstration project, Focus on Optimal Development (FOOD), was described. The project was concerned with providing health and nutrition services for children from low-income families through elementary schools. It was funded through the School Food Service. An interdisciplinary team worked in a public school setting. It consisted of a coordina- tor, assistant coordinator, health educator, nutrition educator, mental health educator, and six paraprofessional aides. Parent participation was enlisted; the assumption was that child nutrition was a shared responsibility. Significant Findings Objectives were presented with plans for attaining and evaluating them. The first was to increase parent participation and to document it. Increased utilization of existing community resources was an objective and a comparative study of utilization for previous years was planned. Attitude tests and plate waste surveys were suggested to demonstrate and document positive changes in pupils in the area of nutrition intake, attitudes, learning, and self- concept. Training of professionals and paraprofessionals to create an awareness of the impact of nutrition was suggested. Biochemical, physical, and dental care data were to be collected to demonstrate improvement in the physical status of the children. Tests were to be admin- istered to teachers to document changes in their awareness of the educational, emotional, and nutritional needs of the children. Evaluation This article presents an outline of the objectives similar to those advocated by the coordinators of many other health service programs, but it goes beyond the statement of what should be accomplished and provides some plans for action. Most important is that it provides evaluation criteria for each objective. This is an essential element of design for any program. Applicability to Planning Agencies In this program, nutrition education is not treated as a separate entity to be plugged into an elementary school curriculum. It is well integrated and the participation of parents, teachers, and students is encouraged. This would facilitate learning and awareness. In addi- tion to the general philosophy, the specific criteria for objective evaluation should be studied by planners. 206152 Sipple H: Problems and progress In nutrition education. JADA 59:18-21, 1971 Geographical Area National and international implications. Study Design The need for nutrition education and some ways in which it could be achieved was presented, using two studies as examples: a survey of the families of Black children enrolled in Head Start in upstate New York in 1971 by Dr. Diva Sanjur, and a study by Dr. Joaquin Cravito of the Hospital Infantil de Mexico in 1970. Significant Findings Sipple concluded that an understanding of family life patterns must be achieved before programs can be designed to motivate people to change their eating behavior. Possible methods for education were suggested. These included the utilization of existing educational systems, the development of a television course, use of the USDA's Cooperative Extension Service, and presentation of nutrition education workshops. Evaluation The general conclusions drawn in the article are valid, but the speculations are dated; presently there are specific examples of working programs that could more effectively communi- cate the ideas presented. Applicability to Planning Agencies It is important to include nutrition education as a component in any health plan. Much malnutrition (under- and over-nutrition) in all segments of the population is due to lack of sound nutrition information. 153 Sinacore J, Harrison G: The place of nutrition in the health education curriculum. Am J Pub Health 61:2282-2289, 1971 Geographical Area New York, HEW Region II. Study Plan A plan for nutrition education in the schools in New York State was presented. Significant Findings A comprehensive plan for cumulative nutrition education as an integral part of the curricu- lum during the elementary and secondary school years was proposed. In-service health education programs were planned for teachers. Teacher training television programs were developed and institutes of higher education conducted intensive teacher training programs. Curriculum guides were developed; they were designed to be adaptable to local needs. The goal was not to teach nutrition facts, but to guide the behavior of children in relation to food. Ten nutrition concepts provided the basis for the curriculum which became increasingly complex for higher grades. At the primary level the concern was with developing positive atti- tudes toward food and eating. Grades four through six stress the relationships among food, health and growth. Application of nutrition knowledge was encouraged at the junior high school level and the senior high school curriculum dealt with nutrition and social concerns. Evaluation Program evaluation was difficult; it will be a long time before definitive answers are available. Inclusion of some evaluation components as well as some specific curriculum activities would make the nutrition education plan stronger.Applicability to Planning Agencies Nutrition education should be comprehensive and curricula should be designed to be cumulative. FOOD ASSISTANCE PROGRAMS 154 Benezra N: Would you eat your child's school lunch? Today's Health pp. 40-43,53,54, Sept 1977 Geographical Area National implications. Study Design The meals provided by different school systems participating in the National School Lunch Program are reviewed. Significant Findings Type A guidelines for school lunches stipulate that food quantities furnish at least one-third of the Recommended Dietary Allowances of nutrients for youngsters. A report by the USDA Food and Nutrition Service, which shows that 15% of the food provided is thrown away, was cited as were reports from New York and Chicago which indicated that Type A minimum requirements were not being met. In addition to the nutrition inadequacy of the meals, the palatability was questioned. Examples of poor meafs were given,but successful systems were also described. It was recommended that meals be prepared daily on the premises. Evaluation The article raised important questions about the quality of the food provided in the National School Lunch Program; if the food is not consumed it cannot be expected that nutrition status will be altered. Although it pointed out some problems, the tone of the article was not entirely negative. Examples of programs that provided acceptable food were included. Applicability to Planning Agencies If the School Lunch Program is to continue and is to be successful, priority must be given to increasing the quality of the food provided. 155 Braden J (ed): Program Evaluation Status Reports: Completed Studies. USDA Food and Nutrition Service, Office of the Administrator, 1977 Geographical Area National implications. Study Design This report contained summaries of completed studies and projects concerning evaluation of Food and Nutrition Service Programs conducted since 1974. A division was made between Child Nutrition Programs and Family Food Programs. For each program objectives, methodology, and findings were summarized. Significant Findings Topics covered include: School Food Service Personnel, aspects of the School Lunch Program and the School Breakfast Program, menu planning, waste, nutrition education, Child Nutrition Programs, the Food Stamp Program, the Supplemental Food Program for Women, Infants and Children. 208Evaluation Evaluation projects are reported. The report is entirely objective, which includes a simple statement of what has been done. Applicability to Planning Agencies The report is a good source for determining what food and nutrition programs and services are available through USDA. Evaluation components and methods are also presented. 156 Paige DM, Graham G: School milk programs and Negro children: a nutritional dilemma. J School Health 44:8-10, 1974 Geographical Area Connecticut, HEW Region I. Study Design A study was carried out to determine the milk drinking habits of school children of differ- ent races in an effort to assess the practice of providing milk for children. It was postulated that Negro children would consume less milk because of a physiological intolerance to milk, lactose intolerance, common to Negro children. Students from the first through fifth grades at two elementary schools located in the lowest socioeconomic census track in Stamford, Connecticut were observed. Both schools served type A school lunches and participated in the USDA milk distribution program. The children received milk with their lunches. When they returned their trays the milk cartons were removed and name tags were affixed. The containers were weighed and the children were characterized as milk drinkers, those who consumed 50% or more, by weight of the milk, or non-milk drinkers, those consuming less than 50%. Significant Findings Of the Negro children, 36% were categorized as non-milk drinkers. Only 18% of the white children were characterized as non-milk drinkers. Evaluation A statistically significant difference in milk consumption by race was presented. This demonstrates an association but not a cause-effect relationship. The children were tested on the basis of preferences, not on the basis of physiological tolerance. Applicability to Planning Agencies Regardless of the reasons for rejection, a milk program will not be successful if the milk is not consumed. Alternate sources of protein and nutrients should be available for children who reject milk. 157 Wells CE: Nutrition programs under the Older Americans Act. Am J Clin Nutr 26:1127-1132, 1973 Geographical Area National implications. Study Design This paper describes Title VII, National Nutrition Program for the Elderly. 209Significant Findings Title VII is a formula grant program to be administered by designated State Agencies on Aging, which possess available persons knowledgable in nutrition or dietetic sciences. Each state may receive an amount of funding based on the number of elderly (60 years or older) per- sons in the state. State agencies must identify target groups, select those areas in the state with the greatest concentration of target groups as project areas and assist local public or private non-profit agencies to develop congregate feeding programs which provide one hot meal per day, five days a week. Projects serving the low-income and minority group elderly should receive priority funding. Each project must have a council whose responsibilities include decisions on the type of meals and their cost, when they will be served, and in what environment they will be consumed. More than one-half of the council members must be chosen from the pool of active consumers of project services. Out-reach, transportation and escort services may be funded as part of pro- gram projects. Evaluation Title VII provides funding for special groups of elderly people. There is no doubt that programs such as Title VII will demand increased attention and funding in the coming years as a larger percent of the population becomes older. This article fails to mention any evaluation component in Title VII and, if there is none, Title VII lacks a control component for an objective analysis of the program. Information on the unusual success or failure of particular projects must be kept. Standard format evaluations will allow federal, state and local governments to assess the significant and efficiencies of projects. This article also fails to mention a nutrition education component. Rather than seek to make the elderly dependent upon such programs as Title VII, major emphasis should be given to training the elderly, or groups of elderly people, to care for each other. Applicability to Planning Agencies This suggests an on-going nutrition program currently available to state and local govern- ments. 158 Jackson ML: HUD's role in the interagency action in nutrition and aging. Am J Clin Nutr 26:1124-1126, 1973 Geographical Area National implications. Study Design The elderly who live in or near HUD constructed or assisted housing. Significant Findings Department of Housing and Urban Development (HUD) housing contains large concentrations of consumers who could benefit from food service and nutrition education programs. Of older HUD occupants 70% are living alone, mostly women, with an average income of $2,665 for couples and $1,655 for individuals. Regular food service has been absent from HUD housing but the passage of the enablement of Congregate Housing in 1970 and the enactment of the Nutrition for the Elderly Act in 1972 provides the basis for nutrition services. Subsidized food service will be required so that otherwise eligible tenants, with potentially the greatest need, will not be excluded by the added monthly cost of food. To provide food service, broad long-term community planning and interagency coordination are necessary. Evaluation This general article suggests possible approaches to serving the elderly. The need for the approaches described probably still exists but the information presented may be dated. With five to seven years since the passage of the legislation there may be sample projects now in existence. 210Applicability to Planning Agencies The need for an interagency planning team to coordinate the utilization of monies available from the federal government and a possible format for coordinating independent nutrition and housing programs is suggested. The need for planning at the local level is stressed. 159 Pelcovits J: Nutrition to meet the human needs of older Americans. JADA 60:297-300, 1972 Geographical Area National implications. Study Design The author analyzes reports from various nutrition demonstration programs for the elderly which were funded under Title IV of the Older Americans Act. Significant Findings A large proportion of the participants lived alone. Women outnumbered men two to one. The average age of the participants was seventy-one. Of the participants, 81% had incomes below $200 per month. A variety of facilities housed feeding programs; senior citizen centers, community centers, homes for the aged, public housing, churches and schools. Transportation to the pro- ject facility is essential, especially in rural areas. Perhaps 20 to 30% of per meal cost is a reflection of transportation expenditures. No matter how attractive the program, how accessi- ble the location, or how convenient the transportation, out-reach is necessary to induce parti- cipation in the program. The social aspect of a program was enhanced when six to eight people were seated at small tables. Meal preparation varied depending upon the resources of the facility. Little data were available on the success of nutrition education in terms of impact on life style. Evaluation The fact that these programs attract participants reflects the need for some form of feed- ing program for the elderly, but to justify continuing expenditures, and to ensure that addi- tional expenditures will be made in the most efficient manner, each program must be compared with the others in order to find the most successful components of each. A future monograph will analyze the success of the various nutrition education and out-reach programs. Applicability to Planning Agencies Planners should note that a need exists for feeding programs for the elderly in all parts of the country. Feeding projects have been established in a variety of facilities. Funds should be allotted to programs for a continuous out-reach program to ensure that those eligible for the program participate. A low level of participation may solely reflect the timid, with- drawn, reclusive or proud nature of the elderly. 160 Paige DM: The school feeding program: an underachiever. J School Health 42:392-395, 1972 Geographical Area Maryland, HEW Region III Study Design A biological evaluation was carried out to assess the impact of the school feeding program on children exhibiting a less than optimum nutrition status. The population studies consisted of 742 children in the first, second and third grades in four schools within the Baltimore City school system; two schools were predominantly Black and two predominantly white. All students were of lower socioeconomic background and were served medically by a comprehensive Children 2JJLand Youth Project. The children were screened for height, weight, and hematocrit. Two groups, those participating in the school feeding program and nonparticipants, were followed for a year Significant Findings The assessment of height, weight, and hematocrit independently and jointly over a one-year period showed no significant difference between children participating or not participating in an organized feeding program. It was recognized that there may be short-term benefits such as improved classroom performance following meals. Several factors that might contribute to the lack of success were named: high rates of absenteeism, incomplete consumption of lunch, and poor nutrition reinforcement at home. The design of the "Type A" school feeding program was criticized because it ignores the factors mentioned and does not incorporate new food technology in meal planning; rather it sim- ply continues to supply one-third of the minimum recommended daily requirements. Evaluation This article is especially good because it points out the need to objectively evaluate the biological impact of a feeding program designed to improve nutrition status. Applicability to Planning Agencies Traditional concepts, such as the "1/3 RDA" prescription for school lunches must be modi- fied as new information and new technology become available. At the same time, community reaction to the implementation of change in feeding programs must be considered. 161 Hill MM: The National School Lunch Program. Clin Pediat 10:651-655, 1971 Geographical Area National implications. Significant Findings Hill reviews the history and background of the National School Lunch Program. The foundation of the present program is the National School Lunch Act (P.L. 79-396, June 4, 1946, 60 Stat. 231). This Act was amended by the Child Nutrition Act of 1966 (P.L. 89-642, October 11 1966, 80 Stat. 885-890). Key features of the current legislation are listed and the Type A meal pattern is described. The special milk program, school breakfast program and school dinner program are mentioned. Evaluation Although this article mentions the number of children assisted by the school lunch pro- grams, there is no discussion about whether the meals provided actually made a measurable difference in the nutrient intake and dietary habits of those fed. Applicability to Planning Agencies A list of some of the federal nutrition programs available to states and localities allows a planner to ascertain whether these services are currently offered in his/her state. 212CHAPTER III. NUTRITION PLANNING AND NUTRITION POLICY ELEMENTS IN NUTRITION PLANNING 162 Background Document for Technical Discussions on The Importance of National and Inter- national Food and Nutrition Policies for Health Development. WHO Tech Disc No A30, 1977 Geographical Area National and international implications. Study Design The purpose of the document is to stimulate governments to review their nutrition/health problems and to consider ways to deal with them. The report discusses such topics as: defining nutrition problems, contributions of the health sector to nutrition improvement, limitations of nutrition impacts of health measures, choices of health sector interventions, and responsi- bilities of health sector planners. Significant Findings Defining the problem at the national level: Improving food supplies may have chief importance in increasing prices relative to earnings. Identification of "vulnerable groups" is not sufficient for practical policy: identifi- cation of families at-risk and subsequent attention to vulnerable individuals within these families are more useful. Population groups used in problem statements should be defined so that they are relatively homogenous both in the problem being experienced and in probable response to specific policies or programs. Defining the problem at the community level: A diagnostic frame of reference, in which the natural history of disease can be divided into the prepathogenic period, the preclinical, and clinical stages, is useful in designing nutrition assessment system. Useful data can be gathered by casual observation or by systematic inquiry, such as food intake, anthropometry, clinical surveys, health service records, and demographic data. Detailed information on malnourished groups is more useful to find reasons for malnutrition than general information'based on a random sample of the total population. Contributions of the health sector to nutrition improvement: Appropriate nutrition interventions are determined by the stage of evolution of the malnutrition process. Curative interventions are required for the clinical phase and both direct and indirect interventions are required for the prepathogenic and preclinical phases. 213Some direct nutrition interventions, such as supplementary feedings, should be considered and designed as emergency measures, while others, such as water fluoridation, should be seen as permanent measures: Supplementary feeding programs should include a formal education component and should be associated with other aspects of health care; Fortification or enrichment can be effective when widespread deficiency of one essential nutrient is present; Since nutrition education is implemented by several sectors and by private sector agencies, it should be planned and implemented in a coordinated way. Health sector interventions with an indirect impact on nutrition status, such as environ- mental sanitation, infection control, maternal and child care, and family planning, are sometimes very cost-effective. Nutrition impact of health measures—their limitations: Health services alone cannot resolve nutrition problems if causes are rooted in the state of society. All elements of food and nutrition strategy—food demand, food supply and biological utilization—must be incorporated simultaneously into food and nutrition planning. Choices of health sector intervention: Preventive intervention is usually more economical than curative intervention. In choosing specific nutrition interventions, decision-makers should use the following criteria: Type and degree of malnutrition; its economic and social repercussions; Cost of intervention; Administrative viability with special reference to infrastructure and personnel; Degree of nutrition impact; Time span for desired impact; Degree of focus on target group; Complementary effects on other interventions. Complementary interventions among different sectors and even complementary interventions within the health sector should be most effective. Nutrition services should be provided within total health care system. Guidelines for nutrition activities within primary, secondary, and tertiary health care, should be adopted and implemented by the health sector. Responsibilities of the health sector planners include: Problem identification; Problem definition; Identification of relevant measures; Formulation of nutrition objectives and goals (expressed in terms of health status); Design and implementation of programs involving other sectors; and Data support systems for nutrition planning. There should be a national food and nutrition board, consisting of representatives of various departments, to give coherence and consistency to policies and programs within the different departments relating to health/nutrition. There should be a nutrition unit in the central health department to assist the above food and nutrition board in food and nutrition planning. Evaluation The document presents an excellent analysis of the potential and already existing inter- relationships between the nutrition and health sectors. Although the target audiences are international and national health planners, especially in lesser developed countries, the docu- ■ent could also be useful for state and regional health planners. 214Applicability to Planning Agencies Target groups, or individuals at-risk, should be defined as precisely as possible in food and nutrition plans. Each category in the final categorization of individuals should be homo- genous with regard to nutrition problems and needed interventions. Detailed information on specific populations at-risk sometimes can be obtained from records kept with local health or nutrition programs, such as WIC, MIC, community mental health centers, outpatient clinics, and family planning programs. This information could be used to shed light on causes of nutrition problems in particular localities. Analysis of nutrition intervention using this approach would probably lead to highlighting of various groups in available services. HSA's should include in their food and nutrition plans recommendations for inclusion of a formal education component in feeding programs, such as School Lunch, WIC, and day-care centers. This recommendation should be discussed with program administrators. HSA's should assure that someone or some organization is responsible for coordination of nutrition education efforts at regional levels. HSA's should include discussion and recommendations on supply, and biological utilization in food and nutrition plan. Planners should take these criteria into consideration when recommending possible inter- ventions in their food and nutrition plans, HSP's and AIP's. Guidelines for nutrition services within all levels of health care should be adopted by the HSA's and relevant portions incorporated into HSA plans. 163 Food and Nutrition Strategies in National Development. Ninth Report of Joint FAO/WHO Expert Committee on Nutrition, FAO Nutr Meet Rep No 56, 1976 Geographical Area National and international implications. Study Design Prior to the meeting, the World Food Conference held in Rome indicated "that all govern- ments and the international community as a whole. . . formulate and integrate concerted food and nutrition policies in their socioeconomic and agricultural planning. ..." The objectives of the meeting were: (1) to review the scope and objectives of a national food and nutrition policy; (2) to review methodologic approaches on food and nutrition planning and provide guidance as a scientifically sound yet practical method, particularly for developing countries; (3) to recommend a workable mechanism for integrating nutrition into national development plans; and (4) to identify areas of training and research, particularly those calling for action by FAO and WHO. Significant Findings A food and nutrition policy usually deals with three areas: Food demand (per capital income, income distribution, food subsidies, consumer preferences and nutrition education, supplementary feedings programs, and population policy); Food supply (pattern and level of food production and prices, food marketing, storage and processing, nutrition value of range of available foods, food exports and imports, food standards, and food safety); and Biological utilization (environmental factors affecting appetite and absorption, pregnancy spacing, lactation, physical activity, and food intolerances). A food and nutrition strategy should include, at least, three elements: Improvement in food production and income distribution; Improvement of the quality of diet to all income groups via the combination of foods produced, the processing techniques used and the distribution of the goods; and Nutrition-related health activities and nutrition intervention programs. Some degree of decentralization of planning is necessary so that the deprivation of specific population groups can be identified and planned for. Since various forms of deprivation are generally interdependent, interventions should be coordinated. 215National plans are expressed in both national policies, such as prices, taxes, subsidies, and local programs. Identification of weaknesses in planning structures may allow identification of needed changes. Awareness is growing that capital intensive technologies used in developed countries will have to change, because of over-nutrition, pollution, and so forth. Planning is part of the political process and planners have an important political role to play— that of contributing to a better understanding of policies and programs feasible within the country's resource constraints. Agricultural price policy is important in national planning because it influences food produc- tion and consumption at all income levels of the population. Thus, food policy should be attuned to avoiding price increases which have undesirable nutrition effects. Orienting agricultural research and extension activities to promote expanded production of commodities which enhance the nutrition quality of the national diet is needed. The pattern of food available and consumed can be changed by tax and subsidy policies. Taxation of low-nutrition quality products can decrease their consumption; direct subsidies and prefer- ential taxes on high-nutrition quality products can increase their availability and consumption. Government regulations on food processing and labeling can help protect consumers. Increased effective demand for animal fats and refined sugars, associated with dental caries, obesity, heart disease, and diabetes, should be discouraged. Since the risk of deficiency or excess of nutrients is greatest when there is a narrow range of foods consumed, planning should encourage variety in foods available to the population. Health and nutrition programs should work in cooperation with all relevant services available in the community and should enlist community involvement in establishing priorities and encouraging participation. Types of programs include: (1) food fortification; (2) supplementary foods and feeding programs; (3) incorporating immunization programs and environmental sanitation pro- grams within health programs; (4) maternal and child health activities; and (5) nutrition education. Nutrition planning is based on identification of the nutrition problem in terms of who, in what ways, in what circumstances, and why. Lack of complete data should not stop planning. Imme- diate and ultimate causes of malnutrition should be specified. Prediction and detection of trends should be included. Malnourished groups should not be too narrowly defined: there are significant differences in the situations of different categories of families. Identification of relevant alternatives includes appraisal of ongoing program approaches and analysis of other programs which may have nutrition effects. Not only should different alter- natives be examined in this way, but the overall impact on nutrition of the totality of inter- vention should be reviewed. Organizational requirements for food and nutrition planning include a central planning body which is: Responsible for overview of analyzing all development programs with regard to nutrition effects; Placed so that it can require various ministries to provide information and meet on their nutrition effects, and placed so that it can affect the decisions of the planning authority; Financially independent of the ministries and credible; and Responsible for cumulative analysis of the overall national nutrition picture, but also able to assist in area-level planning.Data support requirements include: Direct and indirect indicators of nutrition collected on a large scale; Detailed indicators collected on a smaller scale which can be related to above indicators; Special purpose surveys will pertain to selected population groups. Common problems with existing data are: Food production data are voluminous but consumer information data are scanty; and Large-scale survey information is often too highly aggregated to be useful to planning needs. Construction of "need indicators"—values assigned to different increments of improvements— makes explicit priorities and underlying values. Need indicators would also be a function in each case of the degree of damage and its relative significance. Then each need indicator can be compared to its cost. Implementation of the nutrition program at the local level requires attention also. Nutrition services should be fully integrated into other basic health, agricultural, and child health programs. Community participation is necessary for effective programs. Cost-benefit analysis is a major weakness in that its valuation of "benefits" is based on market price criteria which are a function of the current income-distribution pattern. Cost-effective- ness analysis offers many useful concepts: Cost and effectiveness of each alternative; Depreciation and renewal of equipment for each alternative; Multiplier and spin-off effects of each alternative; Desirable technological and attitudinal changes; and Who would benefit? Other issues which have to be addressed are: timing of nutrition benefits (a few children now or many later) and the political acceptability. Knowledge about food and nutrition problems must reach the top decision-makers and the needy population equally effectively. Human resources must be trained for: Planning at national and sectoral levels; Planning, implementation, and administration of programs at national and other levels; Delivery of services; Coordination of services at local level; Community personnel (local leaders); and Local auxiliary workers. Evaluation This report is an excellent overview of the present food and nutrition situation both on a national and international level. Although past approaches to the nutrition problem are only briefly covered, suggestions for new approaches are well treated with a description of the necessary elements of a food and nutrition policy: (a) food demand; (b) food supply; (c) bio- logical utilization. The need for research on identification and analysis of nutrition problems on populations, program development, direct intervention programs and evaluation is stressed. Applicability to Planning Agencies Food and nutrition plans at the regional level should address issues of food demand, food supply, and biological utilization. Subarea councils should assist the HSA's in development of food and nutrition plans, especially in areas of problem definition and integration of nutrition into health and social welfare activities. Planners should play this role at the local and regional levels also. HSA's should be sensitive to the potential effects of price increases on nutrition status of their region's population. HSA's should be attuned to national tax and subsidy policies, particularly during hearings or debates on changes. 217Coordination and integration of health and nutrition programs at regional and local levels should be a concern for HSA's and their subarea advisory councils. HSA's could set up a formal mechanism, or they could work with other agencies (e.g. health department) to do so. All HSA plans should recommend this, and relevant project proposals should be reviewed with this cri- terion in mind. 164 Burkhalter BR: A Critical Review of Nutrition Planning Models and Experience. Ann Arbor, Mich, Community Systems Foundation, 1974 Geographical Area National and international implications. Study Design The purposes of the document were to identify techniques used in nutrition planning; to develop a classification and to evaluate the different classes of techniques. The report is divided into three major areas: What is Planning: Definitions, Classifications and Lessons National Nutrition Planning: Theories and Practice Specific Nutrition Interventions: Unplanned and Evaluated Significant Findings The major conclusion reached by the author was that: "Nutrition planning will be most successful if it is explicitly designed to be a learning process, in which each activity is perceived as a discrete step in a learning sequence." Other conclusions drawn were: "There are several traditions of planning, none of which are clearly the 'best'." "Some planning has been successful, but more often it has failed." "The evidence is building that the national tradition of planning, as it has been practiced, does not work well in many situations." The process of planning is more important than the plan. The style of planning should fit the environment in which it is practiced. Commitment of key persons at all levels is necessary for successful planning. Projects frequently fail to be implemented for lack of capable management. Persons responsible for implementation should be involved in pre-implementation planning activities. Attempts should be made to achieve a small success in the minimum possible time; In governments, the budget is the key operational device for real planning. The practice of planning differs considerably from what is espoused, and with good reason. With regard to the two major instruments for covering change, policy and project, policy will become the major tool of central planning while projects will be the forte of decentralized planning. Successful planning will focus far more on humans and humaneness. 2M.Evaluation The document is an excellent summary and integration of various models and perspectives in the planning literature. It also provides an excellent critique of several national planning experiences. This is a very valuable document for nutrition planners, especially national nutrition planners. Applicability to Planning Agencies HSA's should be aware of the several available planning models. HSA's should be aware of the use of planning as a learning process, and the use of planning as a change agent. 165 Planning National Nutrition Programs: A Suggested Approach. Vol I: Summary of the Methodology. Vol: II, Case Study. Washington DC, Agency for International Development, 1973 Geographical Area National and international implications. Study Design These documents presented a simple, practical guide to national nutrition planning, adaptable to any planning situation. The second document presents a case study in the use of the methodology. Significant Findings The systems approach as applied to nutrition requires five sequential steps: Description of the national nutrition system, qualifying all relevant factors to fullest extent possible. Selection of target groups, priority objectives, and tentative goals. Identification of intervention points within the system. Comparison of alternative points of intervention and alternative interventions at each point. Development of the implementation plan. The nutrition system is composed of three sub-systems (food supply, distribution, processing and consumption) and often related systems (domestic economic, health care delivery, demography, foreign economic, and government administrative). The interaction of elements in the sub- systems and related systems affects the supply and flow of nutrients to the consumer and his ability to purchase and utilize the nutrients. Important relationships between causes and effects should be selected for study on the basis of: Choice of target groups, nutrition goals desired, and time period in which goals are to be achieved. Degree of causal connection (those causes most closely connected to effects). Amenability and responsiveness to change. Expression of these relationships should be specific and quantified. Through successive stages of expression of these relationships, the nutrition system becomes a framework within which the consequences of alternative policies can be predicted. If data are lacking, assumptions can be made. Description of the consumer sub-system leads to the selection of specific relationships for further study, selection of target groups and selection of tentative goals. Describing nutrition status can be done by showing who consumes how much of what foods in what places and at what prices. Describing nutrition problems follows from compar- ing the above to nutrient requirements. 219Important relationships or causal factors in the consumer sub-pattern which may require further study are: income distribution; food habits; spacing of children and family size; and health status of the family. The food supply sub-system is divided into production output and production input, i.e., Calculating agricultural output, food availability, and nutrition requirements allows planners to estimate adequacy of aggregate food supply, given the assumption that the population is healthy. Further analysis should be done on data describing: the production of staple foods for the target groups; foods which could be sources of needed nutrients or vehicles for fortification; and products which are principal output of low-income farmers. Analyzing production factors and costs of production allows the planner to calculate how much nutrients cost to produce. Important relationships in the food supply sub-system are: comparison of food available for human consumption and national nutrition requirements rates of productivity and factors affecting them; and costs of production. The food distribution and processing sub-system should be described in two stages: the flow of commodities from primary producer to the consumer, and significant cross-commodity activities that affect several different foods. The effect of each step from primary producer to consumer on the commodity should be quantified (e.g. waste, nutrient loss through processing). Cross-commodity activities include storage, credit, excise taxes, labor problems, and retail practices. Important relationships in the food distribution and processing sub-system are: effect on retail price or price of unit of nutrients from different foods; and pff^ct on supply of nutrieqts to target groups. Related systems which should be taken into account are: Foreign trade. Domestic economic system (its interdependence with nutrition status); income and distribution of income; and food prices, production, and distribution costs Health sector. Population system. Making links between nutrition and characteristics of the above related systems may suggest further intervention alternatives to the planner. Selection of target groups and tentative goals is a political decision which can be aided by technical analysis from the planner. A nutrition goal should be stated so that: the expected improvement is specified and linked with an already identified problem; the target groups are identified; and the time period for attaining the goal is specified. 220.Nutrition goals can be stated in terms of: food or nutrient intake; nutrition status; and benefits from improved nutrition status. Data from four areas continually modifying goal and target group selection include: extent and severity of the problem; benefits from solving the problem; feasibility of solving the problem; and program performance. Comparison of alternative interventions can be done at two levels: at points where interven- tions begin, and alternative programs which begin at some point. To choose best points and kinds of intervention, the following criteria can be used: responsiveness to change; probable impact on goals and target group; time requirements; and resource constraints. Comparison of alternative programs can then be done considering: constraints (funds, talent or manpower, political conditions, social mores, etc.); conditions (feasibility of each class of intervention); and cost comparisons (estimates of costs and benefits throughout nutrition system, taking into account risks and discounting for time). Evaluation of nutrition interventions should be designed into the intervention itself, so that data from initial steps can influence later evaluation activities. Strategy and tactics of nutrition planning and programming include: Arguing for the value of nutrition interventions in terms of: productivity; human capital; cost reduction (e.g. cost/hospital day of nutrition-related diseases); increased real income. Organization of planning and programming to involve: adequate staff and budget; legal authority; sensitivity to policy-makers; contact with private sector; and staff with broad backgrounds. Resources for planning. Evaluation The methodology suggested is practical, yet analytical, and would have great value to nutrition planners at all levels. The systems approach—dividing the nutrition system into the sub-systems of food supply, distribution and processing, and marketing—is an excellent way of analyzing problems and potential solutions. Applicability to Planning Agencies This approach can be adapted for use by regional health planners. Local data or data extrapolated from national sources can be used in the description of regional nutrition problems. 2liDescription of the consumer subsystem and the food distribution and processing sub-system are probably most useful: the first for identification of target populations and goals, and the latter for identification of most cogent (for regional planners) alternative interventions. Description of related systems, especially the economic system and the health system, should also suggest relevant potential alternative interventions. When the plan has been adopted, advocacy can proceed at all levels, from local institutions to national government. 166 Berg A, Muscat R: An approach to nutrition planning. Am J Clin Nutr 25:939-954, 1972 Geographical Area National and international implications. Study Design This document discusses a broad, systematic approach to understanding malnutrition, to propose a framework to analyze nutrition needs, and to identify the most appropriate methods to fulfill them. The approach outlined is an adaptation of established planning techniques to nutrition. Significant Findings. Some of the major factors and policies influencing nutrition status, such as income redistri- bution, agriculture, and so forth, are outside the interest and reach of nutrition planners, and those who do formulate these policies do not specifically include nutrition needs as part of their planning. The planning sequence of identifying the problem, setting objectives, identifying and comparing alternative interventions, making the decision and evaluating the resu1*-'. should be applied to nutrition problems. Methods for measuring the nature and extent of malnutrition include: food balance sheets, consumer expenditure surveys, foods consumption surveys, and medical nutrition surveys. Each has special uses and limitations, but if used together, can provide fairly usable information. General criticism is that surveys are usually designed without regard to policy questions. Identification of possible objectives should result from interaction of the decision- makers and the nutrition planner. Nutrition objectives should: cite specific deficiency and numerical target or final output, in order to allow estimation of needed resource inputs; specify time frame, which requires planned sequence of action; and specify needed resources, which then lead to sub-objectives. Analysis of the causes of the problem should be directed at socioeconomic factors directly influencing diet and utilization that can be manipulated. Practical application of the systems approach will yield guidance to decision-makers within desired time period, identify major determinants of nutrition problems, and suggest criti- cal points for policy levers. Nutrition planning should be seen as a conceptual approach, a systematic way of looking at a problem to sharpen decision-making. Identification and comparison of alternative interventions consist of judging the rele- vance and relative effectiveness of usual interventions and developing new interventions. Alternatives are compared for cost and relative effectiveness, possible impact on non- nutrition sectors, and other general constraints. Issues included in cost-effectiveness analysis include: whether the project will be self-sustaining, the nature and source of needed resources, and the accounting for non-quantifiable costs and benefits. Nutrition activities consistent with non-nutrition objectives are preferable; however, nutrition planning should not necessarily be subordinated to those other objectives. 222-Some possible constraints on alternative selection are: replicability, time, and practical bureaucratic questions (such as commitment of officials and potential corruption). The planners should superimpose these considerations on the purely technical judgments. Planners are generally only marginally involved in the final decision-making stage. Evaluation should determine whether the program or policy hypothesis is true: whether the activities have contributed to achievement of the broad objective. Results of evaluation are fed back into the planning process. The planning process has many limitations: Conclusions depend heavily on availability and quality of data and personal judgments. There is a discrepancy between what makes sense logically and what works operationally. Planning can be overdone, hinderipg flexibility. Evaluation This is an excellent article on the systematic planning approach as applied to nutrition. Practical problems, such as quality and quantity of data available and planner's role in the decision-making process, are also discussed. Applicability to Planning Agencies Data from many sources can be used by planners to assess the nature and extent of nutrition problems in their region. Possible local sources of data, such as hospitals and community health programs, can be used to assess more accurately local nutrition problems. Project proposals submitted to HSA's for review should include objectives consistent with these criteria. HSA plans should state objectives in quantifiable terms. 167 Berg A, Scrimshaw N, Call DL (eds): Nutrition, National Development, and Planning. Cambridge, Mass, MIT Press, 1971 Geographical Area and Study Design National and international implications. This book reports the proceedings of the International Conference on Nutrition, National Development and Planning held at the Massachusetts Institute of Technology, October 19-21, 1971. The purpose of the conference was to discuss the place of large-scale nutrition programs in national development planning, especially in the developing countries and among low-income groups. Another important purpose of the conference was to stimulate communication among nutritionists and development specialists. Participants included nutritionists, economists, development planners, and national and international administrators from Asia, Latin America, the United Kingdom and Europe, Africa, the Middle East, Canada, and primarily from the United States. Significant Findings Papers and discussion focus on two main issues: Problems of nutrition as they affect both the individual and the nation and the most feasible means of alleviating the problems; and The integration of nutrition planning into an overall national development program in countries with limited economic resources. The book presents papers on six main subjects: The Effects of Nutrition on the Individual The Role of Nutrition in National Development Diagnosis of Food and Nutrition Problems and Establishment of Priorities Determinants of Malnutrition and Alternative Nutrition Intervention Programs 223A Conceptual Approach to National Nutrition Program Planning Case Studies Evaluation While much of the material focuses on problems of developing countries, there is valuable material for U.S. planners. Applicability to Planning Agencies This book can be used as a resource for specific nutrition planning problems. PLANNING AT INTERNATIONAL, NATIONAL, STATE, COMMUNITY, AND INSTITUTIONAL LEVELS 168 Forward Plan for Health: FY 1978-82. Washington DC, Govt Ptg Off, 1976 Geographical Area and Study Design National implications. The purposes of the Forward Plan are to provide a more rational basis for decisions in the annual Federal budgetary and legislative process and to allow the Assistant Secretary for Health to present his views on health in order to stimulate public debate. The plan identifies five major health concepts which set the frame of reference for Public Health Service (PHS) activities. The five issues are: control of health care costs; development of new knowledge; prevention of disease; improvement of the health care delivery system; and quality of care. Significant Findings The following areas in HEW's health plan relate to nutrition. Prevention of Disease More healthful food consumption should be fostered via: public school nutrition education programs; nutrition education of the public; research into nutrition education methodology. Nutrition concerns should be integrated into the health care system. Training of health-related personnel in nutrition is one method of doing this. Nutrition pro- grams should be considered by HSA's and the State Health Planning and Development Agencies in their planning. The nutrition status of the nation's people should be determined through local and national surveys. Monitoring and surveillance should be done continuously. Data from HANES and the USDA Food Consumption Survey should be interrelated. Perhaps a national survey on nutrition in institutions will be conducted. The FDA may do studies on excess consumption of vitamins and minerals. Knowledge Development NIH is the only agency with an internal coordinating group for nutrition activities. The NIH Coordinating Committee meets monthly and, among other things, is developing a Nutrition Plan for NIH. Nutrition-related research is being done on a broad range of topics by various NIH categorical agencies. Further research and more coordination of research efforts are needed. Problems in the application of nutrition research arise from; the inadequacy of current training of M.D.'s and other health professionals in practical nutrition; the difficulty of scientific validation of nutrition information. 224Because of these problems, the PHS's tasks are to support nutrition research and to devise mechanisms to make this information socially useful. The limitations on nutrition knowledge will have to be accepted. Thus, general nutrition advice for both healthy and ill people will have to include a safety factor, similar to the RDA's safety factor. As statements of objectives for improved food products can be made, the food industry should respond, especially in such areas as improving nutrition quality of convenience foods and supplemental foods for particular age groups. Evaluation The plan accomplishes its purpose in that it stimulates thought on the current problems in health. Although the sections related to nutrition are brief, they are thoughtful and realistic Applicability to Planning Agencies HSA's should include in their nutrition plans recommendations for high quality public school nutrition education programs and community nutrition education programs. HSA's should sponsor meetings of regional health and nutrition educators, representatives from all levels of educational institutions, and representatives of the communications media to discuss development and implementation of community and school nutrition education programs. HSA's should encourage development of nutrition components in medical and health pro- fessional school curricula. 169 The A.I.D. Nutrition Program Strategy. Washington DC, Agency for International Develop- ment, 1973 Geographical Area International and national implications. Study Design This document describes the rationale and strategy for A.I.D.'s nutrition program and the recommended approaches. Significant Findings While the emphasid of this document is on the nutrition problems of lesser developed countries, some findings have general applicability: Progress in nutrition will not occur until national policy makers recognize poor nutrition status as a problem, establish program goals, and allocate significant resources to attain them. Better data on alternative programs are needed in order to compare: how they work; what they cost; under what conditions they are most suitable and so on. Inclusion of the nutrition dimension in analysis of relevant sectors, such as agri- culture, health and education, could encourage adoption of policy which would address nutrition concerns. Evaluation The document is a clear statement of A.I.D.'s nutrition strategy. It highlights many of the nutrition problems and causes in lesser developed countries, and attempts to show how inter- sector program approaches may be most effective in dealing with the problems. Applicability to Planning Agencies HSA's should attempt to make local, state and national decision-makers aware of the impor- tance of nutrition in the health of our people. This should be done continuously at all levels of government and using multiple channels, i.e. mass media, letters, resolutions, conferences, plans, and task forces. 225When reviewing project proposals, HSA's should emphasize the need for data on alternative program approaches and request reasons for particular program choices. Nutrition concerns should be incorporated into HSA health plans. Planning at State and Community Levels 170 Breslow L, Somers A: The lifetime health-monitoring program—a practical approach to prevntive medicine. N Engl J Med 296:601-608, 1977 Geographical Area and Study Design National, state and local implications. The article proposed a lifetime health-monitoring program that used clinical and epi- demiological criteria to identify specific health goals and professional services appropriate for ten different age groups. Sigiifleant Findings Preventive medicine was defined as measures that can be incorporated into personal health services and financed through direct patient payments, health insurance or other mechanisms normally used to pay for such services. The concept of a "checkup" as an example of preventive medicine was considered ineffective and emphasis was given to the detection and prevention of chronic rather than communicable disease. The use of existing patterns of medical practice and health-care financing was advocated with the combination of public health and private practices to bring together epidemiological and clinical approaches to diseases. Basic concerns common to the approaches were recommended. They included a focus on personal health service involving a continuing doctor-patient rela- tionship, the identification of specific preventive measures for specific age groups at rationally prescribed intervals to replace the vague "annual checkup," specified test procedures to detect early onset of disease or risk factors of disease, and educational and counseling procedures designed to influence health-related behavior. The life cycle was divided into ten periods, each reflecting common life styles, health needs and problems. These included pregnancy and perinatal period, infancy (first year of life), preschool child (1-5), school child (6-11), adolescence (12-17), young adulthood (18-24), young middle age (25-39), older middle age (40-59), elderly (60-74), and old age (75 and over). A set of health goals and services was formulated for each group. Examples of specific proce- dures were given for two groups. The procedures were recommended on the basis of their rele- vancy and acceptability to the population, their direct connection with the prevention of a clearly identified disease which has a period during which morbidity or mortality can be reduced if it is detected, and on the ease with which it can be administered and the resources available to administer it. Definitive information concerning program costs was not available. Comparison with similar programs projected a favorable estimate of annual expenditures. Traditional underfinancing of preventive health care was cited and it was suggested that the program plan might be used by insurance companies to help formulate specific definitions for the purpose of covering preventive care. Evaluation The article did not present a finished working plan; rather it proposed a design for the delivery of preventive health care services. Age groups were identified and goals and services were specified. The focus was not on manpower or cost analysis, but these aspects of the health care services could be easily accommodated with the adoption of the basic concepts presented in this plan. Applicability to Planning Agencies Differentiation of program components is advantageous. The plan for any program will not be effective if provisions are not taken to ensure participation; consumer and professional incentives must be provided. 226171 Preliminary Guide for Developing Nutrition Services in Health Care Programs. Washington DC, Govt Ptg Off, 1976 Geographical Area National, state and local implications. Study Design This document presents a practical guide for the incorporation and delivery of nutrition services in health care programs. In addition, the document provides information on the dietary questionnaire, DHEW's nutrition policy, standards for nutrition services, resources for nutrition information, resources for food assistance, a directory of public health nutrition directors in State health agencies, and more. Significant Findings Planning for Nutrition Services in Health Programs Planning nutrition services should follow the same steps as any health planning effort. A Nutrition plan should include: basic information on identified food and nutrition needs of the target populations and nutrition services available; nutrition goals and objectives in relation to broader health program goals; nutrition resources required; and policies necessary for implementation. The public health nutritionist and the program administrator should have major responsi- bility for developing a written plan. An advisory committee with broad representation can be helpful in planning and implementing nutrition services. Providing Nutrition Services All Bureau of Community Health Services-supported projects and programs should provide, at the minimum: Screening and assessment A minimal screening program requires: basic knowledge of the community and information on the food intake practices, physical findings, and a few laboratory analyses of the individual. Delivery of services 1. Dietary counseling— Decisions should be made regarding who should receive counseling and who should be responsible for what aspects of the counseling. 2. Nutrition education— The goal of nutrition education is the acquisition of knowledge as the basis for making wise food choices and the acceptance of the need for changes in eating behavior when nutrition inadequacies exist. 3. Community resources for nutrition food assistance— The health provider should keep updated information about current community resources available to improve diets. 4. Coordination and referral system— Referral procedures are essential for continuity of care and to take advantage of services available from other resources. Assessing quality of nutrition services The assessment plan should include provision for assessment of structure, process, and outcomes of the care provided. Specifics of the assessment plan will vary with setting and type of nutrition service delivered: whether it be part of comprehensive care, alone, or part of broader health care services. 227Recording pertinent data Patient records should be kept by all those providing nutrition services in order to monitor the patient's progress, communicate information to other team members, and assess quality of care. Program records or reports should help administrators to document need for and effect of nutrition services on outcomes. Monitoring and evaluation Accountability requires that program effectiveness and efficiency be determined. All team members should be involved in program evaluation. Standards for Nutrition Services High quality nutrition services should be based on acceptable professional standards and criteria. Who Provides Nutrition Services? The administrator should be aware of the significance of nutrition to health and gain support and resources to solve the problems. The public health nutritionist should have major responsibility for planning, organizing, and managing nutrition services. Other members of the health team who can provide services include: community health or nutrition aides, physicians, nursing personnel, social workers, physical therapists, and health educators. Alternative Approaches to Provide Nutrition Services If resources cannot support a full-time nutritionist, other ways to provide for nutrition services are possible: Employ part-time personnel; Contract for specific services; Obtain consultation from State or local health agency nutrition staff. Standards for qualifications of nutrition personnel are appended. Financing Nutrition Services Every health care program should include nutrition as a specific budget item. Salary ranges for nutrition personnel may be mandated by State or Federal programs. Evaluation This is an excellent document for all administrators of health programs providing nutrition services. The information provided is comprehensive, useful, and practical, and is clearly written. t 1 Applicability to Planning Agencies Nutrition plans developed by HSA's should include all components in other health plans. Nutrition plans should be developed with the help of public health nutritionists. Other health professionals and consumers should also be involved. HSA's should review all community health services-supported programs with these criteria in mind. Other nutrition programs could be reviewed using these criteria, when relevant. HSA's should make program administrators and other health professionals aware of this document and should encourage its use in developing nutrition programs or projects. 172 Nutrition Practices: A Guide for Public Health Administrators. New York, American Public Health Association, 1955 Geographical Area National, state, and local implications. Study Design The purpose of the document is to help administrators of public health departments initiate, conduct and evaluate nutrition services. 22SSignificant Findings Nutrition programs should be continuing, preventive, and health promoting to be effective on a long-range basis. The basic public health problem is not to provide food, but to teach people to select and prepare the right foods in adequate amounts. Nutrition services are generally directed towards meeting needs of specific groups. The public health administrator should take the responsibility for assuring that the total community nutrition services are adequate and effective in meeting the existing needs. To assess whether the needs are being met, (s)he should review information from the following areas: community conditions; food supply; legislation; public understanding; professional train- ing; treatment facilities; and group feeding. There are a variety of approaches to surveying needs and resources. The program administra- tor should design the approach to suit needs. Some of the various survey methods are: review of population characteristics and community facilities; restudy of departmental vital statistics and review of records; obtaining a clear picture of population information and attitudes about nutrition; establishing a statistical basis for action (hospital medical records, industrial medical departments, etc.). To have the most effective nutrition service, all members of the health team must contribute. Nutritionists could carry out the following activities: Help develop a complete nutrition program; Consult with health department staff in planning programs of education and control of dietary deficiencies and obesity; Meet with representatives of other community agencies to work out interagency relationships; Consult and advise other services in agriculture, education, welfare, industry, and professions; Help plan and participate in community nutrition and food studies; Help prepare or select both technical and popular educational material in community programs; Participate in the broad nutrition education program through mass media; Help plan and implement pre-service and in-service training for agency staffs. Nutrition should be an integral component of such unit programs as maternal health, child health, tuberculosis control, chronic disease control, oral hygiene, environmental sanitation, occupational health, and mental health. The function of the nutritionist is to provide consul- tation to the various departmental personnel who give direct services in these areas. In addition to knowledge of normal nutrition, the nutritionist should possess special skills in: Understanding of cultural and psychological factors influencing food habits; Knowledge of food economics; Experience in quantity food service; Experience with new research methods in nutrition; Awareness of functions and service areas of other agencies with similar concerns. Performance records and periodic reports may be means to: Measure progress; Point up neglected opportunities for service; Orient new staff members; Justify the worth of nutrition services. In order to avoid duplication, the administrator should do a community inventory to determine what nutrition services, are provided in: departments of education, especially in public schools; state extension service; the local experiment station; other departments (i.e., municipal, general hospitals,); voluntary health agencies; and commercial agencies. Since nutrition spreads across so many activities interdepartmentally and out into so many interagency relationships, a broad advisory committee would be useful. Evaluation of nutrition services is necessary just as evaluation of any health service is necessary. Evaluation should be done to see: how the program is operating, if it is reaching the target population, the effects of the program on other departments, and ultimately, if the nutrition status of the target group improved. 229Evaluation This document is an excellent presentation of the public health nutritionist's role in a public health program. It is comprehensive, balanced, and practical, and lists other sources of valuable information. It is one of the classic documents on Public Health Nutrition. Applicability to Planning Agencies HSA's should incorporate some of the recommendations discussed into their nutrition plans. HSA's should encourage the use of this document by public health administrators providing or potentially providing nutrition services. Planning at the Institutional Level 173 Galbraith AL: Hospital dietetics in transition. JADA 67:439-444, 1975 Geographical Area National, local and institutional implications. Study Design This article discusses trends in delivery of acute care and the effects these trends may have on hospital dietetics. Significant Findings Hospital dietary departments provide clinical and administrative services in: food ser- vice systems management, dietary counseling, nutrition education and dietary consultation. These are distinct but overlapping areas. One trend has been to extend the physician's services by using ten or more "caretakers." Dietitians have increasingly been recognized as members of the health care team who can and should initiate care plans. Since the physician continues to have primary responsibility for the care of the patient even after discharge, dietetics has remained largely hospital-based. The National Center for Health Statistics reports that the total number of dietitians and nutritionists employed in 1971 was over 30,000. About 15,000 work in hospitals. Administrative dietetics is faced with severe problems of cost containment and increasing skills required in traditionally unskilled jobs in the dietary department. The clinical dietitian should provide for the needs of the patient through all stages of his episode: from admission, to convalescence, to discharge. The goal of each and the resources needed to provide care may differ for each stage. Increasing pressures on hospitals for earlier discharge of patients increases pressure on the dietitian. Dietary counseling should involve the client in long-term goal-setting and continuing support when needed. It is unrealistic to expect the physician to be the primary source of nutrition education. A study on 200 individual records at Cleveland Metropolitan General Hospital showed that 86 of these patients needed nutrition services but were not referred to a dietitian. In Massachusetts General Hospital, the day-to-day ratio of dietitians to patients ranges from 1:50 to 1:100. Each registered dietitian in clinical services leads a team of 2 or 3 diet aides and 4 to 6 service aides. About 100 patients/week are instructed in diets for con- tinuing use. All menu choices are reviewed daily. About 10% of the patients who are eating are monitored with daily intake approximations. The dietitian assesses the dietary prescrip- tion made by the physician. Group classes in the clinic or health center are seen as effective follow-up services. Another trend is the expectation of comprehensive services from the hospital. The American Hospital Association's "Patient's Bill of Rights" states that hospitals have responsibility for follow-up planning and detail of implementation. The Massachusetts Department of Public Health requires that hospital continuing care referral includes dietary assessment. Long-range objectives for hospital dietetics should include: Nutrition care should be recognized as an integral part of health and medical care. Diagnostic screening and monitoring should be developed. Hospitals should have a role in education for prevention and health maintenance. 220More specialized skills should be appropriately used. Technical advances in food service systems and food processing should continue to be used. Appropriate evaluation should be built into all programs and services. Evaluation The article provides an interesting description of hospital dietetics past and present. The effects of changing health care on hospital dietetics are well described. Applicability to Planning Agencies HSA's should encourage development of linkages between the hospital and community agencies in order to provide appropriate follow-up care for discharged patients. HSA's should include in their plans standards for nutrition care in hospitals and follow-up after discharge. Dietitians, hospital dietary workers, hospital administrators, physicians, consumers, and others should be encouraged to participate in the planning process. HSA's should encourage the development of evaluation activities in departments or services within hospitals. 174 Kocher RE: Monitoring nutritional care of the long-term patient. JADA 67:45-46, 1975 Geographical Area and Study Design National, state, local, and institutional implications. The purpose of the article is to discuss and describe policies and systems that support monitoring of the nutrition care of long-term care patients. Significant Findings Periodic Medical Review under Titles XVIII and XIX of the Social Security Act (Medicare and Medicaid) is focusing attention on quality of care in skilled nursing facilities. A medical review team visits patients on medical assistance annually to determine if patients are eligible and are receiving services which are "optimum in quality, adequate in quantity and sufficient in scope." Effective nutrition care can only be accomplished with strong cooperative relationships with other services and understanding and commitment of all the staff. Monitoring implies that the facility: Systematically and regularly assesses food intake and factors affecting it. Monitors weight and other measures of nutrition health. Responds to the changing needs of patients. Organizational support that fosters nutrition monitoring include: The admission process which allows for early assessment of nutrition needs. Effec- tive transfer agreements can facilitate the flow of information from hospitals. A clearly established process for planning patient care so that nutrition goals are consistent with other aspects of care. A good system of communication between services. A planned schedule of purposeful visitation and observation of food intake. A firm dietetic system which assures consistency in food production, portion control, nutrition content of meals, and accuracy of therapeutic diets. Patient care policies generally set the stage for a good monitoring program. These are best developed by the patient care professionals with a statement of responsibilities for each one. Policies are then implemented by written procedures with personnel training. Other factors which affect the provision of quality nutrition care are: the quality of dietetic supervision; the time spent by the dietitian in the facility; the adequacy of staff; and, most important, the commitment of administration and key department heads to the health of their patients. Evaluation This is an excellent article on the description of structures and processes conducive to effective nutrition monitoring of the long-term care patient. The article is clear, concise, and practical. 231Applicability to Planning Agencies HSA's should incorporate standards of nutrition monitoring into their long-term care plans. HSA's should assess the proposed structures and policies to govern patient care, including those relating to nutrition care, in project proposals of new applicants. If the applicant is already operating a long-term care facility, these should be assessed by a site visit and examination of relevant records. 175 Treadwell DD: Planning the nutrition component of long-term care. JADA 64:56-60, 1974 Geographical Area Regional, local and institutional implications. Study Design The article discusses the nutritionist's role in planning the individual patient's nutri- tion care in long-term care institutions. Significant Findings The needs of the long-term care patient may differ significantly from those of the acute care patient, since the long-term care patient often has one or more disabilities and is older. The need for a patient care plan for each individual has been recognized and codified by Medicare regulations, Joint Commission on Accreditation of Hospitals' standards, and individual state regulations. The patient care plan is a systematic, written guide which should define goals and prepara- tion, coordination, and implementation of measures to meet these goals by the health team. The person, rather than any dysfunction, should be the focus of treatment. Each member of the health team—the physician, nurse, social worker, dietitian, physical therapist—should contribute to the care of the. individual patient. Each member should set priorities, identify problems in his area, and offer solutions congruent with goals suggested by other team members. Each team member is responsible for implementing those goals in his area. Progress should be evaluated -continually, both formally and informally. Information should be shared among professional and para-professional staff. The Recommended Dietary Allowances for people over age fifty-five should be used as a guide for planning menus. Individual adjustments, such as pureed foods, and therapeutic adjustments, will frequently be necessary. The primary nutrition goal of providing optimal nutrition may be combined with or modified by secondary goals, such as: retraining the patient to feed himself, increasing socialization through food, or keeping the patient comfortable. Some physical or mental impairments or certain drugs may affect the ingestion of food, appetite, personality, or elimination processes of patients. The dietary para-professional should help the dietitian develop procedures for implementing nutrition goals, direct the implementation, and report any problems. Tools, such as the "plate waste chart," may be used to evaluate the dietary intake of the patient. Another tool is the use of standardized recipes and portions. Nutrition goals should be reviewed, evaluated, and updated when necessary. Success of the nutrition component of patient care plans can be measured by the acceptance of meals and appetite. The multidisciplinary team should establish a practical system of communication and fix the standards for the system so that problems and progress can be measured. This is done through the medical record. The medical record should include: Nutrition goals for the patient; Procedures for implementing these goals; Type of diet; Consistency of diet with rationale; Weight maintenance; Modified dietary regimen; Patient reaction to and acceptance of foods; Description of appetite and effect on food intake; 232Identification of nutrients which may be deficient; Special problems. Entries on the medical record should be made at least monthly and should be dated and signed. Evaluation The article provides a good description of the activities required to provide quality nutri- tion care to long-term care patients. Applicability to Planning Agencies Applications for long-term care projects should be examined with regard to plans for the nutrition care of the patients. Particular attention should be given to staffing patterns; the presence of adequate and qualified dietitians and para-professionals, supervisory relation- ships, and provision for multidisciplinary planning and evaluation of individual patient care plans. Applicants with ongoing facilities should be examined with these criteria in mind. HSA plans for long-term care facilities should include standards for nutrition care provided; qualifications of personnel; and so on, as discussed in this article. ELEMENTS IN NUTRITION POLICY Need for a Nutrition Policy 176 Gershoff SN: Science-neglected ingredient of nutrition policy. JADA 70:471-478, 1977 Geographical Area International and national implications. Study Design This article discussed areas in which nutritionists could contribute to the formation of public nutrition policy. Significant Findings ‘ ' *• y i »' ► t > t* ■ To improve the quality of nutrition services offered, it is necessary to have better infor- mation on such topics as: the nutrition status of populations; their food preferences and social and cultural customs; the availability, production, distribution, and processing of food; and continual evaluation of programs. Nutrition scientists have had little responsibility for the conception, development, administration, or evaluation of the US major nutrition programs. Malnutrition in our society can be classified into three forms: When a person does not receive his minimal nutrient requirements for a very long time, or receives an excess of calories or nutrients which compromise his health; When, for economic or other reasons, a person experiences prolonged hunger, without symptoms of deficiency disease; When an individual is unable to acquire those foods most commonly used in his culture. Nutrition scientists should take responsibility for developing methodologies to accurately assess nutrition status and to- determine the nutrition requirements of such groups as the elderly. More precise knowledge of nutrition requirements is needed, especially because of the effects changes in nutrition standards may have on nutrition policy. The Recommended Dietary Allowances are often misused, even by trained nutritionists. Nutritionists too often conclude that people with diets providing less than the RDA's are deficient, while in most cases, no public health problems are apparent. There has been little scientific evaluation of the effectiveness of costly domestic nutri- tion programs. The question is not the presence of needs for programs aimed at over- and under- nutrition, but, are we getting good value for the money being spent? 233US policy toward the FAO food policy is made by many government agencies with no coordinating agency, and tends to be reactive rather than creative. Generally, our foreign nutrition programs lack a sense of urgency. Our perception; of malnutrition in developing countries are distorted, and, therefore, our programs are often unsuccessful. The major sign of malnutrition in developing countries is retarded growth and development which is not as dramatic nor apparent to policy-makers as classic cases of severe protein- calorie malnutrition. Thus, the prevalence of malnutrition is often grossly underestimated. A large number of important nutrition problems are unresolved, partly because nutrition scientists have not provided policy-makers with basic information. A basic controversy has existed: one group of scientists advocates systematic evaluation of the effect of nutrition and health interventions prior to large-scale implementation, and another group advocates immediate implementation of large-scale programs on the basis that prior negative evaluations may be a reflection of other factors which mask the nutrition benefits and should not be used to jeopardize implementation of programs. A study on fortification of rice (with amino acids, iron, thiamine, riboflavin and Vitamin A) in poor villages in Thailand has revealed no measurable effect on health or nutri- tion status of the experimental group. It appears then that the hypothesized cause of retarded growth is faulty, and that the cause may be simply a caloric deficiency in the presence of adequate food supplies. Since the hypothesis is wrong, there has been little improvement in the last seven years in our ability to mount low-cost, practical programs to improve nutrition s'tatus of children in developing countries. A nutrition office at a high level in our executive branch of government is essential to coordinate and evaluate existing programs and to point out areas requiring new or more effec- tive effort. Evaluation The author presents a convincing discussion of the need for more science in nutrition policy decisions. Examples of misguided policies are powerful illustrations of the conse- quences of non-rational decisions. Applicability to Planning Agencies HSA's should stress the need for good program evaluation in their plans and when reviewing applications under Certificate of Need laws. Evaluations should address actual outcomes: is the target population any better off in terms of health or nutrition status because of the program? When developing nutrition or nutrition-related plans, HSA's should seek involvement of qualified nutrition scientists, in addition to consumers and health professionals. In establishment of a region's nutrition needs, HSA's should carefully evaluate and inter- pret the evidence, paying particular attention to the use of the RDA's. The HSA Boards should consider the recommendation for establishment of a national office of nutrition. 177 Winikoff B: Nutrition and food policy: the approaches of Norway and the United States. Am J Pub Health 67:552-557, 1977 Geographical Area National implications. Study Design The article compares Norway and the US with regard to stated food and nutrition policy, means to implement the policies, and reasons for differences in the two approaches. The principal policy document of Norway was presented by the Royal Norweigian Ministry of Agriculture to the 1975-76 Storting (Parliament). The principal policy documents of the US government are two documents prepared by the U.S. Senate Select Committee on Nutrition and Human Needs. The two are: "Towards a National Nutrition Policy: Nutrition and Government" (1975) and "Dietary Goals for the US" (1977).Significant Findings Several characteristics of the Norwegian nutrition and food policy proposal stand out: The Norwegian goals are based on scientific understandings of nutrition/health interrela- tionships . The Norwegian goals are based on two perceptions: that diet and cardiovascular disease are linked, and that significant changes (-mostly deleterious) have taken place in the Norwegian diet. In the US, no policy-making agency or office of the federal government has elaborated a national nutrition policy with specific goals. The goals proposed by the Senate Select Committee are only weakly linked to policy. They are de- signed to change individual behavior rather than develop means to promote societal change. The Norwegian: goals are more important than the institutional arrangements of government in dealing with nutrition. The focus in the US has been on creating the appropriate insti- tutions to deal with nutrition, which could never, in themselves, change American dietary patterns. U.S. policy attempts have arisen from a legislative focus, while the Norwegian policy has arisen from an executive focus. U.S. policy often reflects confusion or conflict between health and welfare goals. In addition, uniformity of purpose and administration are often lost as implemen- tation policies are modified or set at the local levels. The Norwegian national government considers itself responsible for setting overall policy directions in such areas as health, nutrition of people in developing countries, and national economic goals. The Norwegian report consistently states that the goal is change, and the responsi- bility of the government is to direct change in the desired direction. The principle of consumer freedom of choice is not rejected; the government merely recognizes that government always creates the environment in which consumer choices are made. Thus, the Norwegian approach will attempt to integrate nutrition goals into the general structure of consumer subsidies. In contrast, US policymakers seldom make overt interventions in the marketplace. The Norwegian document includes education in food production and practical work in schools as a means for influencing individual lifestyles, while the US govern- ment shies away from activities seen as inducing changes in the American lifestyle. The nutrition problems and goals of Norway and the US are similar. While Norway has cer- tain advantages in being able to implement a nutrition policy (i.e. less serious social and economic problems, easier administration), the U.S. should follow Norway's example and begin to attend to the nutrition and health needs of its citizens. Evaluation The article presents an insightful analysis of some of the basic causes for the US lack of a food and nutrition policy. This article is a requirement for anyone interested in nutrition policy issues. Applicability to Planning Agencies HSA's should promote public understanding of the link between nutrition and health. HSA's should promote the conception of government directing beneficial changes in food supply and lifestyle. HSA's could include within their regional food and nutrition plans recommendations for a national focus on food and nutrition. Nutrition concerns integrated into the system of agricultural subsidies should be recommended. HSA's should encourage within their regions a broader perspective on nutrition education.178 Dwyer J: Challenge of change—nutrition and policy. J Nutr Ed 9:54-56, 1977 Geographical Area National implications. Study Design The author discusses some of the issues involved in a nutrition policy and some of the roles the Society for Nutrition Education can perform in pursuing a nutrition policy. Significant Findings There are two main approaches as to how nutrition policy could be implemented: "Genesis" viewpoint: Nutrition policy should originate in and involve only government. "Impact" viewpoint: Any activity which impacts on nutrition is a legitimate topic for policy consideration. Nutrition policies and implementation of nutrition goals result from negotiation and interactions among public, private, and voluntary organi- zations. Recent developments indicate that the Federal government is relatively receptive to public sector nutrition education approaches. Policy-making with regard to the "impact" approach above will require: Identifying, discussing, and debating activities affecting nutrition status in all sectors; and Deciding which of these actions should take place. Sanctions in the public sector should be applied in order to protect the consumer from harmful or unhygienic foods and deceptive marketing practices. The Society for Nutrition Education should: Develop plans for handling current issues related to nutrition education: objectives in Dietary Goals for the U.S. (by Senate Select Committee on Nutrition and Human Needs), universal nutrient labeling, extension of labeling to include polyunsaturated and saturated fat, complex and simple carbohydrate, full ingredient labeling, unit pricing, and open dating; Develop more effective consumer education efforts on such topics as guides to healthful food consumption practices and food advertising rules for nutritipn claims; and Find ways to strengthen and finance nutrition education and nutrition care components in the health care system. Evaluation The author's description of the two viewpoints concerning how food policy should be imple- mented is excellent. Discussions of this year's topics of concern for the Society of Nutrition Education highlights their importance to Americans in general. Applicability to Planning Agencies The HSA should establish contact with local members of the Society of Nutrition Education to assist in food and nutrition planning activities. THE HSA Board or sub-area advisory councils may want to adopt some of the Society's recommendations. 236179 Dwyer JT, Mayer J: Beyond economics and nutrition: the complex basis of food policy. Science 188:566-570, 1975 Geographical Area National and international implications. Study Design This article examines the factors which are impeding the development of practical and acceptable policies in foods and nutrition, especially the disciplinary limitations that prevent physicians, nutritionists, and economists from working together with governments to produce food and nutrition plans. Significant Findings Many actions and interventions are effective in improving nutrition status. However, physicians, nutritionists, and dietitians tend to lose sight of this. The prerequisites for centralized direction of food supply and distribution do not exist within most countries today. The rational model is thus not relevant for intervention. Controlled demand, non-income models also are inadequate intervention models, since economic factors such as price and income have much influence on consumer demand. Economic models that are not health-directed often suffer from two limitations: Only commodities exchanged in the marketplace are counted; subsistence foods and other home-produced foods are ignored; and Theoretically cost-efficient interventions, such as fortification, tend to be empha- sized regardless of suitability or comparative effectiveness. The data that economists want are in the areas where nutritionists are most reluctant to make hard statements. However, nutrition scientists should be encouraged to make serviceable definitions of malnutrition. Economists often turn to physicians for advice on nutrition matters. However, for a variety of reasons, physicians are likely to be the wrong advisors. Nutrition scientists generally fail to advocate scientifically-based nutrition interven- tions, thus allowing less knowledgable consumer spokesmen to fill the gap. As a result, necessary interventions are not undertaken and no systematic trials or evaluations are conducted. Practical nutrition advice for laymen, cultural nutrition literacy for the intelligent public, and civic nutrition literacy for professionals should be striven for by our society. Nutrition interventions are often misclassified: certain nutrition programs may have objectives far broader than nutrition and, on the other hand, "non-nutrition" programs, like Social Security and minimum wage laws, may affect nutrition greatly. While economists tend to view nutrition as competition to reinvestment money, nutrition expenditures can also be seen, in part, as an investment. While economists may occasionally err in recommending cheap, straight-forward, but unproven solutions, nutritionists may sometimes be too leery of enrichment and fortification approaches. The macroeconomic approach to analysis has several limitations: intervention factors other than price and income are not taken seriously; microeconomic factors, such as distribution of food within the family, are missing; and groups at highest nutrition risk within a society have the lowest effective demand. Food policy planning will require a fusion, not just an exchange, of disciplines of physicians, nutritionists, and economists. 237Evaluation The authors present an excellent analysis of various factors hampering effective communica- tion and planning among physicians, nutritionists, and economists. Although the focus is on effects on nutrition planning, the analysis is generally applicable to all health-related inter- disciplinary planning efforts. Applicability to Planning Agencies Planners should listen and take advice on nutrition with discretion. Qualified nutritionists, through health departments, universities, or other reputable organizations, should be sought for principle advice on nutrition matters. Planners should be sensitive to the nutrition and health effects of non-nutrition pro- grams and policies. Opportunities for collaboration of physicians, nutritionists, and economists, along with others, should be taken advantage of, particularly on plans dealing with nutrition and nutrition- related health problems. 180 Margolis FM: New international committee on food and nutrition policy. USDA Nutr Program News, 1975 Geographical Area National and international implications. Study Design The purposes of the article are: To discuss the background and goals of the International Food and Nutrition Policy Committee, an advisory body to the Food and Agricultural Organization (FAO) of the United Nations. To discuss several interdisciplinary issues pertaining to national policies which could conflict with food and nutrition policies. Significant Findings Food and nutrition problems and programs in the US cannot be understood in isolation from the rest of the world. As stated by the FAO Food Policy and Nutrition Division, nutrition problems do not necessarily require nutrition solutions. In fact, nutrition problems should not be treated in isolation; food and nutrition objectives should be better integrated with national plans and projects. Other social and economic policies which should be considered include policies for: National economic development; nutrition goals should be compatible, rather than competitive, with economic development goals. Agricultural production and marketing: strategies for changing agricultural pro- duction, food technology, and marketing and distribution systems should be approached cautiously, since changes may be irreversible. Consideration of how much risk is acceptable and justifiable should be resolved by experts from many disciplines. Population control: population policies and implementation programs should be compatible with food and nutrition policies. Family planning: the concept of achieving desired child quality, is partly determined by nutrition and thus should be included in population, as well as food and nutrition policies. Functioning of individual households: specific nutrition interventions, to be most effective, must be congruent with family customs and beliefs. Programs can weaken or disrupt other family functions, or can be designed to strengthen family responsi- bility. 238.Role of women: distribution of family food supply among family members and other "gate-keeper" functions need not be performed by women, but should be performed adequately. Another approach is to enhance prestige of functions per- formed by women, rather than releasing women from responsibility to perform them. Evaluation The article presents an excellent summary of FAO approaches to the goal of improving nutri- tion status. The reasons for a change in 1973 of approach and the relationship of the Food and Nutrition Policy Committee to the 1974 World Food Conference are important for understanding of the FAO's current approach. The second section of the article, that dealing with interdisciplinary issues in food and nutrition policy planning, is also well done. This section is particularly important and use- ful to domestic planners. Applicability to Planning Agencies Food and nutrition objectives should be integrated into regional and local health plans. The feasibility of local and regional consumer-operated marketing and distribution systems could be studied for potential cost savings, particularly for poorer people. Regional and local plans on family planning services should include a discussion of nutri- tion considerations of child spacing and size of family. Nutrition counseling services should be integrated into family planning services. Applicants providing nutrition services should discuss their proposed services in light of the role of the family. What will be the likely effects of intervention on the family? Are these desirable or undesirable? Are other modes of delivery possible which would be more desirable? 181 Hegsted DM: Food and nutrition policy: now and in the future. JADA 64:367-371, 1974 Geographical Area National and international implications. Study Design The purpose of the article is to discuss several issues which need to be resolved in the development of a national food and nutrition policy. Significant Findings Food Production and Surpluses Nutrition programs in the US based on surplus foods have long been productive in that they have fostered consumption of poor diets. Foreign food aid programs can no longer be based on surplus foods, on moral and economic commitments of the US. The extent and shape influence agriculture and nutrition policy in the US. Government Organization Some of the recommendations of the White House Conference on Food, Nutrition and Health have been heeded, especially by USDA and FDA. However, others, i.e. the creation of a Nutrition Office in the White House, are no longer viable. Nutrition programs are spread throughout many governmental agencies. They should not necessarily be grouped under one agency, but some type of recognizable administrative structure and coordination is needed. Nutrition Surveillance recognized as counter- but will have to rest of this commitment will A nutrition surveillance system is needed in the US to monitor the problems and evaluate the effectiveness of programs. 239Since nutrition problems are variable throughout the country, regional or state systems should be developed. Adequate program evaluation requires that the surveillance system be independent of the programs. Conservation of Resources The US is wasteful and inefficient with regard to both production and utilization of food. For example, substantially more energy is required to produce the same amount of corn than in 1945. It is uncertain whether lesser developed countries can afford the technology of the "Green Revolution," which requires fertilizers and insecticides, and whether this high-energy crop production should be continued in the US. The long-term solutions to the food problem are not to produce more and more, but to make more efficient use of the world's resources. Food Conservation Food production costs in the US are relatively high, although the percentage of per capita income spent on food is relatively low. Plant materials in the US are also inefficiently used, for it takes 7 lbs. of grain to produce 1 lb. of beef, and meat consumption is extremely high relative to need. There is increasing evidence that a diet high in meat, milk, and eggs, as well as of highly processed foods, may be a primary cause of such health problems as cancer of the colon, diverticulosis, diabetes, dental caries, atherosclerotic heart disease, and others. Emphasis on the essential nutrients, i.e., protein, minerals, and vitamins, may be irrele- vant to the primary nutrition problems in the US today. Food Pricing Factors influencing food costs should be better understood and given more attention by nutritionists. The efficiency and utility of our present food production and marketing system is questionable, for it encourages consumers to waste money. For example, the 30 to 40 types of cereal in the supermarket are not much different from each other. A food and nutrition policy should encourage greater production of those foods for which nutrition need can be demonstrated and, at the same time, keep prices reasonable. Conclusion As food shortages become more prevalent, economy and efficiency will become more important. Our present lack of a food and nutrition policy arises more out of irresponsibility than ignorance. Evaluation The author presents an excellent discussion of some of the most crucial and difficult issues in developing a food and nutrition policy. The perspective is long-term, historical, and related to the international as well as the domestic situation. Applicability to Planning Agencies HSA's should encourage the development of regional or state-wide nutrition surveillance systems. Data collected through this system could then be used in HSP's and AIP's to help define regional nutrition needs and evaluate effectiveness of programs in addressing these needs. Regional HSA nutrition plans should include recommendations on composition of foods. HSA's and sub-area advisory councils could publicize these diet recommendations and reasons for them in order to promote consumer awareness and understanding. 240182 National Nutrition Consortium: Guidelines for a National Nutrition Policy. Nutr Rev 32:153-157, 1974 Geographical Area and Study Design The National Nutrition Consortium is composed of the American Institute of Nutrition, the American Society for Clinical Nutrition, the American Dietetic Association, and the Institute of Food Technology with a combined membership of about AO,000. The purpose of the article is to identify the factors which need to be considered in public planning and implementation of food and nutrition programs. Significant Findings Need for a Stated National Nutrition Policy Nutrient requirements of the population should be defined and translated into food re- quirements for food production plans at the agricultural and manufacturing levels. An adequate distribution system is necessary. The quality and safety of the food supply must be assured. Our policy toward the rest of the world should include providing adequate food and main- taining world food reserves, providing technical assistance, and participating in world trade. Goals of a National Nutrition Policy Assure an adequate wholesome food supply at reasonable cost to all segments of the population. Maintain food reserves for emergency needs. Develop public understanding of nutrition and foods. Maintain a system of quality and safety control of food. Support research and education in foods and nutrition. Programs Needed Nutrition surveillance programs on all segments of the population are needed, with periodic national reporting of: Prevalence of specific nutrition problems; Effects of nutrition intervention programs on nutrition status and prevalence of nutrition problems; Food consumption of various populations. Nutrition programs within the health care system should be expanded. Health care centers such as clinics and hospitals should be responsible for nutrition diagnosis and counseling; Malnutrition in disadvantaged groups should be alleviated. The prevention and therapy of nutrition problems should be recognized as a continuing public health responsibility. Reimbursement for nutrition services should be provided under National Health Insurance. Nutrition centers of excellence for diagnosis, treatment, research and training should be established. Nutrition should be incorporated into all levels of formal education, specifically, in: Schools (elementary, secondary, and college); Training of nutrition professionals and paraprofessionals, physicians, dentists, other health professionals, social workers, physical education teachers, etc.; General public education via all components of the communications media, food labeling and food advertising (which should be truthful and regulated), and public programs, such as the Food Stamp program. Basic and applied nutrition research should be supported at all levels in such essential areas as food production, processing and use, food science, and human nutrition. Nutri- tion research should be coordinated. Food production and distribution in the US and in other parts of the world should be con- sidered from the perspective of nutrition. Nutrient composition, quality, and safety of foods should be studied and assessed con- tinually. The development of wholesome new foods and fortification of existing foods should be encouraged. 241Implementation of a National Nutrition Policy A food and nutrition policy board should be formed at a high level of government. An Office of Nutrition (or National Nutrition Center) should be established to: Identify and coordinate food and nutrition programs within government; Provide for continuing food and nutrition surveillance; Establish a nutrition information service; Periodically evaluate nutrition policy and programs. An Advisory Nutrition Council (or Board) should be formed to advise the Office of Nutrition. Evaluation This is an excellent analysis of the areas which should be addressed in a national nutri- tion policy. The rationale is tightly structured: goals and objectives of a desired nutrition policy are linked to strategies and programs needed to attain them. Applicability to Planning Agencies HSA's should encourage the provision of appropriate high quality nutrition services in health care settings. The needs of high-risk groups should be emphasized and provisions developed for meeting them. HSA's should encourage education in nutrition for professionals, paraprofessionals, and the public. 183 Mayer J: Toward a national nutrition policy. Science 187:237-241, 1972 Geographical Area and Study Design The Whte House Conference on Food, Nutrition and Health took place in December 1969; it brought together over 4,000 health and nutrition experts, food company managers, consumers, and other interest groups to examine the food and nutrition problems in the US and to offer recommendations. This article summarizes what has happened since the White House Conference and offers suggestions for what remains to be done. Significant Findings The problem of poverty and its related health effects has still not been solved: income distribution has not changed in the past 30 years and, partly as a consequence, the infant mortality rate and incidence of stillborns in one impoverished group—migrants—is comparable to those in lesser developed countries. Malnutrition is still prevalent in many groups in the United States. At the time of the White House Conference, only three major food programs were operating: the Food Commodity Program, the Food Stamp Program, and the School Lunch Program. However, these programs were poorly designed and administered and reached only 5 to 6 million of a poten- tial 25 million. Another problem is our changing food supply: 50% of our food is now highly processed; snack foods are becoming increasingly more popular; and advertising is concentrated on promotion of the least nutritious foods. The recommendations put forth by the White House Conference covered: food assistance for the poor, nutrition and health programs, regulatory aspects of food production and supply, and nutrition education. The Conference seemed to be an effective planning and action device. Since the Conference: The food stamp program has been radically revised, although a further revision should be to shift from the USDA's "economy" diet to low-cost diet as the program's basis; The Commodity Program is gradually being withdrawn; and The School Lunch Program has been expanded to cover more poor children. However, problems still exist: Many eligible school children still do not receive free lunches; Local communities seem reluctant to start school lunch and breakfast programs, because of lack of flexibility and resources at the local level, and lack of sharply defined objectives at the national level; The Federal government has been slow to start other general nutrition programs, such as child health programs providing comprehensive health and nutrition services; and The elderly are vulnerable and under-served. 242Consumers see labels as their primary source of information regarding contents, safety, and nutrition value of foods, especially for new foods. Authoritative, yet understandable, information about food safety is badly needed. Scien- tists should make recommendations based on their best information, for this would allow better decisions. The safety of the (over 1500) chemical additives in American food should be studied more and each compound's evaluation of safety balanced against its potential usefulness. Long-range problems include: Reluctance of organized scientific bodies to make recommendations; Lack of action by food industry to reduce sugar, saturated fat, and cholesterol content of foods; Failure of social sciences to learn means of changing attitudes and behaviors; and Lack of Federal funds for applied nutrition research, nutrition education, and food control. Greater public awareness of our social problems will be necessary to eradicate hunger and poverty. Food policy problems are present continuously and are more difficult to solve. A national nutrition policy can come about only after advanced nutrition training is required for medical personnel, health scientists, and educators. Evaluation The author presents an excellent summary of the history of food problems, public awareness of them, and programs to alleviate them in the US during the 60's and early 70's. Recommenda- tions about what issues have to be addressed in a national food policy and some prerequisites for establishing a food policy are presented. Applicability to Planning Agencies The HSA could sponsor a regional conference along the lines of the White House Food Con- ference in which local panelists would convene to discuss local food, nutrition, and health problems and recommend potential solutions. HSA nutrition plans should recommend special attention to the at-risk populations in the region: the poor, members of minority groups, migrants, the elderly, mothers with young children and no husbands, and other groups. The plan should also assess coverage of local at- risk populations by food and nutrition programs and recommend areas where programs should be expanded, started, or even terminated. The HSA should include in its plan on health profession training a recommendation for nutrition training in medical and other health profession schools. Nutrition and Health Issues 184 Senate Select Committee on Nutrition and Human Needs: Dietary Goals for the United States. 1977 Geographical Area and Study Design National implications. The purpose of the document is to provide authoritative dietary guidelines to consumers in order to encourage the selection of a more healthful diet. The goals are based on testimony given at Select Committee hearings, other guidelines established by governmental and pro- fessional bodies in the US and other nations, and expert opinion within the US. Another purpose of the document is to serve as a catalyst for government and industry action to facilitate consumer adherence to these guidelines. The report is divided into two parts: Dietary Goals for the United States and Recommen- dations for Governmental Action. Significant Findings Dietary habits in the U.S. have changed radically in the last 50 years: fat and sugar consumption from soft drinks, candy and baked goods, processed foods and meat has increased greatly and complex carbohydrate consumption from fruit, vegetables, and grain products has decreased greatly. These dietary changes are linked directly to heart disease, cancer, obesity, and stroke, among others. 243Six basic dietary goals call for reduction of overall fat, saturated fat, cholesterol, salt, and sugar, and increase of complex carbohydrate consumption. Consumer guidelines for attaining these goals are: Increase consumption of fruits, vegetables, and whole grains. Decrease consumption of meat and increase consumption of poultry and fish. Decrease consumption of foods high in fat and partially substitute polyunsaturated fat for saturated fat. Substitute non-fat milk for whole milk. Decrease consumption of butterfat, eggs and other high cholesterol sources. Decrease consumption of sugar and foods high in sugar content. Decrease consumption of salt and foods high in salt content. Recommendations to government to encourage achievements of these goals include: Congress should appropriate money for public nutrition education programs. Congress should require food labeling for all foods. Congress should increase funding for human nutrition research. Evaluation The document is a clear, concise statement of dietary guidelines. The rationale for the dietary goals is clearly stated, and the goals are translated into understandable consumer dietary guidelines. Applicability to Planning Agencies Publication of these goals has caused much controversy. Industry groups are energetically attacking the goals. The American Medical Association has opposed the goals in that there is insufficient evidence presented to assume that benefits will accrue as a result of the universal adoption of these goals. The American Dietetic Association states that while it is true that data are incomplete to assure that everyone would benefit from adopting these dietary goals, data are sufficient to expect that many people, particularly those at risk of degenerative diseases and obesity, would certainly benefit. The ADA makes several recommendations: Continuous evaluation of the goals. Study of the role of diet in preventing disease. Study of impact of goals on institutional and home food services and on food production and distribution. Training of dietitians in knowledge and skills needed for nutrition education. Integration of nutrition education into preventive and health care programs. Adoption of a Nutrition Policy. Although there is much controversy and uncertainty with regard to these dietary goals, this document makes the first attempt by any branch of the Federal government to change the American diet. 185 Recommendations from Workshop on "Leadership and Quality in Ambulatory Health Care." Sponsored by the Bureau of Community Health Services (HEW) and the Association of State and Territorial Public Health Nutrition Directors 1977 (unpublished) Geographical Area and Study Design This document summarizes the work of ten sub-groups in a National Public Health Nutrition Workshop. The group covered the following subjects: Summary statement of specific problems; Developing an organized integrated system of nutrition care in ambulatory health care services in a local community; Health planning; Nutrition assessment and surveillance; Developing standards for outcomes of nutrition care; 244Patient care standards for ambulatory care centers; Proposed standards for public health nutrition staffing ratios; Manpower; Resource development—payment mechanisms; and Measuring the effectiveness of nutrition services. The summary of each group's work includes problem definition, recommendations, and some- times objectives and strategies. Specific recommendations developed in the workshop are: National Nutrition Standards—There should be a national coordinated effort to develop and implement nutrition standards. These standards should include both process and outcome criteria, and should be adapted to local circumstances. Health Planning—Nutritionists should participate in the planning process already existing in the community, such as HSA's and professional organization planning. Participation in the HSA should include involvement on HSA boards, committees, and task forces; provision of data on nutrition needs and services; and development of nutrition outcome standards for inclusion in HSA plans. Payment Mechanism—Nutrition services should be recognized as reimbursable services. Nutrition Surveillance—Data collected in the public and private sectors should be pooled in a national system and fed back to local programs. Nutrition data should be coordinated with other local health programs. Cost-Effectiveness—Nutritionists should develop cost-effectiveness data on nutrition as a component of prevention, early diagnosis, and treatment. Staffing Ratios—Public health nutritionist (PHN) staffing ratios should be: ratio for general population: 1 PHN/50,000 population; ratio for ambulatory care programs: 1 PHN/1,000 client population. Training of Public Health Nutritionists (PHN)— Problem-oriented approaches should be developed for graduate biochemistry/ physiology courses. Graduate students in PHN programs should have competence in food science and diet in health and disease. A task force of representatives from Graduate Faculties and the Association of State and Territorial Public Health Nutrition Directors should be set up to study the community component of dietetic technician training. A national workshop of practitioners and faculties should be organized to study and act on standards for field experiences, sources of money for concurrent field work, cost/benefit analysis of field experiences, and manpower needs. Health planning curricula should include nutrition. Program Planning—Nutritionists should improve their skills in program planning and management by incorporating program planning in undergraduate and graduate programs and by planning postgraduate workshops. Funding Sources—Identify potential funding sources, private and public, at the local, state, and national levels that support integration of nutrition services into other health services. State Standards—Each state should develop nutrition standards for quality ambulatory health care. State Nutrition Bureau—Nutrition should be an identifiable unit in the state organi- zation with adequate manpower. The upshot of the conference was the submission of a proposal by the Association of State and Territorial Public Health Nutrition Directors to HEW for funding of the development of national public health nutrition standards. As outlined in the proposal, standards for nutri- tion care services could be used to: Provide a regulatory review of professionals in the absence of licensure laws. Document the cost-benefit and cost-effectiveness ratios for nutriton service in primary care. Provide Federal, State, and local health planning agencies with a tool for planning and evaluating nutrition services in public health and related programs. Identify the expected outcome from the nutrition component of public health programs. Determine via a national nutrition surveillance system, the percentage of the popu- lation at-risk. 245Determine local staffing patterns once outcome criteria were available. Provide quality assurance in third party reimbursement systems and in a national health insurance system. The proposal is now being considered by several funding sources. Evaluation The summary of current problems in the nutrition field is excellent and the recommenda- tions developed from the various problem statements are comprehensive and appropriate. It represents the current thinking of practicing public health nutritionists. The document is readable and worthwhile. Applicability to Planning Agencies HSA's should make use of nutritionists at all levels in the planning and review process. HSA plans on nutrition should include standards for training, staffing ratios, and the provision of services. 186 Prevention of Disease through Optimal Nutrition. A Nutrition Symposium, April 22-25, 1976, Mt Sinai Medical Center, New York City and the Institute on Man and Science, Rensselaerville, New York. 1976 Geographical Area and Study Design National implications. The purposes of the Symposium were to: enhance communication among representatives from industry, research, academia, media, and government and to develop specific courses of action for implementation of public nutrition policy as relating to prevention of disease. Recommendations were directed toward both the consumer and the national policy maker. The Symposium was divided into five panels, each of which met and developed recommendations. The five were: Nutrition Education/The Media and Nutrition; Definition of Optimal Nutrition/ Nutrition and the Promotion of Good Health; New Trends and Changes in Diet and Food Supply/Regu- lations on the Food Industry; Nutrition in Health and Disease; Nutrition and the Prevention of Disease. Significant Findings Nutrition Education/The Media and Nutrition A larger proportion of available health research funds should be allocated to evaluation of various educational approaches in altering food behavior. A concensus should be developed to change food habits to: Increase consumption of fresh fruits and vegetables; Use of whole grain cereal and cereal products; Increase use of vegetable sources of protein; Adjust animal protein intake (no greater than protein RDA); Decrease food waste. The USDA should be funded to supplement its household consumption surveys with smaller quarterly or semi-annual surveys and to have a continuously updated source of food composi- tion data for unprocessed produce and complex goods. HEW should support the development of coordinated nutrition education programs involving health departments, schools, and other public and private agencies. A mass media nutrition campaign for a community should be developed and its effectiveness in changing food product use evaluated. The FCC should require broadcasters to balance food advertising directed at children through public service pro-nutrition messages. Health professionals should become informed and participate in the FTC's hearings on a food advertising "trade regulation rule." A variety of short-term and long-term nutrition education modules should be made available to medical, dental, nursing, public health, and other health professions schools. Schools should be encouraged to employ well trained nutrition education specialists to help teachers develop effective food and nutrition courses. 246Definition of Optimal Nutrition/Nutrition and the Promotion of Good Health Optimal nutrition is an essential, but not sole, factor in achievement and maintenance of good health. The following food and health practices should be promoted: Wide variety of foods in diet each day; Maintenance of desirable body weight for height and age and increased energy expenditure; Breast feeding and delay of solid food feeding to 4 to 6 months; Moderation in sugar and salt intake; Discouragement of alcohol ingestion. New Trends and Changes in Diet and Food Supply/Regulations on the Food Industry There has been a deterioration in the nutrition quality or the US food supply because of: Increased production and consumption of fabricated foods; Steady narrowing in the genetic base of commercial crops; Uncertainty about nutrition quality of animals bred in US. Agriculture should change emphasis of production to those foods with high nutrition quality. The population should be encouraged to eat natural and unrefined foods and not fabricated foods. The government should assure that fabricated foods are nutritionally equivalent to their corresponding natural foods. Manufacturers should be prohibited from deceptive advertising, labeling, and so on. There has been an increasing number of new foods on the market. These new products should be closely regulated as to nutrition quality. Since there is an increasing trend to eat food away from home in establishments which have no nutrition criteria, these institutions should be required to meet the same standards as retail products purchased in the supermarket. In addition, an ingredient listing of restaurant foods should be available to the consumer. State and local units should incorporate nutrition quality and consistency into their regulations related to food supplies. Nutrition in Health and Disease The excessive caloric intake of many Americans should be reduced. Dental health should be encouraged by: Eating foods readily cleared from the mouth and which are low in sucrose and fermentable carbohydrates; Eating snacks of fruits and vegetables rather than candy; Fluoridating public water supplies. Nutrition demonstration programs should be adapted to various population groups and then implemented. Nutrition and the Prevention of Disease More knowledge is needed in prenatal and early infancy periods, such as optimal weight gain during pregnancy and early infancy. Better standards of nutrition development are needed for use in the WIC pogram. Lowering cholesterol in at-risk populations is desirable. Cholesterol content in foods should be decreased, and cholesterol content of foods should be clearly labeled on their packages. More research is needed to determine the effects of lowering cholesterol in the genera}, population. Weight loss and sodium control are recommended for hypertensive individuals. More research is needed to determine prevention and identification of individuals susceptible to hyper- tension. Obesity is the major nutrition problem in the US. Preventive programs early in childhood are needed. More research is needed to determine methods for early detection and treat- ment, appropriate weight gain during pregnancy, and so forth. More data are needed to determine to what extent altered food intake increases prevalence of maturity onset diabetes, the degree of nutrition control needed to maintain normal blood sugar and its relationships to complications of diabetes, and similar problems. The effect of food additives on cancer should receive high research priority.The panel agreed that it is difficult to alter individual human behavior when diseases may have multifactorial causes and long incubation periods. More research is needed regarding the variability of response in population subgroups. Evaluation This document provides an excellent summary and discussion of the most important nutrition problems facing the consumer and policy-makers today. The recommendations presented are timely and creative and should be given attention. Applicability to Planning Agencies HSA's should recommend diet changes consistent with this report in order to decrease the incidence and prevalence of certain nutrition-related diseases. These recommendations should be included in HSA plans and should be publicized for the public and health professionals. HSA's could sponsor a meeting of local educators, nutritionists, other health professionals, community agency representatives, food service managers, media representatives, and others to discuss the development of a coordinated nutrition education program for the community or region. HSA's should work with local health training institutions and professional societies to incorporate nutrition education courses into their curricula and continuing education programs. HSA's should work with State Dietetic Associations and other professional societies to identify individuals with skills in nutrition education. These individuals should be encouraged to work with public school administrators and teachers to develop effective nutrition education courses. HSA's should work with local health boards in setting food safety and quality guidelines and providing for their adequate enforcement. 187 Millar JD: The Future of Preventive Services. Presented at the meeting of State and Territorial Health Officers, Washington DC, Dec 16, 1975 Geographical Area National implications. Study Design The purpose of the paper is to provoke discussion and encourage action regarding disease prevention under national health insurance. Significant Findings Curative medicine and public health have evolved in different directions and have different philosophies. Curative medicine has limited itself to the individual, while public health has evolved to fill this gap by emphasizing the ramifications illness has on the community in addition to the individual. Fundamental differences are emphasized in cases where organized medicine and public health have fought each other. Some see the basic difference as public health's primary assumption of the right to full and equal protection for all persons against preventable disease and disability. In this light, the curative health system is seen as a barrier to adequately pro- tect the public's health. Our public health services now include responsibility for preventive measures for whole populations (community) and individual preventive and curative measures (personal). Personal preventive health services are provided for certain groups and conditions within the total population. Community preventive health services include environmental hazard control, public health laboratories, disease control and prevention, family planning, health educa- tion, nutrition, maternal and child health, and dental disease prevention. None of the current proposals for national health insurance contain any provisions for the support of community preventive health services.Legislation is needed to allow national health insurance monies to flow to communities to support community preventive health services. Various funding mechanisms are possible: Trust fund: a percentage of the national health insurance budget devoted to pre- ventive services; Capitation charge: a charge for each person enlisted in the national health insurance system used for preventive services; Federal-State cost-sharing plan: reimbursement of preventive services delivered by State and localities; Combined cost-sharing and grant; cost-sharing of preventive services delivery and project grants to States to support particular activities. The disadvantages and advantages of these funding options should be debated publicly. Competition for funds by medical care and public health must be put on an equitable basis under national health insurance, since medical care financing is non-controllable (medical care costs have already been incurred) and public health budgeting is controllable (budgeting is controlled by legislative and administrative action). All plans for comprehensive national health insurance now before Congress have provisions for the financing of personal preventive health services. States and localities should now press for appropriate legislative attention to community preventive health services. The HSA's could broaden this local support for preventive activities. The philosophy of public health should be re-articulated. Evaluation The author presents an insightful discussion of the importance of national health insurance to the future of preventive services, especially community preventive services in the US. The differences in philosophy and financing between medical care and public health are extremely important in understanding the conflicts between the two. The article discusses these differ- ences and their implications for the future of preventive services. Applicability to Planning Agencies HSA's should be aware of the continuing debates on the national health insurance proposals, in addition to the views of regional members of Congress. HSA's and sub-area advisory councils could sponsor hearings to determine the views of local consumers and providers on preventive health services: what types of services are needed; how are they to be included in a national health insurance system; and so on. HSA's and sub-area advisory councils could draft position papers on preventive health services and their place in a national health insurance system. These could be sent to Congress and local decision-makers. 188 Subgroup of Panel on Nutrition and Health for Senate Select Committee on Nutrition and Human Needs (Collins, Forbes, Kocher, Yanochik): National Nutrition Policy, 1974 Geographical Area National implications. Study Design This document states the objectives and actions needed to reach the objectives for the im- plementation and delivery of nutrition care services in the health care system. In addition, other topics are addressed: costs of inadequate nutrition care, where and how nutrition care services should be provided, quality of nutrition care, and manpower for nutrition care services. Significant Findings "Mandate nutrition input into planning, organization and implementation of health care systems." 249"Assure the availability and accessibility of nutrition care services to enable the popu- lation of the US the opportunity to achieve and maintain optimal nutrition health. High pri- ority should be given to individuals with specific nutrition problems and needs." "Assure linkage of 'non-health' nutrition care services with the nutrition care component of 'health care' services." "Adequate funding to study methods of developing, implementing and evaluating nutrition care programs." "Assure sufficient, competent nutrition personnel to provide nutrition care throughout the health system." Evaluation The recommendations, which include five objectives and action needed to further each objective, address the most important issues in nutrition today. The background material pre- sents useful information, and provides a context within which the recommendations are even more relevant. The appendices are also excellent: they provide a history of the place of nutrition services, manpower needs and supply, and a suggested pattern of nutrition care. Applicability to Planning Agencies Incorporate nutrition into HSP and AIP. Incorporate nutritionists into planning process. Encourage provision of nutrition care services in regional health facilities and community health programs. Encourage special planning efforts with local health care providers and consumers to address the special needs of those with nutrition problems. Work with local dietitians/nutritionists, other health providers, and consumers to set guidelines and policies for provision of quality nutrition services. Work with the local health department or other health care facilities to develop uniform nutrition screening system applicable to all population groups. Resolve to support inclusion of nutrition care services within health care financing systems at Board and sub-area council levels. Identify nutritionist/dietitian shortage areas within the HSA region. Assist creative recruitment efforts. Work with local university personnel in developing community-oriented nutrition/dietitian programs or in studying feasibility of establishing them. 189 Recommendations on Policies and Practices in Infant and Young Child Feeding and Proposals for Action to Implement Them. PAG Regional Seminar, Singapore, Nov 25-27, 1974, Doc 1.14/45. Geographical Area International and national implications. Study Design This document presents recommendations emanating from a regional seminar held in Singapore in 1974 for the countries of Hong Kong, Indonesia, Malaysia, Philippines, Singapore, Sri Lanka and Thailand. The conference was sponsored by the (U.N.) Protein-Calorie Advisory Group (PAG) to discuss problems and potential solutions in infant and young child feeding practices. Pediatricians, physicians, nutritionists, health department officials, senior officials from ten infant food companies operating in the region, and FAO and WHO representatives attended the conference. 250Significant Findings Recommended feeding policies and practices: Breast-feeding whenever possible for infants for as long as possible. Alternative feeding as a last resort and only if mother has enough money; mother can properly substitute food; there is adequate food hygiene; and mother has had proper education. After 6 months of age, gradual introduction of foods consistent with locality; Development of inexpensive, easy to prepare, calorie dense weaning foods to be prepared, as much as possible, locally, from available foods. Proposals to medical and health professions: Education of mother before birth of baby and supportive education after birth on breast- feeding. Training course for medical and health professionals on breast-feeding. Education of non-breast-feeding mothers on bottle feeding. Meetings between medical staffs and infant food industry officials about common problems. Proposals to industry: Cooperation of infant food industries in establishment of code of ethics for advertising of infant food and promotion of products so as not to discourage breast-feeding. Increased distribution of educational material on infant nutrition, hygiene, importance of breast-feeding, and feeding during weaning to medical and health professionals and parents. Development of code of ethics on relations between company employees and medical and health professions and the public. Cooperation in all possible ways with governments to make weaning foods available. Improvement of labels, instructions, and measuring devices for infant foods. Proposals to government: Development of policy on infant and child nutrition, emphasizing importance of breast- feeding. Establishment of criteria for processed infant food and ways to make foods available to vulnerable groups. Encouragement of adoption of code of ethics for distribution, sale, advertising, and pro- motion of products by firms. Development of regulations for labeling of infant formulas stating that breast-feeding is best. Consideration of prescribing minimum period of maternity leaves and encouragement of em- ployers to provide facilities for breast-feeding. Implementing the proposed actions: Formation of an international industry council comprised of companies that prepare and market infant foods to implement above proposals. Evaluation This document presents recommendations which have been developed through consensus, of such diverse groups as infant food company officials, pediatricians, and health department officials. Because infant food policy will be determined principally by the groups represented at this conference, the document offers a realistic indication of the kinds of recommendations and policies which could be implemented. Applicability to Planning Agencies Recommend the practice of breast-feeding, as a beneficial health practice. Recommend in-service training of medical and health professionals and paraprofessionals on benefits and techniques of breast-feeding. Recommend that hospitals provide education, support and needed facilities for mothers wishing to breast-feed.Discuss these recommendations with local chapters of professional organizations (AMA, ADA, ANA, etc.), public organizations (local Health Departments), and private organizations (boards of hospitals). Manpower Issues 190 Lewis M, Beaudette T: Coordinated education in dietetics. JADA 70:596-601, 1977 Geographical Area National implications. Study Design The purpose is to outline an approach to the transition of a traditional undergraduate dietetics program to a coordinated approach. This transition can take place through phases. Significant Findings The new philosophy of health care requires participation of the dietitian in the health care team. Undergraduate education programs should respond to these new needs by developing coordinated educational programs in dietetics. Coordinated programs can be developed through a series of transitional stages: Phase I—Clinical Integration: Integrate clinical phase of dietetic education into the undergraduate program by interrelating studies in the classroom and in the clinical environment. Phase II—Subject interrelation: Interrelate subject matter of two or more courses by faculty team planning and teaching. Phase III—Transdisciplinary Coordination: Coordinate teaching of subject matter from several disciplines into interrelated didactic and clinical experience. Phase IV—Evaluation and Revision: Constantly analyze and evaluate effectiveness of the coordinated program in developing the dietitian's professional competence. Some of the barriers to change in professional education are: the attitudes and per- spectives of faculty members and practicing professionals; the structural inflexibilities of academic institutions; and the structural inflexibilities of early career paths. The coordinated program approach may be more expensive and require more faculty time than the traditional educational approach, but no more costly than other programs requiring clinical study. Standardization of the product or the process of professional education is unnecessary and undesirable, given certain standards for excellence. Schools should take advantage of the academic and community resources available. Evaluation The authors present a practical, useful approach for the transition of traditional dietetic training programs to coordinated programs. Implementation problems in each phase are discussed. Applicability to Planning Agencies HSA's should include in their nutrition care plans standards for dietetic training programs. 191 Johnson CA: Entry-level clinical dietetic practice as viewed by clients and allied pro- fessionals. JADA 66:261-263, 1975 Geographical Area National implications. 252Study Design This study explored the views of both clients and relevant professionals on the delivery of clinical dietetic practice. Specific objectives were to determine the views of entry-level clinical dietitians, their clients, educators, and employers and to ascertain whether group membership affects the impor- tance attached to selected clinical activities of dietitians. Significant Findings Two questionnaires were developed: one to determine clients' perceptions about how dietitians had helped them and the other to determine the relative importance attached to vari- ous activities performed by the dietitian. The Client Questionnaire was sent to 240 clients; responses were then ranked. The Professional Questionnaire was sent to 143 employers (hospital administrators or physicians), 303 directors of dietetic educational institutions, and 386 hospital dietitians. Response rates for each group were: 72.4% from clients; 60.7% from educators; 39.4% from employers; and 36.2% from dietitians. Results showed: a significant correlation among rankings of 12 client-defined variables by clients and professionals; a significant correlation among dietitians, educators, and employers on ranked mean scores of client-defined variables; significant positive correlation of dietitians' responses on importance of and time spent in 32 of 33 clinical activities. The authors conclude that: there is significant agreement among all participating groups on relative importance attached to client-identified activities; there is significant agreement among dietitians, educators, and employers about rela- tive importance of the 33 activities studied here; the importance dietitians place on any activity may affect the time spent in that activity. The authors recommend that the study be replicated periodically to assess whether per- formance requirements are meeting changing client needs. Evaluation This study asks an important question: are dietitians performing functions perceived by clients as being needed? Some biasing factors may be present, e.g. the response rates from educators and dietitians were low. Also, what activities dietitians and other professionals perceive as important may be influenced by the amount of resources already allocated to them, rather than vice versa. More realistically, influence is probably being exerted in both directions. Applicability to Planning Agencies HSA's could work with local educators, employers, professionals and consumers to develop or adapt this study questionnaire for use in regional and local facilities providing nutrition care. 192 Peck EB: A Model for Professional Development. Presented at the 57th Annual Meeting of the American Dietetic Association, Oct. 11, 1974 Geographical Location and Study Design National, regional, and local implications. This paper presents a model of the professional so that professionals can analyze their education and experience needs and plan to correct deficiencies. 253 .Significant Findings The model of the knowledge and skill needed by professionals is composed of three inter- related components: Thinking and reasoning in the use of the scientific and problem-solving methods; Scientific and technical knowledge and skill; Knowledge of, and ability to intervene in the human environment. The technician uses only the second component; the technologist only the first and second; only the professional uses all three. Use of the scientific or problem-solving method includes observation of data, analysis, logic, conceptualization, development of a hypothesis or objective, testing the hypothesis or alternative, setting criteria for acceptance of the hypothesis or the most workable plan, and accepting or rejecting the hypothesis or evaluating the outcome of the planned intervention. Conscious, systematic use of the skills of problem-solving allow professionals to develop a unique solution for each problem. The component technical and scientific knowledge consists of the social, behavioral, and biological sciences which affect humans and knowledge about how society is organized for the human-helping professions. In spite of the overlap and common backgrounds of health professionals, each profession should have expert knowledge in one area of human need and focus on its relation to other areas of need. However, we should also guard against the historical trend to territoriality of the professions. Most professionals are comfortable with this component; professionals must be careful not to develop it to the exclusion of other components. The third sector requires knowledge of psychological, socio-psychological, and sociological forces affecting human behavior, the political milieu, our own personal values, and the skills of human relationship. This sector determines the professional's skill as a change agent. Dietitians have often neglected this component because: Many have not realized they could or should learn skills in this area; Dietetics has traditionally attracted more women than men, and women's social- ization as subordinates has dissuaded women from taking the initiative in this area; Socialization as dietitians has included viewing nutrition scientists and physicians as authority figures. To bring about change in this sector, dietitians should analyze the human environ- ment in the same way that nutrition problems are analyzed and develop plans to bring about change. Continuing education can be particularly meaningful in this component since the concepts can be more fully realized in practice. Public health nutritionists often lack skills in program planning and evaluation because: They do not see the need for them. Some are mystified by the jargon and new techniques. They tend to feel that they have to be absolutely certain of the technical knowledge or evaluation data. Planning and administration techniques, such as Program Planning Budgeting (PPB) and Program Evaluation Review Technique (PERT), are useful tools but not panaceas. Many see nutrition education of the public as the best method, rather than only one way to approach nutrition problems. Dietitians can use their professional skills not only to bring about beneficial changes in people's food habits, but to help produce changes in the organization in which they work and the larger social system. Dietitians should be aware of the similarities and differences in the change processes used by professionals and select the ones appropriate to the cur- 't problem. 234.Evaluation The article presents a useful way to view continuing education of the professional. While the model presented here is applied to dietitians, it could be used by other health professionals. Applicability to Planning Agencies HSA's should recommend professional standards of competency congruent with this article in nutrition and other health plans. HSA's could work with professional societies such as ADA, ANA, and AMA to develop courses in needed areas such as program planning and evaluation. 193 Report of the Workshop: Program Planning for Public Health Nutrition. Held at the School of Public Health, University of California, Berkeley, March 17-21, 1970 Geographical Area National implications. Study Design This document presents information on a week-long workshop on program planning for public health nutrition field supervisors, public health nutritionists, and others. Significant Findings The following Program Planning topics were discussed: Planning defined. States of problem solving: Setting priorities; Defining the problem; Designing alternate programs; Implementation of programs through Program Evaluation Review Technique (PERT); Evaluation. According to the workshop evaluation, program planning is viewed as important by practicing public health nutritionists, and the workshop was valuable to the participants. Evaluation Sessions included the use of health statistics and demographic data for defining problems, setting program priorities, specification of program outcomes and parameters, long-range program budgeting, cost-benefit and cost-effectiveness analysis, and building the information system. Applicability to Planning Agencies Nutritionists, other professionals, and health workers in general could gain from in-service training in program planning. HSA's could promote this activity through: Working with on-going health agencies, such as health departments, hospitals; Working with local chapters of professional associations, such as ADA, AMA, ANA, APHA; and Recommending in-service training in program planning in regional health plans. .215.Regulation Issues 194 Price CC: The Consumer and Open Date Labeling. National Food Situation (USDA Economic Research Service NFS-157), 1976 Geographical Area and Study Design National implications. This article discussed food shoppers' knowledge, use and preferences for open dating and problems and possible solutions. Data were gathered from personal interviews with over 1,400 shoppers in the spring of 1974. Four different data prefixes were considered: "Packed On," "Sell By," "Use By," and "EXP." Shoppers were asked to indicate what the four different date prefixes meant to them by selecting from a list of possible meanings. Significant Findings Shopper Knowledge of Open Dates Most shoppers correctly interpreted pack and pull dates. Those who misinterpreted these were primarily older and less educated males, with incomes under $10,000 a year. Conversely, 70 to 80% of food shoppers misinterpreted "EXP" and "Use By" labels. One of the most serious misinterpretations by many shoppers is that open dates represent the last day a food is safe or should be used. Use of Open Dates Ninety percent of shoppers look for open dates always or some of the time. Shoppers over 65, with little education, or male, are less likely to look. Shoppers were more concerned about dates on some products than others: e.g., milk and bread. Attitudes Toward More Open-Dated Products Most shoppers are apparently satisfied with the level of open dating now existing under the voluntary program. Few shoppers think all products should be open dated. Shopper Preferrences for Types of Open Dates Most shoppers preferred the expiration and quality assurance dates. The quality assurance data were by far the most popular choice for most food items. Shopper Preferrences for Presentation Method Shoppers disliked any method where the year was not indicated. The less educated and elderly liked complete identification of month, day, and year best, e.g., March 22, 1976. Problems With Open Dates Many shoppers had problems, such as: Confusion about whether letters and numbers on packages are open dates; Confusion as to what dates mean; Difficulty in reading the date; Difficulty in finding the date on packages. Occasionally food was spoiled before date passed. Since January 1975, 31% of food shoppers who looked for dates threw out food, probably unnecessarily, because they misinterpreted open dates. 256Evaluation The information in this article is useful and necessary for policy formation on food label- ing. Shopper knowledge and preferences are analyzed in terms of important demographic variables which have further policy implications. Applicability to Planning HSA's could sponsor or initiate public hearings or workshops on food labeling and other health consumer subjects in order to enhance communication between food manufacturers, retailers and consumers, and educate consumers in the effective use of food labels. HSA's should encourage angencies which deal with the elderly, the poor, and the less educa- ted to emphasize proper use of food labeling, perhaps by a simply worded flyer. 195 Nutrition labeling: excerpts from a Scientific Status Summary by the Institute of Food Technologists' Expert Panel on Food Safety and Nutrition and the Committee on Public Informa- tion. Nutr Rev 32:251-255, 197A. Geographical Area National implications. Study Design This article reviewed the pertinent facts about nutrition labeling in the US: its history, development from testing, legal requirements and voluntary actions, its proper use, and its place in an overall nutrition education policy. Significant Findings The present system of nutrition labeling arose from FDA studies of six alternative labeling systems as used by a wide diversity of consumers. The studies showed support of label- ing by consumers and their understanding and use of labeling. The labeling system became effec- tive January 1, 1975. The principal objectives of nutrition labeling are: To provide consumers with extensive nutrition information about packaged foods. To assist in the education of consumers in nutrition. To encourage improvement of the nutrition content of the food supply. To safeguard the nutrition content of the food supply. Full nutrition labeling is required when food is fortified and when a nutrition claim is made for the food in its labeling or advertising. Nutrition labeling for most foods is volun- tary, but all food manufacturers are being encouraged to provide labels. The format for nutrition labeling is standard. Nutrients which must be included are: calories, protein, carbohydrate, fat, Vitamin A, Vitamin C, thiamine, riboflavin, niacin, calcium, and iron. Other nutrients are optional. Other regulations differentiate among foods, dietary supplements, and drugs. A food has to contain at least 10% of a particular nutrient before claims can be made that the food is a significant source of that nutrient. Any food which provides more than 50% of the RDA per serving in any added nutrient is classified as a dietary supplement and is subject to further regulations. Any food which proyides more that 150% of the RDA per serving in any added nutrient is classified as a drug and is subject to drug, rather th^n food regulations. The dietary standard used, the RDA, was developed by the FDA and is based on the Recommended Dietary Allowances of the Food and Nutrition Board of the National Academy of Sciences-National Research Council. Generally, the RDA values are the highest values for each nutrient in the RDA tables for males and non-pregnant, non-lactating females over three. RDA for special groups such as infants and children under four and pregnant and lactating women have been established for use on appropriate food labels. The costs of implementing, sustaining, and regulating this nutrition labeling program totals millions of dollars and is shared by consumers. 257Tests show that when consumers are aware of labeling, they do use it to the extent that they understand it. Consumer's knowledge of nutrition also increased in tests. Consumers think that labeling will increase food manufacturers' efforts to provide more nutritious products and direct advertising to provide factual and useful information. In the future, nutrition labeling will be extended to additional nutrients and may be extended to unprocessed foods. Nutrition labeling is one part of better nutrition education. Responsibility for nutrition education should be shared by educators, food producers and manufacturers, professional societies, government agencies, physicians, and consumer groups. A nutrition education curricu- lum should be incorporated into schools at ail grade levels. Evaluation The article provides a good overview of nutrition labeling regulations. However, more in- depth study of specific aspects would be necessary for use by nutrition educators, consumer groups, and other groups. Applicability to Planning Agencies HSA's could conduct surveys on consumer use of nutrition labeling information and needed improvements in the system. Recommendations of any changes could be submitted to the FDA. 218PAPERS OF THE SENATE SELECT COMMITTEE ON NUTRITION AND HUMAN NEEDS: REPORTS—1968 TO 1977 The Senate Select Committee on Nutrition and Human Needs was formed in 1968. It had been the main proponent for better nutrition within the Senate. As of. December 1977 the committee is no longer in existance. A wealth of materials is available through the Senate Select Committee on a variety of food and nutrition issues. Committee hearings, working papers, Committee prints, and staff reports are available. Table 4 contains the list of Committee hearings and prints from 1968 through 1977. Topics covered in the Senate Select Committee documents include: 1969: National Nutrition Survey; Food Assistance Reform; Child Nutrition and Food Assistance; Welfare Reform and Food Stamps; Nutrition and Private Industry; Nutrition and the Aged; Nutrition Needs in Health. 1970: National School Lunch Program; Housing, Sanitation and Health; Environmental Health Problems; Food Programs at the Local Level. 1971: Food Stamp Regulations; White House Conference on Food, Nutrition and Health; Food Distribution Program; National School Lunch Act of 1970; Summer Feeding Program. 1972: School Breakfast Program; Summer Lunch-Preschool Feeding; Food Additives; Migrant Children's Food Program Failures. 1973-1974: Maternal, Fetal and Infant Nutrition: Consequences of Malnutrition; the WIC Program. 1973-1975: Federal Food Programs: School Lunch Programs; Supplementary Food Programs; Fuel Crisis Impact on Low-Income and Elderly; Domestic Emergency Food Assistance. 1974, National Nutrition Policy Study: Famine and the World Situation; Nutrition and Special Groups; Food Availability; Nutrition and the Consumer; Nutrition and Health; Nutrition and the Government. Nutrition and Diseases (1973-1974): Obesity and Fad Diets; Sugar in Diet, Diabetes, and Heart Diseases. Nutrition Education (1972-1973): Federal Programs; Advertising of Food to Children; Phosphate Research and Dental Decay; School Nutrition Education Programs. Nutrition and the Elderly (1973-1974): Nutritional Needs of Elderly. 1975: 1975 Food Price Study; the Food Stamp Controversy; Nutritional Surveillance in the U.S. 1976: The U.S., FAO, and World Food Politics: Need for National Meals on Wheels Program; Medical Evaluation of WIC; Food Stamp Program Profile; Role of Federal Government in Human Nutrition Research. 1977: Dietary Goals for the U.S.; Diet and Killer Diseases; Nutrition at HEW; Role of USDA in Nutrition Research; Food Quality in Federal Food Programs; Improved Food Programs on Indian Reservations. 259Table 4: Senate Select Committee on Nutrition and Human Needs 1968 to 1977 COMMITTEE HEARINGS Title and dates Problems and Prospects December, 1968 USDA, HEW, and OEO Officials January, 1969 The National Nutrition Survey January, 1969 South Carolina February, 1969 Florida (Immokalee and Ft. Myers) Florida: Appendix March, 1969 Food Assistance Reform March, April, 1969 District of Columbia April, 1969 The Nixon Administration Program May, 1969 California (Los Angeles and San Francisco) May, 1969 SCLC and East St. Louis May, June, 1969 Child Nutrition and School Food Assistance June, 1969 Welfare Reform and Food Stamps September, 1969 Nutrition and Private Industry July, 1969 Nutrition and Private Industry: Federal Regulation—New and Fortified Foods—Overseas Experience July, 1969 Nutrition and Private Industry July, 1969 Nutrition and Private Industry: Food From the Sea July, 1969 Nutrition and Private Industry August, 1969 Nutrition and the Aged September, 1969 Human Needs in Health November, 1969 Hunger and the Income Gap March, 1970 National School Lunch Program (Modesto, Calif.) March, 1970 The Urban Crisis (Chicago, 111.) April, 1970 National Nutrition Survey April, 1970 Food Programs at the Local Level June, 1970 Progress Report—USDA June, 1970 260Housing and Sanitation September, 1970 Environmental Health Problems Health and Housing Rural Housing Review of the National School Lunch Act Review of the Results of the White House Conference on Food, Nutrition, and Health Kansas City, Kansas Food Stamp Regulations P.L. 91-248—Implementation, 1970 Amendments to the National School Lunch Act Implementation of Public Law 91-248, National School Lunch Act of 1970, in Michigan (Lansing and Detroit) Summer Feeding Program and USDA Decision to Withhold Funds for Section 32 Crisis in the National School Lunch Program Food Distribution Program Food Distribution Program Universal School Lunch Program Micronutrient Supplements for School Lunch Program School Breakfast Program Survey Migrant Children's Food Program Failures (Joint Hearings with the Subcommittee on Migrant Labor) Nutritional Needs of Nation's Older Americans Section 13 Funds: Summer Lunch-Preschool Feeding Unused Food Assistance Funds: Food Stamps; Administration Witnesses Food Additives FEDERAL FOOD PROGRAMS Part 1—Vending Machine Competition With National School Lunch Program Part 2—Hunger in 1973 Part 3—Supplementary Food Programs Part 4—School Food Program Needs Part 5—Domestic Emergency Food Assistance Part 6—Fuel Crisis Impact on Low-Income and Elderly September, 1970 September, October, 1970 October, 1970 October, 1970 February, March, 1971 March, 1971 April, May, 1971 May, 1971 May, 1971 June, July, 1971 September, 1971 September 15, 16, 1971 September 22, 23, 1971 October, 1971 December, 1971 April, 1972 May, 1972 June, 1972 April, June, 1972 June, 1972 September, 1972 April, 1973 June, 1973 August, 1973 September, 1973 261 October, 1973 January, 1974Part 6A—Appendix Part 7—Oversight: National School Lunch Program Part 8—Administrative Failure of Food Stamp Program, Detroit, Mich. Part 9—Food Stamp Certification Problems, Miami, Fla. MATERNAL, FETAL AND INFANT NUTRITION Part 1—Consequences of Malnutrition Part 2—Governmental Responses Part 3—Oversight—The WIC Program Part 4—Delays and Cutbacks of WIC Program NATIONAL NUTRITION POLICY STUDY Part 1—Famine and the World Situation Part 2—Nutrition and the International Situation 2A—Appendix Part 3—Nutrition and Special Groups 3A—Appendix Part 4—Nutrition and Food Availability 4A—Appendix Part 5—Nutrition and the Consumer 5A—Appendix Part 6—Nutrition and Health 6A—Appendix Part 7-7A—Nutrition and Government with Appendix NUTRITION AND DISEASES Part 1—Obesity and Fad Diets Part 2—Sugar in Diet, Diabetes, and Heart Diseases Part 3—Appendix to Hearings Part 4—Diabetes and the Daily Diet NUTRITION EDUCATION Part 1—Overview—Consultants' Recommendations 1A—Appendix Part 2—Overview—The Federal Programs 2A—Appendix March, 1974 February, 1975 March, 1975 June, 1973 June, 1973 December, 1973 April, 1974 June, 1974 June, 1974 June, 1974 June, 1974 June, 1974 June, 1974 June, 1974 April, 1973 April, May, 1973 April, May, 1973 February, 1974 December, 1972 December, 1972 262Part 3—TV Advertising of Food to Children March 5, 1973 Part 4—TV Advertising of Food to Children March 6, 1973 Part 5—TV Advertising of Food to Children March 13, 1973 Part 6—Phosphate Research and Dental Decay April, 1973 Part 7—School Nutrition Education Programs May, 1973 Part 8—Broadcast Industry's Response to TV Ads June, 1973 NUTRITION AND THE ELDERLY Part 1—Feeding the Elderly May, 1973 Part 2—Elderly Americans' Nutritional Needs March, 1974 Options for Reforming the Food Stamp Program July, 1975 1975 Food Price Study: Part 1—Food Prices: The Federal Role September, October, 1975 Report on the Eighteenth Session of the Conference of the Food and Agriculture Organization of the United Nations December, 1975 U.S. Participation in the Food and Agriculture Organizaton of the United Nations March, 1976 WIC and Commodity Supplemental Food Programs March, 1976 The Need for a National Meals-on-Wheels Program June, 1976 Diet Related to Killer Diseases July, 1976 COMMITTEE PRINTS The Food Gap: Poverty and Malnutrition in the United States August, 1969 Poverty, Malnutrition, and Federal Food Assistance Programs: A Statistical Summary September, 1969 Special Summer Project: An Evaluation December, 1969 Promises to Keep January, 1971 Seattle: Unemployment, The New Poor, and Hunger November, 1971 Seattle: Unemployment, The New Poor, and Hunger—With Supplement December, 1971 Hunger in the Classroom: Then and Now January, 1972 Hunger and the Reform of Welfare: A Question of Nutritional Adequacy February, 1972 Promises to Keep—Revised 1972 April, 1972 Studies of Human Need June, 1972 263The Elderly and Disabled Under H.R. 1 October, 1972 Publication List with Research Reference February, 1973 Emergency Food and Medical Services February, 1973 Dollars for Food—The Fiscal Year 1974 Budget March, 1973 Hunger—1973 May, 1973 School Food Program Needs: State School Food Service Directors' Response September, 1973 Impacts of Domestic and Foreign Food Programs on the U.S. Agricultural Economy October, 1973 "Hunger, 1973" and Press Reaction November, 1973 To Save The Children January, 1974 Publications List with Witness Reference February, 1974 Index to Hearings, 93d Congress, 1st Session February, 1974 Food Price Changes, 1973-74, and Nutritional Status—Part I February, 1974 Reference Material to Part I—Food Price Changes February, 1974 Food Program Technical Amendments National Nutrition Policy (working papers): March, 1974 The Food Industry—Its Resources and Activities in Food Production and Nutrition April, 1974 Guidelines for a National Nutrition Policy May, 1974 National Nutrition Policy Experiences May, 1974 Nutrition and the International Situation May, 1974 Nutrition and Food Availability May, 1974 Nutrition and the Consumer May, 1974 Nutrition and Health May, 1974 Nutrition and Special Groups May, 1974 Nutrition and Government May, 1974 Selected Papers on Nutrition Information and Programs June, 1974 Selected Papers on Food Security and Availability June, 1974 Selected Papers on Technology, Agriculture Advances and Production June, 1974 Nutrition, Health, and Development June, 1974 Nutrition and the Consumer—II June, 1974 Nutrition and the International Situation—II June, 1974 Background Reading Document June 1974 2(j4National Nutrition Policy Study (report and recommendation by): Panel on Nutrition and Food Availability June, 1974 Panel on Nutrition and the Consumer June, 1974 Panel on Nutrition and Government June, 1974 Subpanel of Health Care Systems of the Panel on Nutrition and Health June, 1974 Subpanel on Popular Nutrition Education of the Panel on Nutrition and the Consumer June, 1974 Panel on Nutrition and the International Situation June, 1974 Subpanel on Nutrition and Disease of the Panel on Nutrition and Health June, 1974 Panel on Nutrition and Special Groups June, 1974 Report on Nutrition and the International Situation September, 1974 Implementation and Status of the Special Supplemental Food Program for Woman, Infants, and Children October, 1974 Index to Hearings of the National Nutrition Policy Study October, 1974 Report on Nutrition and Food Availability December, 1974 Compilation of the National School Lunch Act and the Child Nutrition Act of 1966 December, 1974 Nutrition and the International Situation—II. Report on Rome: The Challenge of Food and Population December, 1974 Index to Publications on Nutriton and Human Needs—93d Congress March, 1975 Report on Nutrition and Special Grous: Part I— Food Stamps March, 1975 Report on Nutrition and Special Groups: Appendix B to Part I—Food Stamps March, 1975 School Food Program Needs—1975: State School Food Service Directors' Response April, 1975 WIC Program Survey—1975 April, 1975 Report on Nutrition and Government April, 1975 Toward a National Nutrition Policy May, 1975 Who Gets Food Stamps? August, 1975 The Food Stamp Controversy of 1975: Background Materials October, 1975 Food Stamp Legislative Alternatives November, 1975 Food Price Study: Part 2—A Questionnaire Approach to Determine Food Price Factors December, 1975 265 Part 3—Concentration in the Beef Industry Part 4—Economic Organization of the Milling and Bread Industry Part 5—A preliminary Evaluation of USDA's Farm to Retail Price Spread Series Food Stamps: The Statement of Hon. William E. Simon, Secretary of the Treasury, with a Staff Analysis Nutrition and Health—With an Evaluation of Nutritional Surveillance in the United States Food Industry Studies Compilation of the Naional School Lunch Act and The Child Nutrition Act of 1966 with Related Provisions of Law and Authorities for Commodities Distribution The Role of the Federal Government in Human Nutrition Research WIC and Commodity Supplemental Food Programs Commodity Supplemental Food Program Survey Title VII Survey The United States, FAO, and World Food Politics: U.S. Relations The Need for a National Meals-on-Wheels Program Nutrition and Health II. Nutrition and Health Revised with a Study of the Impact of Nutritional Health Considerations on Food Policy Diet Related to Killer Diseases, I Food Stamp Program Profile: Part 1 Food Stamp Program Profile: Part 2—Appendix Medical Evaluation of the Special Supplemental Food Program for Women, Infants and Children The Homebound Elderly Legislative History of the Select Committee on Nutrition and Human Needs The Homebound Elderly: The Need for a National Meals on Wheels Program Diet and Killer Diseases with Press Reaction Dietary Goals for the United States Diet and Killer Diseases, II (Part 1, Cardiovascular Disease) Diet and Killer Diseases, II (Part 2, Obesity) December, 1975 December, 1975 December, 1975 December, 1975 December, 1975 January, 1976 March, 1976 March, 1976 March, 1976 April, 1976 April, 1976 June, 1976 June, 1976 July, 1976 July, 1976 August, 1976 August, 1976 August, 1976 September, 1976 October, 1976 October, 1976 January, 1977 January, 1977 February, 1977 February, 1977 246March, 1977 Diet and Killer Diseases, III (Response to Dietary Goals for the United States: Re Mear) Diet and Killer Diseases, IV (Dietary Fiber and Health) Recommendations for Improved Food Programs on Indian Reservations National Meals-on-Wheels Program—Cicero, Illinois Diet and Killer Diseases, V (Mental Health and Mental Development) Diet and Killer Diseases, VI (Egg Industry Response) Federal Food Programs, Kansas Edible TV: Your Child and Food Commercials Nutrition: Aging and the Elderly Food Quality in Federal Food Programs World Food and Nutrition Study, National Academy of Sciences (Study Team 9) Role of USDA in Nutrition Research Nutrition at HEW March, 1977 April, 1977 April, 1977 June, 1977 July, 1977 August, 1977 September, 1977 September, 1977 September, 1977 October, 1977 October, 1977 October, 1977CHAPTER IV. ISSUES IN COST CONTAINMENT COST-BENEFIT AND COST-EFFECTIVENESS 196 Stason WB, Weinstein MC: Public Health Rounds at the Harvard School of Public Health: allocation of resources to manage hypertension. N Engl J Med 296:732-739, 1977 Geographical Area and Study Design National implications. The purpose of this paper was to apply cost-effectiveness analysis to the management of essential hypertension, both to determine how resources can be used most efficiently within programs to treat hypertension and to provide a yardstick for comparison with alternative health-related woes of these resources. Specific questions addressed were: (1) To what extent does treatment of hypertension pay for itself? (2) How efficient a use of health resources is the treatment of essential hypertension? (3) What are the priorities for treatment? (4) How should resources be allocated between screening programs and efforts to improve con- tinuity of care and adherence to prescribed medical regimens in patients known to have hyper- tension? Significant Findings The relation between net costs and net health benefits was expressed by the cost effective- ness ratio. Cost-effectiveness is universally related to the magnitude of this ratio. The formula presented was: C net expected medical care costs in dollars E net expected health benefits in quality-adjusted life years AC. ’RX incremental cost of a lifetime of antihypertensive treatment AC morb cardiovascular morbid events ASE costs of treating medication side effects AC. RXALE costs of treating non-cardiovascular illnesses in added years of life Ay increase in life expectancy AYmorb the value, in equivalently valued life years, of the improved quality of life that results from the prevention of non-fatal cardiovascular events Ay, SE the value, in the same terms, of the net reduction in quality of life that results from side effects of medicationsSeveral examples of the type of data generated by this technique are: Cost Effectiveness of Hypertension Treatment According to Age, Sex and Pretreatment Blood Pressure In no case did treatment pay for itself. For both sexes, the cost-effectiveness ratio was inversely related to the pretreatment level of diastolic blood pressure. The ratios for men ranged from $3,300 at the age of 20 to $16,300 at the age of 60 and for women, from $8,500 at age 20 to $5,000 at the age of 60. Ratios could serve to guide the selection of age specific blood-pressure cutoff levels for treatment. Cost Effectiveness of Hypertension According to Treatment Level of Diastolic Blood Pressure Achieved Cost-effectiveness of treatment depends not only on the initial diastolic blood pressure level, but also on that achieved by treatment. For example, in a male patient whose initial pressure is 110 mm Hg, the ratio value was $10,800 if this level was lowered and maintained at 100 mm Hg, and $3,700 if 80 mm Hg was attained. Many other parameters were also considered. In general, however, results indicated that funds spent to improve adherence may well be a better use of resources than efforts to screen a maximum number of subjects. Treatment priorities favor higher initial diastolic blood pressures, younger men and older women. Evaluation This paper clearly and effectively applies the technique of cost-effectiveness analysis to a specific issue (treatment of hypertension). The numerous variables and parameters involved in the calculations were discussed and evaluated. This paper in conjunction with another by the same authors serves as an excellent presentation of the use and potential benefits to be realized from application of this technique. The specific results must be judged with some caution. As the authors point out, there are several points of questionable validity. For example, estimates of mortality and morbidity were derived from a single prospective cohort study and where information was incom- plete, subjective estimates were supplied. However, the claim was never made that results were definitive. Instead, the model is intended to serve as simply the best estimate of the value of the potential alternatives available to health planners who, because of limited resources, are forced to prioritize their options. Applicability to Planning Agencies The applicability of the specific findings are.restricted by several factors. First, the point of view taken was that of society. "Individual decision-makers, whether consumers, pro- viders, health-institution administrators or third-party payers, may have different perspec- tives and should interpret the results of this analysis in the light of their individual situa- tions." Before a final decision can be made, the potential impact of any program or service should be evaluated on different segments of the population. Second, the results are based on present criteria. As more is learned about hypertension, its treatment and prevention, modifications in the analysis would be warranted. This point is relevant to any situation and is emphasized here because cost-effectiveness analysis allows for easy manipulation of the changing variables. The technique has far-reaching potential value and is applicable to almost any program or service. 197 Weinstein, MC, StasonWB: Foundations of cost-effectiveness analyses for health and medical practices. N Engl J Med 296:716-721, 1977 Geographical Area National implications. Study Design The purpose of this paper was to describe the basic foundations of the methods of cost- effectiveness analysis in the allocation of health-care resources. 269Significant Findings The author distinguishes between the often confused techniques of cost-benefit and cost- effectiveness analysis. "The key distinction is that a benefit-cost analysis must value all outcomes in economic (e.g. dollar) terms, including lives or years of life and morbidity, whereas a cost-effectiveness analysis serves to place priorities on alternative expenditures without requiring that the dollar value of life and health be assessed." Formulas are presented and discussed for calculation of cost-effectiveness ratios. Evaluation This paper clearly and effectively presents a model for determining cost-effectiveness ratios. Many of the variables involved are highlighted and discussed. While shortcomings in the techniques are acknowledged, the potential value of this technique for health planners is made clear. The authors point out that, "... resource allocation decisions do have to be made, and the choice is often between relying upon responsible analysis, with all of its imperfections, and no analysis at all. The former, in these times of increasingly complex decisions, difficult tradeoffs and limited resources, is by far the preferred choice." This paper would serve as an excellent introduction to the topic of cost-effectiveness or cost benefit analysis since the two methodologies are clearly defined and contrasted. Used in con- junction with the preceding paper by the same authors (where the model is applied to treatment of hypertension), the value of the application of this technique is readily apparent. Applicability to Planning Agencies Limits on health-care resources mandate that resource-allocation decisions be guided by considerations of cost in relation to expected benefits. In cost-effectiveness analysis, the ratio of net health care costs to net health benefits provides an index by which priorities may be set. Health planners may use this technique to generate data which can be used for priori- tizing new options, seeking new or additional funding or evaluating existing practices. The model presented is applicable to almost any service or program. 198 Dahl T: Economics, management, and public health nutrition. JADA 70:144-148, 1977 Geographical Area National implications. Study Design Findings were drawn from a number of different studies and evaluated in this paper. A bibliography of the studies is included with the paper. The objectives of this study were to: demonstrate the cost-effective potential of a nutri- tion component in health care delivery; and highlight the importance of increasing nutrition- ist's productivity by using simple managerial techniques. Significant Findings Findings from a study on a comprehensive health care project for children and youth suggest that increasing the allocation of funds to the nutrition functional area by 1 percentage point would likely reduce total cost per registrant per year by about 1/11 of a percentage point. The annual registrant cost was $271.52 which is estimated to be $29.30 lower than it would have been had there been no nutrition functional area in the program. Another study revealed that a 1 percentage point increase in funding of the nutrition func- tioal area per registrant per year would decrease medical functional area cost by about 1/6 of a percentage point. Translated into figures, this results in a savings of roughly $14.62 per registrant per year or 13.7%. In still another study, use of properly executed work sampling projects significantly im- proved worker effectiveness while smaller, but still noteworthy, increases were observed in worker efficiency and occupancy.Evaluation In determining the efficiency of an existing program, the author suggests use of a worker participation method which health educators also strongly recommend. The author quickly summarizes a program for promoting preventive health care. The stated objective of the program was "to create a lasting and favorable change in dietary patterns, so that desirable nutrition changes can be accomplished and maintained." This attitude is in complete agreement with the ideals of public health nutritionists. While nutritionists should assume a leading role in developing health policy, the major responsibility for improvement rests with an active, participating population. Thus, the author effectively presents his case utilizing the princi- ples agreed upon by both public health educators and nutritionists. Applicability to Planning Agencies The author points out that by studying what actually happened to the nutrition status of patients, it is possible to assess the efficiency of nutrition care delivery. Given the results, improvements in the role played by the nutritionist may be made using performance and diagnostic code reporting techniques. Work study methods have already demonstrated that significant improvements are feasible. Thus, there is a great potential positive impact on the health of the American public to be realized by better use of nutritionists. 199 Amadio J, Mueller J, Casey R: Benefit/Cost Ratios in Public Health. Springfield, 111. Illinois Department of Public Health, 1976 Geographical Area Illinois, HEW Region V. Study Design The objectives of the study were: to develop a formula for determining the benefit of basic health programs; to apply the formula to known health situations in Jackson County, Illinois, to determine a cost benefit value; and to derive program benefit-cost ratios for a representative sample of basic public health programs. Calculations are based on figures drawn largely from Jackson County, Illinois. Figures were also drawn from New Jersey and Monroe County, New York. The study researched about one-half of the basic public health services provided by the Jackson County, Illinois Health Department. Figures were applied to the program offered in 1974. Significant Findings Calculations were made on the benefit/cost (B/C) ratio of a: New Jersey influenza vaccina- tion, D.P.T. multiple vaccination, rubella, measles, and smallpox eradication vs. vaccination, tuberculosis prevention vs. treatment program, kidney disease screening program, environmental control program, food sanitation inspection program, air pollution program, Monroe County, New York, home health care vs. hospitalization program for cancer patients, home vs. hospital care for stroke patients, and skilled nursing home care program. Public Health Program Benefit/Cost 1. New Jersey Influenza Vaccination (conservative) 64.22/1 (liberal) 149/1 2. D.P.T. Multiple Vaccination 104/1 3. Rubella Vaccination 151/1 4. Measles Vaccination 15/1 5. Smallpox Vaccination 93/1 6. Tuberculosis Control 20.23/1+X* 7. Kidney Disease Screening 14.6/1 or 39.2/1+ 8. Home Dialysis & Center Dialysis .65/1 and .21/1 9. Food Sanitation Inspection low 23/1; high 189/1 10. Air Pollution 10/1 2lLPublic Health Program (continued) Benefit/Cost 11. Monroe County Home Care/Hospitalization 4.75/1 12. Stroke Patient Home/Hospital Care 8.27/1 13. Skilled Nursing Home Care (3 visits/wk) 2.5 /I (1 visit/wk) 7.35/1 14. Home Maintenance 5.2 *X = cost.of contact case finding which was not available. +Figures may vary according to method used. Evaluation The objective of the study was to develop criteria and formulas for determining the benefit/ cost ratio of public health programs. The applicability and value of the B/C ratio was also demonstrated. The study was simply and clearly presented. The problems of assigning numerical values to subjective factors was emphasized. Indirect and intangible costs were thus computed based on several assumptions (i.e. victims of ill health would have the same employment experiences as their well cohorts). So, reported findings, as is made clear in the study, are only estimates. Considerable research is still needed in the development of useful criteria and standards for evaluating subjective variables throughout the country. This study proposes an approach which does appear to be applicable to other communities and is presented in such a way as to make it readily usable by health planners. Other communities should now examine this study and attempt to develop a methodology recognized nationally. Applicability to Planning Agencies Public health agencies must be able to demonstrate economic benefits from their services. Direct (diagnosis and treatment), indirect (effect on national productivity), and intangible (quality of life) parameters must be considered. The benefit/cost ratio is a tool to be used in combination with other tools by decision-makers in planning. Use of the B/C ratio: Necessitates obtaining data. Besides the data's use in B/C calculations, it may be evaluated and the findings used for program modifications; May serve as the criteria for determination of whether or not a program has a positive net economic value; Highlights the economic preferability of different programs; Elucidates the relative effectiveness of one program provider or agency over another; May be used to justify a program's present ineffectiveness relative to its long-term value; and Can be used to predict at what point a program is feasible when a degree of uncertainty exists. For example, the probablity of a particular problem arising and persisting for a given duration can be calculated. Based on this finding, the need for the funding and implementation of a preventive or curative program in the future can be determined. At a time when resources are scarce and planners must set priorities, use of the B/C ratio can be helpful. The study developed a set of criteria and formulas which can be applied to practically any community. 272200 Spears MC: Concepts of cost effectiveness: accountability for nutrition productivity. JADA 68:341-344, 1976 Geographical Area National implications. Study Design This paper presented an approach which when applied to a decision-making process would provide a comparison of alternative courses of action in terms of their costs and effectiveness in attaining a specific objective. The model was applied to a hypothetical case for decision-making in a dietetic department. The particular question concerned the desirability of using food partially or fully prepared off premise as opposed to total preparation within the food service facility. The step-by-step application of the model was described. Significant Findings Since the model was applied to a hypothetical situation, no meaningful objective data were derived. The process of the model's application to a situation was the focus of this paper. Evaluation This model has its shortcomings. The largest drawback is the problem of evaluating the effectiveness of a program. Criteria for an objective assessment of effectiveness have not been developed. Many intangible variables must somehow be quantified. For this reason, methods of analysis can rarely indicate one course of action as clearly preferable to all others or eliminate subjective judgment by the decision-maker. The virtue of cost-effectiveness analysis is that it permits a more systematic and efficient use of judgment. Applicability to Planning Agencies The author points out' that "any program involving costs by federal, state, or local government must withstand scrutiny by the elements of these governments, as well as by the public sector. In times of financial stringency, it is imperative that planners have financial accountability for any projects instituted." Use of the proposed cost-effectiveness model will help the health planner prioritize his or her objectives and develop alternative means for achieving them. The model has already found widespread applicability from use by the Department of Defense to decision-making in a dietetic faculity. This particular paper clearly and concisely describes the model, the principles behind it, and its applications. 201 Monagle E: The Land of Missed Promise? Nutr Forum 3:31-35, 1973. Geographical Area International implications. Study Design The figures and projections offered by this paper are applicable to Canada. Significant Findings The author calculates that for adequate service, Canada requires one therapeutic nutri- tionist per 1500-1600 population. This translates to approximately 1,300 to 2,000 therapeutic nutritionists in community service in Canada. This would cost between 25 and 38 million addi- tional dollars per year. It is further calculated that the savings would range from $5.50 to $8.00 for every dollar spent on provision of adequate community nutrition services. 273Evaluation In the author's words, "These projections are, as stated, crude and no claim is made that they can be statistically validated. On the other hand, estimations of potential reduction were deliberately conservative." Thus, the magnitude of the figures may be used with some con- fidence. The calculations are not elaborate and no attempt is made to assign a value to in- tangible factors. Other studies on benefit/cost calculations attempt to evaluate these impor- tant parameters. The degrees of success vary but, if accurate figures are to be achieved, new, probing approaches are necessary. Applicability to Planning Agencies The findings of this study, appropriately evaluated, at least point out the need for expanded nutrition services. The reported figures may be useful to health planners in establishing priorities. The author points out the problems associated with assigning numerical values to intangible factors but, by the same token, states the need for ascertaining the value of such factors. 202 Sabry ZI: The cost of malnutrition in Canada. Can J Pub Health 66:291-293, 1975 Geographical Area International implications. Study Design The paper drew much of its information from a 1970 Canadian national survey, Nutrition in Canada. The objectives of that study were to: estimate the prevalence of nutrition diseases and disorders and identify the types of foods consumed and estimate the quantity normally ingested. Significant Findings The author estimates the cost of hospitalization, medical-dental care and loss of produc- tivity due to premature death and absenteeism due to diseases and disorders related to nutri- tion is $7,797,128,000 per year. The estimated potential savings from improved nutrition are $2,462,989,000 per year. It was also estimated that the total expenditures of the federal and provincial departments of health on nutrition improvement programs, exclusive of welfare programs, is just over one million dollars per year. The insignificance of this figure is elu- cidated by comparison with the advertising budget of the food industry which reached almost 86 million dollars in 1974. A table of the cost and potential savings from improved nutrition is offered on numerous specific diseases. Evaluation The study simply utilizes data acquired in other studies to estimate the potential benefits of improved nutriture in Canada. The author clearly states, "The estimates presented should be considered as a first approximation with the hope that, as more relevant data become avail- able and as epidemiologists and health economists apply their skills to this subject, more refined figures will be produced." However, the paper effectively states its case and is a good reference for motivating action in the field of nutrition. Applicability to Planning Agencies Papers of this type are useful to planners in that they often adopt novel and thought provoking methods for the presentation of data. The findings are useful when incorporated into the total body of data planners require for decision making. 2f4203 Steiner KC, Smith HA: Application of cost-benefit analysis to a PKU screening program. Inquiry 10:34-40, 1973 Geographical Area Mississippi, HEW Region IV. Study Design This paper measured the cost-benefit parameters of a phenylketonuria (PKU) screening pro- gram for Mississippi and related the costs to the benefits. The study used both retrospective and prospective approaches. The retrospective approach measures the direct and indirect costs of the current population with a disease entity. The prospective method calculates the cost of screening, detecting and treating all of the live births in a given year. Information from three mental institutions in Mississippi provided the data for computing direct and indirect costs. Demographic characteristics of the patients provided base line data. The prospective study was based on 1967 live births in Mississippi. Significant Findings Retrospective The estimated total direct cost for PKU patients was $1,261,050. The estimated total indirect cost for PKU patients was $1,053,545. The total cost to society for the 25 PKU patients was $2,314,595. The estimated cost to detect and treat the 25 suspected PKU patients in the Mississippi mental institutions was $1,392,668. The cost-benefit ratio was then calcu- lated to be 1,392,668/2,314,595 or 1 to 1.66. Prospective The direct cost for institutonalization for 30 years was $89,232 (minimum expected time of institutionalization). The direct cost of institutionalization for 70.8 years was $210,588/patient (normal life expectancy). The indirect costs were estimated at $45,830/patient. The total direct and indirect costs were $135,062/patient for 30 years of institutional care. These data yield cost-benefit ratios of 1 to 1.37 and 1 to 2.60 respectively. Evaluation The present study made no attempt to put an objective value on intangible factors. Instead, after the approach was applied and favorable ratios resulted, this factor was added for empha- sis. In other applications, where the cost-benefit ratio is small, intangible gains or losses may be the deciding factor in starting or terminating a program. The present paper is clearly written and may be helpful to planners who find themselves in need of defending or attacking proposed or existing programs. It therefore behooves health planners and economists to attempt an evaluation of intangible factors. Applicability to Planning Agencies This technique has many applications, i.e., proving the validity of programs such as family planning, vaccination and fluoridation, or assessing the value of different treatment modalities for diseases such as cancer. 27.5ISSUES RELATED TO EVALUATION OF NUTRITION SERVICES 204 Harder EL: Searching for cost effective measures that also improve care. Hospitals 51:255-259, 1977 Geographical Area National implications. Study Design This paper examined the year's literatue in hospital food service in terms of applicability to four concepts of management effectiveness. The concepts were effective management starts with goals, priorities and strategies; centers on human values; looks at results as the measure of success; and brings continuing change for improvement. Significant Findings Goals In Minneapolis a central kitchen was able to cater to a 450 bed public hospital as well as a 1,200 bed private hospital. A desire for expanded use of this arrangement was expressed. Expansion of ambulatory care centers resulted in significant reductions in inpatient care visits in California. Nutritionists have become an integral part of health care teams in New York. Self care units for those sufficiently well to participate are proving effective in Wisconsin. There has been a growth of mid-level dietetic technicians. Departmental Efforts Through the use of computers the number of therapeutic diets was reduced in a hospital in Houston. A restaurant type program has resulted in less waste in a hospital in Michigan. Security and Snacks Electronic devices have reduced security costs in Minneapolis. Purchasing Directions One-stop purchasing has proven to be cost effective in Iowa. In addition to the specific programs and innovations mentioned, numerous suggestions were also proposed. Evaluation This article points out the value of innovativeness in terms of dollars saved and improved quality of services offered. It serves as a source of motivation for health care workers to examine their working conditions in hope of improving them. In addition, it highlights the value of keeping up with the literature. Many beneficial ideas and programs may be applicable to the reader's particular situation. The impact of the findings would have been strengthened by use of more data, but the objective of the paper was clearly achieved. Applicability to Planning Agencies The many ideas and suggestions presented in this paper may or may not be applicable in a given situation. The message that one should constantly evaluate his own working condi- tions in hopes of finding ways to make improvements is applicable to health workers. 276205 Guthrie HA, Guthrie GM: Factor analysis of nutritional status data from Ten State Nutrition Surveys. Am J Clin Nutr 29:1238-1241, 1976 Geographical Area National implications. Study Design The objective of the study was to determine if a reduced number of dietary, biochemical and anthropometric variables can be used in: assessment of the nutrition status of a population, identification of high-risk individuals or groups, and determination of the impact of interven- tion programs on target populations. A reduction in the number of tests used for survey pur- poses would reduce the cost in terms of time and money without any significant loss in diagnostic value. Data from 40,847 participants in the Ten State Nutrition Survey were utilized in this study. From this group, the 6,223 subjects from whom blood and urine samples, a 24-hour dietary recall and anthropometric measurements had been obtained were selected. Data from most of the 28 per- formed tests were available. The population was broken down into six groups; the total group, 6-12 year olds, 12-18 year olds, 18-65 year olds, those over 65 years old, and pregnant women. Significant Findings The number of parameters of nutrition status routinely used in nutrition surveillance can be reduced with no reduction in diagnostic potential. Determination of intake of two compo- nents (Vitamin A and iron), one anthropometric measure (weight), four blood values (hemoglobin, serum iron, folate, and albumin), and one urinary component provide as much information as a larger battery of tests. Evaluation This paper confirms findings from a similar analysis of data from the Preschool Nutrition Survey. Both studies demonstrated that the number of test parameters of nutrition status can be reduced with no reduction in diagnostic potential. Savings in time, money, equipment and personnel are realized with a limited number of parameters. Applicability to Planning Agencies The results of this paper have excellent implications for nutrition surveillance. By using a few key indices for nutrition surveillance, at-risk children can be monitored for their pro- gress resulting from nutrition intervention programs. Additional investigations such as this one should be conducted for different age groups to determine indicators of nutrition status. This then, could aid in expanding the current focus of nutrition surveillance. Such data from nutrition surveillance would be beneficial to planners for the same reasons that are given in the explanation of CDC Nutrition Surveillance discussed earlier. 206 Burgess HJL, Burgess AP: Malnutrition in the Western Pacific Region. WHO Chron 30:64-69, 1976 Geographical Area International implications. Study Design The sample population in this study was comprised of the one billion inhabitants of the WHO's Western Pacific Region. More than three-fourths' of the subjects live in China. A descrip- tion of the population is impossible because almost every level of development, ecological con- dition, and ethnic group is represented. The objective of the paper was to examine data on nutrition status collected within the last ten years in an attempt to determine the degree and types of malnutrition in the developing countries of the Region. A second purpose was to examine some of the factors that hindered efforts to reduce the prevalence of malnutrition. 277Significant Findings The specific nutrition findings will just be summarized since they have little applicability to the present situation in the United States. The most common nutrition problems observed in- cluded: protein-calorie malnutrition, anemia, goiter, xeropthalmia, and riboflavin deficiency. Evaluation The article discusses a number of nutrition problems in the Western Pacific Region of the WHO. The findings are presented as general trends because many problems were encountered in collection and interpretation of the data. Recognizing the limitations of a set of data can be of great value. Besides keeping an investigator from making improper claims, it can motivate additional thinking on how to correct the problems. This is what occurred in this paper. The ideas are presented as thoughts to be explored. Applicability to Planning Agencies There are no data to apply or significant findings to elaborate upon. Instead, the authors pose several thought provoking ideas which may be beneficial to planners. The lack of specificity in describing the factors responsible for existing malnutrition is one of the primary problems hindering its improvement. Investigators in the study often ex- plained the findings with terms like "poverty," "ignorance," and "poor feeding habits and beliefs". If health workers are to develop effective programs to eradicate these problems, the etiologic factors leading to malnutrition must be better defined. This will allow workers to focus on the most significant factors thus allowing the most efficient use of time, energy and funds. Another idea discussed by the author is that of redirecting current thinking toward a more behavioral approach. Instead of spending so much energy attempting to define and under- stand the etiologic agents, many of which are clearly intangible, perhaps greater benefits will be realized if the specific symptoms of a problem are confronted. Improved health and well- being are the goals of current programs. Improving water quality may be more effective than continuing to attempt to alter ingrained beliefs and habits. Another point suggested is that a more socioeconomic approach be tried and tested. Emphasizing the family income, time commitment of subjects, resource and work load instead of physical signs, nutrient intake or agricultural method may lead to enhanced receptivity by participants. To carry this a little further, it has been argued that improvement in the eco- nomic condition of a population is usually accompanied by improvement in nutrition status. Perhaps greater efforts should be made on economic factors Ideas were presented with the findings of the study in mind. However, any of the problems encountered are also present in the US, and perhaps planners can find use for some of these approaches in this country. 207 Peterkin B, Walker S: Food for the baby. . . cost and nutritive value considerations. Fam Econ Rev 3-9, Fall 1976 Geographical Area National implications. Study Design This paper assessed the costs and nutritive value of different infant feeding regimes. Significant Findings Costs Food in the USDA's thrifty food plan for lactating women costs about $3.00 more per week than food in the same plan for nonlactating women. In the liberal plan, the difference is $5.00. In addition, about 50