Family Economics and Nutrition Review [Volume 9, Number 2]

              Feature Articles
3 From the Editor
4
Carole A. Davis and Etta A. Sa/tos
14 Dietary Guidance and Nutrition Promotion:
USDA's Renewed Vision of Nutrition Education
Sharyn M. Sutton, William Layden, and Jackie Haven
Healthy People 2000 Midcourse Review and 1995 Revisions
Summarized by Joanne F. Guthrie
Research Summaries
32 Total and Per Capita Personal Income by State and Region
34 Home Health Care
36 Health Needs of Young Children in Foster Care
38 Effects of Intermittent Labor Force Attachment on Women's Earnings
Regular Items
42
44
45
48
49
so
Recent Legislation Affecting Families
Research and Evaluation Activities in USDA
Data Sources
Journal Abstracts
U.S. DEPOSITOq'.'
PROPERTY OF THE. Li ;· "
JUN 2 5 1996
1ne ur11ve1stty ot 1i01th Ct~tv .......
at Greensboro
Dan Glickman, Secretary
U.S. Department of Agriculture
Ellen Haas, Under Secretary
Food, Nutrition, and Consumer Services
Eileen Kennedy, Executive Director
Center for utrition Policy and Promotion
Jay Hirschman, Director
utrition Policy and Analysis Staff
Editorial Board
Mohamed Abdei-Ghany
University of Alabama
Rhona Applebaum
National Food Processors Association
Johanna Dwyer
New England Medical Center
Jean Mayer USDA Human Nutrition Research Center
on Aging at Tufts University
Helen Jensen
Iowa State University
Janet C. King
Western Human Nutrition Research Center
U.S. Department of Agriculture
C.J. Lee
Kentucky State University
Rebecca Mullis
Georgia State University
Suzanne Murphy
University of California-Berkeley
Donald Rose
Economic Research Service
U.S. Department of Agriculture
Ben Senauer
University of Minnesota
Laura Sims
University of Maryland
Retia Walker
University of Kentucky
Editor
Joan C. Courtless
Editorial Assistant
Jane W. Fleming
Family Economics and Nutrition Review is
written and published each quarter by the
Center for Nutrition Policy and Promotion,
U.S. Department of Agriculture, Washington, DC.
The Secretary of Agriculture has determined
that publication of this periodical is neces­sary
in the transaction of the public business
required by law of the Department.
This publication is not copyrighted. Contents
may be reprinted without permission, but
credit to Family Economics and Nutrition
Review would be appreciated. Use of
commercial or trade names does not imply
approval or constitute endorsement by USDA.
Family Economics and Nutrition Review is
indexed in the following databases: AGRICOLA,
Ageline, Economic Literature Index, ERIC,
Family Resources, PAIS, and Sociological
Abstracts.
Family Economics and Nutrition Review is
for sale by the Superintendent of Documents.
Subscription price is $8.00 per year ($1 0.00
for foreign addresses). Send subscription
orders and change of address to Superinten­dent
of Documents, P.O. Box 371954,
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form on p. 52.)
Original manuscripts are accepted for publica­tion
(See "guidelines for authors" on p. 41 ).
Suggestions or comments concerning this
publication should be addressed to: Joan C.
Courtless, Editor, Family Economics and
Nutrition Review, Center for Nutrition Policy
and Promotion, USDA, 1120 20th St., NW,
Suite 200 North Lobby, Washington, DC
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(TOO). USDA is an equal employment
opportunity employer.
Center for Nutrition Policy and Promotion
Feature Articles
3 From the Editor
4 The Dietary Guidelines for Americans-Past, Present, Future
Carole A. Davis and Etta A. Saltos
14 Dietary Guidance and Nutrition Promotion:
USDA's Renewed Vision of Nutrition Education
Sharyn M. Sutton, William Layden, and Jackie Haven
22 Healthy People 2000 Midcourse Review and 1995 Revisions
Summarized by Joanne F. Guthrie
Research Summaries
32 Total and Per Capita Personal Income by State and Region
34 Home Health Care
36 Health Needs of Young Children in Foster Care
38 Effects of Intermittent Labor Force Attachment on
Women's Earnings
Regular Items
42 Charts From Federal Data Sources
44 Recent Legislation Affecting Families
45 Research and Evaluation Activities in USDA
48
49
50
51
Data Sources
Journal Abstracts
Cost of Food at Home
Consumer Prices
Volume 9, Number 2
1996
PROPERTY OF Tlir.
LIBRA Y
j 2 I 1996
Special Theme Issue: Dietary Guidelines t t ,.~ th c . Y o .. o arolma
at Greensboro
From the editor
An abstract of the first two articles in this special theme issue related to the Dietary Guidelines
was published-as a "commentary" from a policy perspective-in the March 1996 issue
of the Journal of the American Dietetic Association. Additional information reported here
includes the historical background of the guidelines and a more thorough explanation of the
consumer research used in developing the fourth edition of the Dietary Guidelines for
Americans. The third article summarizes the U.S. Department of Health and Human Services'
publication, Healthy People 2000 Midcourse Review and 1995 Revisions. Among the
objectives established for evaluating progress towards the Healthy People 2000 goals are
several related to nutrition and Dietary Guidelines ' concepts, which we believe will be of
interest and will help our readers acquire a broader perspective on uses of the Dietary
Guidelines in national policy development.
1996 Vol. 9 No.2
Information and a limited number of publications from the
Center for Nutrition Policy and Promotion may be accessed
electronically at the following locations:
CNPP Home Page at:
http://www .usda.gov /fcs/cnpp.htrnl
Food and Consumer Service Bulletin Board at FedWorld:
By modem: Dial703-321-3339
For Internet FfP services: ftp.fedworld.gov
3
4
Feature Articles
The Dietary Guidelines for
Americans-Past, Present, Future
By Carole A. Davis
Chief Nutritionist
Center for Nutrition Policy and Promotion
Etta A. Saltos
Nutritionist
Center for Nutrition Policy and Promotion
The Dietary Guidelines for Americans, and the process for their development
are important to all people concerned about food, nutrition, and health
policy and education. The information presented in the Dietary Guidelines
consumer bulletin is the one voice with which the Federal Government
speaks about what healthy Americans should eat to stay healthy and why.
The Dietary Guidelines form the basis of Federal nutrition policy affecting
food, nutrition education, and information programs. The use of the Dietary
Guidelines assures that dietary advice coming from Federal sources is
sound, up-to-date, and consistent.
[QJ overnment nutritionists
have been providing advice
to Americans about what to
eat for nearly a century. In
looking at the contemporary Federal
dietary recommendations from a
historical perspective, it is apparent how
far we have come in food guidance. Yet
at the same time, it is surprising to see
how much is, in fact, the same.
History of U.S. Department of
Agriculture Food Guides
The use of the scientific process to
develop dietary guidance began about
100 years ago at the U.S. Department
of Agriculture (USDA) with W.O.
Atwater, first director of the Office
of Experiment Stations in USDA. He
helped establish important data bases
for the development of food guidance
including dietary standards for protein,
calories, and tables of food composition
(4).
In a Farmers' Bulletin published in 1902,
Atwater emphasized the importance
of variety, proportionality, and
moderation in healthful eating (5).
He stated that, "for the great majority
of people in good health, the ordinary
food materials ... make a fitting diet, and
the main question is how to use them in
the kinds and proportions fitted to the
actual needs of the body." Many of our
dietary guidance efforts have focused
on answering this question.
The frrst USDA food guide, "Food for
Young Children" by Caroline Hunt, a
USDA nutritionist, appeared in 1916 (9).
It translated the emerging science of
Family Economics and Nutrition Review
nutrition into national dietary recom­mendations
for consumers. The food
guide, which specified five food groups,
translated nutrient recommendations
into recommendations for food intake.
As more was learned about vitamin
and mineral requirements and food
consumption patterns of the population,
food guides emerged such as the "Basic
Seven" (1946) and the "Basic Four"
(1958) (15,16). These guides focused on
choosing enough of the kinds of foods
to provide the nutrients needed for good
health. These dietary recommendations
outlined what was called a "foundation
diet" or core of foods that would pro­vide
a major share of protein and the
recommended vitamins and minerals
known at the time these guides were
developed. The "Basic Four"-milk,
meat, vegetable and fruit, and bread
and cereal-remained the centerpiece
of nutrition education for the next two
decades.
New Directions for
Dietary Guidance
By the 1970's, there was a growing body
of research relating overconsumption
of certain dietary components-such
as fat, saturated fat, cholesterol, and
sodium-and the risk of some chronic
diseases, such as heart disease and
stroke.
A new direction for dietary guidance
was set in 1977 with the release of the
Dietary Goals for the United States by
the U.S. Senate Select Committee on
Nutrition and Human Needs, popularly
known as the "McGovern Committee"
(28). The Dietary Goals shifted the
focus from obtaining adequate amounts
of vitamins and minerals to avoiding
excessive intakes of food components
that had been linked to chronic diseases.
1996 Vol. 9 No.2
The Committee's report specified the
amounts of protein, complex carbohy­drates,
sugars, fat, cholesterol, and salt
that Americans should consume. It
generated considerable discussion in
the scientific community about the ap­propriateness
and utility of the Dietary
Goals. Because diets developed follow­ing
these goals were so different from
usual food patterns, USDA did not
adopt the goals as the basis for its food
plans and guides. However, they did
draw attention to the need for guidance
on diet and health.
In response to the Dietary Goals, the
Department of Health and Human Services
(HHS) asked the American Society for
Clinical Nutrition (ASCN) to form a
panel to study the relationships between
dietary practices and health outcomes.
The panel's findings were presented in
a 1979 report entitled Healthy People:
the Surgeon General's Report on Health
Promotion and Disease Prevention
(23 ). The report suggested that people
reduce their consumption of excess
calories, fat and cholesterol, salt, and
sugar to lower disease rates.
Also in 1979, USDA released a colorful
booklet entitled Food, which presented
the "Hassle-Free Guide to a Better Diet"
( 18). This guide added a fifth food
group to the "Basic Four"-the fats,
sweets, and alcohol group. This food
group separated foods that provided
mainly calories with few other nutrients
from the other four food groups. The
guide highlighted the need to moderate
the use of fat, sugars, and alcohol and
gave special attention to cutting calories
and getting adequate dietary fiber.
At about this same time, HHS and
USDA began to develop a set of simple
guidelines that would provide help for
healthy people as they made daily food
By the 1970's, there
was a growing body
of research relating
overconsumption
of certain dietary
components ... and
the risk of some
chronic diseases,
such as heart
disease and stroke.
5
choices. Such guidelines, based in part
on the 1979 Surgeon General's Report
on Health Promotion and Disease
Prevention, were published in 1980
as the first edition of Nutrition and
Your Health: Dietary Guidelines for
Americans (19).
The guidelines called for a diet of a
variety of foods to provide essential
nutrients and more starch and fiber
while maintaining recommended body
weight and moderating dietary constitu­ents-
fat, saturated fat, cholesterol,
sugars, sodium, and alcohol-that might
be risk factors in certain chronic diseases.
These guidelines, even though they were
directional rather than quantitative,
were not totally acceptable to all nutri­tion
scientists and health professionals
and to certain consumer, commodity,
and food industry groups. One concern
was that use of the term "avoid" would
be interpreted to mean "eliminate"
foods that contained fat, saturated fat,
and cholesterol from the diet.
Later in 1980, a Senate Committee on
Appropriations directed that a committee
be established to review scientific
evidence and recommend revisions
in the Dietary Guidelines (27). Such
a review was considered desirable be­cause
of the continued intense interest
in the information and because the state
of knowledge in nutrition and dietary
planning continued to advance. A
Federal Advisory Committee of nine
nutrition scientists selected from outside
the Federal Government was convened
in 1983 to review and make recommen­dations
to USDA and HHS about the
first edition of the Dietary Guidelines
in anticipation of the next edition.
6
New Food Guide Developed
With the release of the fust edition of
the Dietary Guidelines, USDA began
work on developing a new food guide
that would help consumers put the
guidelines into action in their daily
food choices. The food guide focused
on how to make food choices that met
the objectives for nutrient adequacy
and moderation of those components
related to risk of chronic disease.
After development, the new food guide
was first presented as a food wheel to
consumers in 1984 as part of a nutrition
course developed by USDA in coopera­tion
with the American National Red
Cross (3 ). The guide was also used in
tabular form-" A Pattern for Daily
Food Choices"-in several USDA
publications released in the 1980's, in­cluding
"Preparing Foods and Planning
Menus Using the Dietary Guidelines"
(Home and Garden Bulletin Number 8,
1989) and "Dietary Guidelines and
Your Diet" (Home and Garden Bulletin
Number 232-1, 1986).
Continued Revisions of
the Dietary Guidelines
In 1985, HHS and USDA jointly issued
a revised edition of the Dietary Guide­lines
(20 ). This second edition was
nearly identical to the fust. Some changes
were made for clarity in wording; others
added guidance about nutrition topics
that became more prominent after 1980,
such as following unsafe weight-loss
diets, using large-dose supplements,
and drinking of alcoholic beverages
by pregnant women (6). These changes
reflected advances in scientific knowl­edge
of the associations between diet
and a range of chronic diseases. The
second edition received wide acceptance
and was used as a framework for
consumer education messages.
In 1987, a Conference Report of the
House Committee on Appropriations
indicated that USDA, in conjunction
with HHS, "shall re-establish a Dietary
Guidelines Advisory Group on a periodic
basis" (26). In 1989, USDA and HHS
established a second advisory committee
that reviewed the 1985 Dietary Guide­lines
and made recommendations for
revision in a report to the Secretaries
of Agriculture and HHS (7).
The Surgeon General's Report on
Nutrition and Health published in 1988
and the National Research Council's
report, Diet and Health: Implications
for Reducing Chronic Disease Risk
published in 1989 were key resources
used by the Dietary Guidelines Advisory
Committee (10, 25 ). Other major resources
were the lOth edition (1989) of the
Recommended Dietary Allowances and
the draft of a report by the Population
Panel of the National Cholesterol
Education Program (II, 24 ).
Another type of resource, research on
the uses and usefulness of the second
edition of the Dietary Guidelines, con­ducted
at the University of Wisconsin
and The Pennsylvania State University
under USDA sponsorship, was also used
by the Dietary Guidelines Advisory
Committee (I, 2, I4). This type of
research provided the Committee with
input from professionals and consumers.
The 1988 Wisconsin study found wide­spread
adoption and acceptance of the
second edition of the Dietary Guidelines
by Federal, State, and local professionals
involved in the communication of food
and nutrition information (14). The
Family Economics and Nutrition Review
health professionals interviewed empha­sized
the importance of having health
and nutrition experts speak with one
voice in identifying important dietary
practices. They also urged that the
Dietary Guidelines be kept constantly
before the public, in a variety of
presentations.
In the Pennsylvania study, consumer
evaluation of the second edition (1985)
of the Dietary Guidelines bulletin, using
focus groups and in-depth interviews,
showed that consumers wanted more
specific food-related guidance, definitions
of technical terms, and practical tips for
behavior change strategies ( 1, 2 ).
In 1990, USDA and HHS jointly re­leased
the third edition of the Dietary
Guidelines (21 ). The basic tenets of the
Dietary Guidelines were reaffirmed,
with additional refinements reflecting
an increased understanding of the
science of nutrition and suggestions
for communicating that science to
consumers. The new Dietary Guidelines
were more positive and more oriented
toward the total diet. They also, for the
first time, contained suggested numerical
limits for total fat and saturated fat
intake, and short action statements in
an "Advice for Today" section (e.g.,
"check to see if you are at a healthy
weight") along with each guideline. In
response to consumer evaluation of the
previous edition, more practical advice
was given on how to implement the
Dietary Guidelines in daily food
choices by including the food guide­A
Pattern for Daily Food Choices­developed
by USDA in the early 1980's
(3 ).
1996 Vol. 9 No. 2
Also in 1990, The National Nutrition
Monitoring and Related Research Act
(7 U.S.C. 5341) was passed. This Act
requires the Secretaries of Agriculture
and Health and Human Services to
publish jointly a report entitled Dietary
Guidelines for Americans every 5 years.
This legislation also requires review
by the two Secretaries of all Federal
publications containing dietary advice
for the general public to assure that such
guidance either is consistent with the
Dietary Guidelines for Americans or
is based on medical or new scientific
knowledge, which is determined to be
valid by the Secretaries.
The Food Guide Pyramid
Released
In 1992, the Food Guide Pyramid,
which was developed by USDA and
supported by HHS, was released ( 17).
This was a new graphic presentation of
the original food guide developed by
USDA in the mid-1980's. A separate
publication explaining the food guide
was prepared, involving consumer
testing with adults and children during
development. The Pyramid graphic
conveys in a memorable way the key
messages of the food guide-variety,
proportionality, and moderation. The
intent of the Food Guide Pyramid is to
help consumers put the Dietary Guide­lines
into action.
The Food Guide Pyramid has been
widely used by nutrition educators in a
variety of materials, including posters,
textbooks, school curricula, and com­puter
software, and has also been used
by industry on food labels. Such wide
use has helped to communicate the
Dietary Guidelines ' message.
The intent of the
Food Guide Pyramid
is to help consumers
put the Dietary
Guidelines into
action.
7
8
... there have been
few changes in the
overall theme of the
Dietary Guidelines
over the past
15 years.
Process for Development of
the 1995 Edition of the Dietary
Guidelines
In 1994, USDA and HHS appointed
an 11-member Dietary Guidelines
Advisory Committee to review the 1990
edition of the Dietary Guidelines and
determine if, on the basis of current
scientific knowledge, revisions were
warranted. The 1980, 1985, and 1990
editions of the Dietary Guidelines were
issued voluntarily by USDA and HHS.
The 1995 edition was the first report
mandated by statute.
The Dietary Guidelines Advisory
Committee held three public meetings
from September 1994 through March
1995. All meetings were announced in
the Federal Register and open to the
public. Oral comments were received
from the public during the second meeting.
Additionally, written comments were
solicited from the public. A search of
Medline and AGRICOLA data bases
for literature related to each guideline
was performed and results were pro­vided
to the Committee by USDA and
HHS staff. The Committee report was
submitted to the Departments in June
1995 (8). Consumer reactions to specific
design and content elements of the
Dietary Guidelines were obtained by
USDA-sponsored research done in
collaboration with HHS (13 ).
Changes in the Dietary Guidelines
Since 1980
Although the titles of some of the
Dietary Guidelines have changed (see
table), there have been few changes in
the overall theme of the Dietary Guide­lines
over the past 15 years. There are
seven guidelines for each edition. The
target audience for the Dietary Guide­lines
has remained unchanged; they
are directed to all healthy Americans
2 years of age and older.
Eat a variety of foods. The title of this
guideline has remained the same for all
four editions. The fourth edition added
boxes listing good food sources of iron
and calcium. It also added information
about the new Nutrition Facts Label,
which by Federal law is required on
most packaged retail food products. A
discussion of vegetarian diets was also
added to demonstrate the compatibility
of such diets with the advice in the
Dietary Guidelines (8) .
Balance the food you eat with physical
activity-maintain or improve your
weight. The title of this guideline has
seen several changes over the past 15
years. "Maintain ideal weight" was
changed to "Maintain desirable weight"
in 1985 because "ideal" seemed to
imply an unduly precise understanding
of what people should weigh (6). The
title was changed again in 1990 to
"Maintain healthy weight" because a
procedure was introduced to help
people assess their weight relative to
health outcomes. The Dietary Guidelines
brochure has always included a weight
table to help adults assess their own
weight status. The third edition added
information about waist-hip ratio to
help relate weight to risk for chronic
diseases, such as heart disease, certain
types of cancer, and adult-onset diabetes
(7). In 1995, the title was changed to
emphasize the importance of physical
activity and energy balance. The weight
table has been replaced with a chart
that illustrates weight ranges for healthy
weight, moderate overweight, and
severe overweight. The suggested list
of physical activities has also been
updated based on recent research (12).
Family Economics and Nutrition Review
1980
Eat a variety of foods
Dietary Guidelines for Americans
1980-1995
1985 1990
Eat a variety of foods Eat a variety of foods
1995
Eat a variety of foods
Maintain ideal weight Maintain desirable weight Maintain healthy weight Balance the food you eat with
physical activity-maintain or
improve your weight
A void too much fat,
saturated fat, and
cholesterol
A void too much fat,
saturated fat, and
cholesterol
Choose a diet low in fat,
saturated fat, and
cholesterol
Choose a diet with plenty of
grain products, vegetables,
and fruits*
Eat foods with adequate
starch and fiber
Eat foods with adequate
starch and fiber
Choose a diet with plenty
of vegetables, fruits, and
grain products
Choose a diet low in fat,
saturated fat, and
cholesterol*
A void too much sugar A void too much sugar Use sugars only in
moderation
Choose a diet moderate
in sugars
Avoid too much sodium A void too much sodium Use salt and sodium only
in moderation
Choose a diet moderate in
salt and sodium
If you drink alcohol,
do so in moderation
If you drink alcoholic
beverages, do so in
moderation
If you drink alcoholic
beverages, do so in
moderation
* In the 1995 edition, the order of the third and fourth guidelines has been reversed.
Choose a diet with plenty of grain
products, vegetables, and fruits. The
title of this guideline remained the same
in 1980 and 1985. In 1990, the title was
changed, in part due to research that
indicated that consumers found the
earlier title to be too difficult to follow
(7). The new title placed more emphasis
on foods rather than nutrients. In 1995,
this guideline was moved up from
fourth position to third to give it more
prominence. The title was changed
slightly to make it consistent with the
1996 Vol. 9 No.2
placement of food groups within the
Food Guide Pyramid (8). The text of
the guideline has added information on
food sources of folate and carotenoids,
and the relationship of these nutrients to
health outcomes is discussed.
Choose a diet low in fat, saturated fat,
and cholesterol. The title of this guide­line
remained the same in 1980 and
1985. In 1990, the title was changed
to make clear that the fat content of the
total diet, not just individual foods, is
If you drink alcoholic
beverages, do so in
moderation
of concern (7). The word "avoid" was
removed to eliminate the possible
misunderstanding that fats are to be
completely eliminated from the diet.
The 1995 edition concurs with the 1990
wording. The text of the 1995 edition
adds more information about types
and sources of fatty acids in the diet
(including information about omega-3
polyunsaturated and trans fatty acids).
It continues the 1990 recommendation
for upper limits on total fat and saturated
fat but recommends that children
9
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10
... it is likely that the
underlying themes of
variety, proportionality,
and moderation
initiated about
1 00 years ago will
apply to choosing
healthful diets for
many years to come.
gradually adopt the guideline from age
2 to 5 years, so that by the time children
are in elementary school, they should be
consuming diets that follow the Dietary
Guidelines (8).
Choose a diet moderate in sugars.
The title of this guideline was the same
in 1980 and 1985 but changed in 1990.
The term "sugars" was used to more
accurately define the foods of concern
(table sugar as well as other caloric
sweeteners, which were listed in the
text) (7). The word "avoid" was removed
to provide a more positive tone to the
guideline. In 1995, the title of the guide­line
changed again to provide consis­tency
with the other guidelines' focus
on the total diet (8). The text of the 1995
edition placed more emphasis on sugars
as a calorie source and less on the
relationship of sugars' intake to dental
health. The text also added the state­ment
that the body cannot distinguish
between naturally occurring and added
sugars (8).
Choose a diet moderate in salt and
sodium. The title of this guideline
remained unchanged in 1980 and 1985.
In 1990, the word "salt" was added
because it is the source of most sodium
in American diets and is better under­stood
by consumers than "sodium" (7).
As with the fat and sugar guidelines,
the term "avoid" was deleted to give the
guideline a more positive tone. In 1995,
the title changed again, to place an em­phasis
on the total diet. The term "use"
was removed because it might be mis­understood
by consumers to mean that
only salt added by them in cooking or
at the table is a problem, when in fact,
most of the sodium in American diets
is added as salt during processing (8).
Information was added about the rela­tionship
of nutrients other than sodium
to blood pressure, and a list of good
food sources of potassium was added.
The guideline also refers to the level of
sodium (2,400 mg) listed as the Daily
Value on the Nutrition Facts Label.
If you drink alcoholic beverages, do
so in moderation. In 1985, the title of
the guideline changed slightly. The term
"alcohol" was changed to "alcoholic
beverages" to reflect the correct termi­nology
(6). The title of the guideline has
remained unchanged since that time.
The 1995 edition retains the definition
of moderate drinking, but it appears
earlier in the text than in the previous
edition. The list of those who should
not drink has been reordered so that
children and adolescents appear first.
The text expands the statement in the
1990 guidelines to emphasize the food
use of alcoholic beverages rather than
the social drug use (8).
Brochure Presentation: Design
and Format Changes
The "look" of the Dietary Guidelines
brochure has changed over the years.
The graphic on the front cover of the
first edition included a number for
each of the guidelines (see figure). The
numbers were eliminated in subsequent
editions because they led to misconcep­tions
that certain guidelines were more
important than others. The second and
third editions used an interlocking chain
and the fourth edition uses interlocking
circles on the front cover to convey the
concept that all of the guidelines are
interrelated.
Family Economics and Nutrition Review
The Dietary Guidelines brochure has
always included boxes with practical
"how-to" information, such as tips for
reducing fat and sodium intake (19,20).
The third edition added brief "Advice
for Today" sections (21 ). The fourth
edition added subtitles to improve read­ability
of the brochure (22 ).
USDA's Food Guide made its first
appearance in the third edition of the
Dietary Guidelines. The graphic illustra­tion
of the Food Guide, the Food Guide
Pyramid, appears in the fourth edition.
1996 Vol. 9 No.2
Future of the Dietary Guidelines
The Dietary Guidelines have provided
a consensus as to what makes a healthy
diet. They also form the basis of Federal
nutrition policy affecting food, nutrition
education, and information programs.
They will continue to be reviewed every
5 years and revised as the science base
evolves. However, as the Dietary Guide­lines
are revised in the future, it is likely
that the underlying themes of variety,
proportionality, and moderation
initiated about 100 years ago will
apply to choosing healthful diets for
many years to come.
Since the initial release of the Dietary
Guidelines for Americans in 1980, each
edition has gained in acceptance and use
by both professionals and consumers.
USDA and HHS acknowledge the role
that nutrition educators and health
professionals have played in this greater
acceptance and use and look forward to
their continued support (14).
11
12
References
1. Achterberg, C.L., Getty, V.M., Pugh, M.A., Durrwachter, J.G., and Trenkner, L.L.
1989. Evaluation of "Nutrition and Your Health: Dietary Guidelines for Amerians;"
Part I: A Women's Sample. Prepared for U.S. Department of Agriculture, Human
Nutrition Information Service.
2. Achterberg, C.L., Ozgun, M.P., McCoy, J., and Getty, V.M. 1991. Evaluation of
"Nutrition and Your Health: Dietary Guidelines for Americans;" Part II: A Men's
Sample. Prepared for U.S. Department of Agriculture, Human Nutrition Information
Service.
3. American Red Cross. 1984. Better Eating for Better Health: Instructor's Guide and
Participants' Packet. American National Red Cross, Washington, DC.
4. Atwater, W.O. 1894. Foods: Nutritive Value and Cost. Farmers' Bulletin No. 23.
U.S. Department of Agriculture.
5. Atwater, W.O. 1902. Principles of Nutrition and Nutritive Value of Food. Farmers'
Bulletin No. 142. U.S. Department of Agriculture.
6. Dietary Guidelines Advisory Committee. 1985. Report of the Dietary Guidelines
Advisory Committee on the Dietary Guidelines for Americans. U.S. Department of
Agriculture, Human Nutrition Information Service.
7. Dietary Guidelines Advisory Committee. 1990. Report of the Dietary Guidelines
Advisory Committee on the Dietary Guidelines for Americans. U.S. Department of
Agriculture, Human Nutrition Information Service.
8. Dietary Guidelines Advisory Committee. 1995. Report of the Dietary Guidelines
Advisory Committee on the Dietary Guidelines for Americans, 1995. U.S. Department
of Agriculture, Agricultural Research Service.
9. Hunt, C.L. 1916. Food for Young Children. Farmers' Bulletin No. 717. U.S. Department
of Agriculture.
10. National Academy of Sciences, National Research Council, Food and Nutrition
Board. 1989. Diet and Health: Implications for Reducing Chronic Disease Risk.
National Academy Press, Washington, DC.
11. National Academy of Sciences, National Research Council, Food and Nutrition
Board. 1989. Recommended Dietary Allowances (lOth ed.). National Academy Press,
Washington, DC.
12. Pate, R.R., Pratt, M., Blair, S.N., et al. 1995. Physical activity and public health: A
recommendation from the Centers for Disease Control and Prevention and the American
College of Sports Medicine. Journal of the American Medical Association 273(5):402-
407.
13. Prospect Associates. 1995. Dietary Guidelines Focus Group Report. Unpublished
report prepared for U.S. Department of Agriculture, Center for Nutrition Policy and
Promotion.
Family Economics and Nutrition Review
14. Steele, S.M. 1990. Cooperative Extension's Use of Dietary Guidelines and Your
Diet and Suggestions About Revisions. Unpublished report prepared for U.S. Department
of Agriculture, Human Nutrition Information Service.
15. U.S. Department of Agriculture. 1958. Food for Fitness-A Daily Food Guide.
Leaflet No. 424.
16. U.S. Department of Agriculture, Bureau of Human Nutrition and Home Economics.
1946. National Food Guide. AIS-53, Rev. ofNFC-4.
17. U.S. Department of Agriculture, Human Nutrition Information Service. 1992. The
Food Guide Pyramid. Home and Garden Bulletin No. 252.
18. U.S. Department of Agriculture, Science and Education Administration. 1979. Food.
Home and Garden Bulletin No. 228.
19. U.S. Department of Agriculture and U.S. Department of Health and Hwnan Services.
1980. Nutrition and Your Health: Dietary Guidelines for Americans. U.S. Department
of Agriculture. Home and Garden Bulletin No. 232.
20. U.S. Department of Agriculture and U.S. Department of Health and Human Services.
1985. Nutrition and Your Health: Dietary Guidelines for Americans (2d ed.). U.S.
Department of Agriculture. Home and Garden Bulletin No. 232.
21. U.S. Department of Agriculture and U.S. Department of Health and Hwnan Services.
1990. Nutrition and Your Health: Dietary Guidelines for Americans (3d ed.). U.S.
Department of Agriculture. Home and Garden Bulletin No. 232.
22. U.S. Department of Agriculture and U.S. Department of Health and Hwnan Services.
1995. Nutrition and Your Health: Dietary Guidelines for Americans (4th ed.). U.S.
Department of Agriculture. Home and Garden Bulletin No. 232.
23. U.S. Department of Health, Education, and Welfare, Public Health Service. 1979.
Healthy People: The Surgeon General's Report on Health Promotion and Disease
Prevention. DREW (PHS) Publication No. 79-55071.
24. U.S. Department of Health and Human Services, National Heart, Lung, and Blood
Institute. 1990. National Cholesterol Education Program: Report of the Expert Panel
on Population Strategies for Blood Cholesterol Reduction.
25. U.S. Department of Health and Human Services, Public Health Service. 1988. The
Surgeon General's Report on Nutrition and Health.
26. U.S. House of Representatives Conference Committee, lOOth Cong., 1st sess. 1987.
H.R. 498.
27. U.S. Senate Agricultural Appropriations Committee. 1980. Senate Report No. 96-1030
Nov. 20.
28. U.S. Senate Select Committee on Nutrition and Human Needs. 1977. Dietary Goals
for the United States (2d ed.).
1996 Vol. 9 No.2 13
14
Dietary Guidance and Nutrition
Promotion: USDA's Renewed
Vision of Nutrition Education
Sharyn M. Sutton 1
President
Sutton Social Marketing
William Layden
Director, Nutrition Promotion Staff
Center for Nutrition Policy and Promotion
Jackie Haven
Nutritionist
Center for Nutrition Policy and Promotion
The United States has a proven process for continually developing national
dietary guidance. This guidance, as reflected in the bulletin Nutrition and
Your Health: Dietary Guidelines for Americans, represents the Federal
Government's policy on nutrition. Over the last 15 years, a consensus on
diet and its effect on health has developed among U.S. nutrition and health
experts. This paper addresses the relationship between the expert consensus
on "nutrition, diet, and health" and the consumer. It distinguishes between
dietary guidance and nutrition promotion: nutrition promotion uses the
Consumer-Based Health Communications process to translate the science­based
dietary guidance into consumer-oriented messages that facilitate
behavior change. The implications for USDA's dietary guidance and nutrition
education efforts are discussed.
ITJ he United States has an
established procedure for
updating national dietary
guidance. Title ill of the
National Nutrition Monitoring and
Related Research Act of 1990 (7 U.S.C.
5341) requires the Secretaries of Agri­culture
and Health and Human Services
to publish jointly every 5 years a report
entitled Dietary Guidelines for Americans.
1Formerly Director, Nutrition Marketing and
Education, Center for Nutrition Policy and
Promotion.
An appointed Dietary Guidelines
Advisory Commjttee reviews the most
up-to-date research and makes recom­mendations
to the U.S. Department
of Agriculture (USDA) and the U.S.
Department of Health and Human
Services (DHHS). After the recommen­dations
are approved and accepted by
the Departments, the recommended
Dietary Guidelines and explanatory text
are issued in a bulletin called Nutrition
and Your Health: Dietary Guidelines
Family Economics and Nutrition Review
for Americans (15). The Dietary Guide­lines
for Americans constitutes the basis
of the Federal Government's policy on
nutrition.
Over the last 15 years, a remarkable
degree of consensus on diet and its
effect on health has developed among
U.S. nutrition and health experts. The
fourth edition of the Dietary Guidelines
for Americans (15), released by USDA
and DlffiS in 1995, provides nutritional
and dietary information and guidelines
for the general public, based on current
scientific and medical knowledge (9 ).
Consensus on the relationship between
diet and health is critical to improving
public health since diet has been linked
to many chronic and preventable diseases:
• Four of the leading causes of death
in the United States are nutrition­related
(16). Heart disease, cancer,
stroke, and diabetes account for
more than 1.4 million deaths
annually, nearly two-thirds of
the U.S. total (16).
• Diet also plays a role in other
health conditions such as over­weight,
hypertension, and
osteoporosis, which can reduce
the quality of life and productivity
and contribute to premature death
(16).
Taken together, these seven diet-related
health condtions cost society an esti­mated
$250 billion each year in medical
costs and lost productivity (6). Improved
dietary behavior might prevent at least
20 percent of the annual deaths from
heart disease, cancer, stroke, and diabetes
(6). Even small improvements in average
dietary intakes towards the Dietary
Guidelines for Americans can be valuable
1996 Vol. 9 No.2
If intakes in fat, saturated fat, and
cholesterol improved in the range of
0.1 to 1.4 percent, the Food and Drug
Administration (FDA) estimates
between $4.4 to $26.5 billion would
be saved over 20 years ( 13).
This paper addresses the relationship
between the expert consensus on
"nutrition, diet, and health," as reflected
in the Dietary Guidelines, and the
consumer. It examines how the state of
dietary knowledge is transferred to the
consumer and its effect on consumer
eating behaviors. The implications for
USDA's dietary guidance and nutrition
education efforts are discussed.
Nutrition, Health, and
the Consumer
The Dietary Guidelines for Americans
is supported by a rich history of science­based
research and analysis. The guide­lines
are scientifically sound and have
been remarkably consistent over the
past 20 years.
While we have achieved success in
developing science-based dietary guid­ance,
we have been much less successful
in translating this guidance for consumers
in a way that educates and motivates
changes in behavior leading to im­proved
health status.
There is a serious gap between the
experts' agreement on dietary guidance
and the consumer's understanding of
what constitutes a healthy diet. It is
ironic that while scientific consensus
has never been stronger, the consumers
we seek to serve through this consensus
remain very confused about dietary
advice. Several recent national surveys
highlight current consumer perceptions.
• Almost 50 percent of Americans
say that there is too much conflict­ing
information about what foods
are good for them, and they are
uncertain about what to eat (5 ).
• The Dietary Guidelines for Americans
emphasize the importance of bal­ance,
variety, and moderation in
the total diet-meaning that any
food can fit into a healthful diet.
But 70 percent of consumers think
that they must eliminate favorite
foods to improve their diets ( 1).
The percent of consumers con­cerned
about getting a balanced
diet dropped from 11 percent in
1988 to 2 percent in 1995 (4).
• Dietary guidance is presented in a
manner that is frequently misinter­preted
by consumers in their
attempt to build a healthy diet. For
instance, "consumer unfriendly"
advice on limiting total calories
from fat to 30 percent is often inter­preted
by consumers to mean that
they should not eat individual
foods with more than 30 percent
calories from fat ( 1, 5, 8).
• In addition, old perceptions and
past nutrition advice linger in the
minds of consumers. For example,
whereas today's nutritionists are
urging greater consumption of
breads and grains, 40 percent of
Americans still think that bread
is fattening, and 35 percent say
starches should be avoided (17).
Consumer confusion and frustration
over nutrition does not mean that they
have given up or are incapable of changing
their eating patterns. On the contrary,
there are numerous examples that
reflect the changes in the national
nutrition agenda.
15
The increasing focus on fat in the
American diet over the past decade
is related to significant changes in
consumer awareness, concern, and
consumption. Consumer concern over
fat content in foods has escalated
dramatically. When asked:
"What is it about the nutritional
content of the foods you eat that
concerns you most?"
the number of consumers who responded
"fat content" jumped from 27 percent
in 1988 to 65 percent in 1995 (4). Like­wise,
the mean percent of calories from
fat has declined from 36 percent to
34 percent of total calories, although
these levels are still above dietary
recommendations (7).
The fact is that many consumers do
change their dietary behavior-but the
changes reflect their understanding and
interpretation of dietary advice. The
ability of consumers to improve their
health depends upon how successfully
they can translate the science-based
dietary guidance into appropriate patterns
of eating behaviors that lead to improved
nutritional status. For example, an
attempt to reduce intake of dietary fat
by decreasing consumption of red meat
will be successful only if meat consump­tion
is not replaced by an equally high­fat
substitute (e.g., high-fat salad
dressings) ( 11).
Dietary Guidance and
Nutrition Promotion
Changing diet-related behaviors is
more complicated than once thought.
Although it is possible to improve
people's knowledge and attitudes about
food and nutrition, this does not neces­sarily
result in the needed behavior
change. There is now serious concern
16
whether providing consumers with
dietary guidance is sufficient to support
behavior changes that lead to improved
health.
A recent discussion among nutrition
education leaders from various national
organizations revealed strongly held
beliefs that dietary guidance is not the
best message for consumers, particu­larly
if the goal is behavior change.
"Consumers do not even have to see
the [Dietary] Guidelines" (2). This
contrasts greatly with the traditional
nutrition education efforts surrounding
the Dietary Guidelines. These efforts
centered on the publication of a con­sumer
bulletin, Nutrition and Health:
Dietary Guidelines for Americans, that
outlined seven guidelines and provided
explanatory text. The focus was the
nutrition science-base, not the needs of
the consumer. The nutrition education
leaders conceded that we currently
know more about what a healthy diet
is than about how to get it across to
consumers. These professionals stated
that consumer needs and behavior must
play a central role in driving nutrition
education programs to produce behavior
change (2) .
This consumer perspective is the foun­dation
of USDA's renewed vision for
nutrition education. In May 1995, the
Secretary of Agriculture announced a
new comprehensive nutrition promotion
effort to develop consumer-based
messages. USDA's recommitment to
nutrition as one of six key mission areas
is reflected in the establishment of the
Center for Nutrition Policy and Promotion
(CNPP) (10) "to improve the nutri­tional
status of Americans by serving
as the focal point within USDA for
linking scientific research and the
consumer."
The term "nutrition promotion" is used
to differentiate this new concept from
past definitions of "nutrition education."
Nutrition promotion is defined as
the translation of science-based dietary
guidance into consumer-oriented messages
that facilitate the appropriate eating
behaviors. Nutrition promotion is based
on consumer research. It follows the
Consumer-Based Health Communica­tions
approach, which combines the
science base with the consumer's reality
to create a message strategy that is
meaningful and motivating to the
consumer. The outcome of nutrition
promotion is a consumer-based message
strategy that will lead consumers to
follow science-based dietary guidance
(14).
Consumer Perceptions of
Dietary Guidance
Traditionally, the actual Dietary Guide­lines,
as suggested by the Dietary
Guidelines Advisory Committee and
approved by USDA and DHHS, have
been issued in a bulletin called Nutrition
and Your Health: Dietary Guidelines
for Americans (15).
The Dietary Guidelines Advisory
Committee recognized the difficulty of
having a single dietary guidance bulletin
to address the needs of consumers,
policymakers, and health professionals.
The Committee felt it was important to
investigate consumers' reaction to the
guidelines and their understanding of
nutrition concepts in the Dietary Guide­lines
bulletin as a first step, preceding
the focus on nutrition promotion to
improve dietary behavior ( 3).
Family Economics and Nutrition Review
The Advisory Committee encouraged
USDA and DHHS to continue to con­duct
consumer research to determine
understanding of selected dietary guid­ance
messages proposed for the 1995
Dietary Guidelines for Americans
bulletin (15). The Committee also
urged the Departments to use consumer
research to design more meaningful
messages to consumers.
In response to the Committee's recom­mendation,
CNPP/USDA, in consulta­tion
with DHHS, sponsored focus group
research to gauge consumer reactions to
specific design and content elements of
an early draft of the 1995 bulletin as
published in the Technical Report (3).
The following section describes the
methodology and research objectives
(12).
Focus Groups on Dietary
Guidelines
A series of 12 focus groups was con­ducted
between May 31 and June 8,
1995. To obtain some geographic
dispersion, four groups were conducted
in each of three cities-Richmond, VA;
Chicago, IL; and San Francisco, CA.
Half of the 12 groups were conducted
with women and half with men. A total
of 107 consumers participated. In addi­tion,
four of the groups were conducted
with general consumers representing a
variety of respondents-within broad
age, income, and education restrictions­while
still maintaining enough homo­geneity
so the groups could discuss the
issues in a coherent fashion.
The remaining eight groups were
conducted with four target audiences:
African Americans, older consumers,
overweight consumers, and food stamp
recipients. These target audiences were
selected because of their potentially
1996 Vol. 9 No.2
different perspectives on the Dietary
Guidelines reflecting different health
and diet attitudes, practices, and needs.
During the group discussions, partici­pants
were presented with three versions
of a mocked-up Dietary Guidelines
bulletin. Throughout the sessions,
participants were asked to read and
respond to various sections and formats
of the mock-ups.
Specific research objectives included:
Assessing consumer perceptions and
understanding of selected dietary con­cepts
and key terms such as moderation;
assessing perceived barriers in follow­ing
the Dietary Guidelines; and assess­ing
consumer reaction to the actual
presentation of the consumer bulletin.
As a qualitative research methodology,
focus groups are not projectable to any
population. However, they provide
valuable insight into how the consumer
views the world and what the consumer
thinks-in this case-about nutrition
and eating.
Emerging Consumer Themes
Findings from this focus group research
can be presented under four general
themes with illustrative quotes. All
quotes from individuals participating in
the focus groups are taken from the un­published
report prepared by Prospects
Associates for USDA (12).
1. Distinguish Between Dietary
Guidance AND Nutrition Promotion
The focus group research found strong
support for making the distinction be­tween
dietary guidance and nutrition
promotion. Reactions from the partici­pants
made it very clear that there is a
difference between dietary guidance-
The ability of
consumers to
improve their health
depends upon how
successfully they
can translate the
science-based
dietary guidance
into appropriate
patterns of eating
behaviors that
lead to improved
nutritional status.
17
18
... consistent
consumer-based
messages leading
to behavior change
must be based on
dietary guidance.
what is known about nutrition-and
nutrition promotion-what is needed by
consumers to actually follow the
dietary guidance. Both are critical.
Dietary guidance or nutrition knowledge
does not necessarily give consumers
the information and/or motivation to
change their behavior. Nutrition knowl­edge
does not in itself help consumers
to act. However, it must be acknow­ledged
that consistent consumer-based
messages leading to behavior change
must be based on dietary guidance.
We need both dietary guidance and
nutrition promotion.
"I think it's [the Dietary Guide­lines
brochure} good for a brief
overview ... /' m going to need
something that's going to give me
more about what I want to know."
[African American male]
"It would have no bearing for me.
I wouldn't even know how to begin
controlling it [fat intake]. ... They
need to say that you need to eat
these items that are lower in fat."
[General public-male]
"I just know that there are a lot
of fats, and they are bad."
[General public-male]
2. Effective Nutrition Promotion Must
Communicate Consumer Benefits
The focus group discussions showed
that participants were not motivated by
the health consequences that underpin
the Dietary Guidelines. Consumer bene­fits,
as perceived by the consumer, were
what mattered most. Therefore, we need
to identify and promote benefits for
healthy eating that have meaning in
the mind of the consumer.
"What's in it for me? ... What
would I get out of it?"
[General public-male]
"What's the pay-off for doing
this? That's what I want to know."
[General public-male]
If we don't offer meaningful, motivating
consumer benefits, we will lose our
audience:
"And after a while, you get so
discouraged, you say the heck
with it. I'm just going to eat it
and see what happens."
[General public-female]
3. Translate Dietary Guidelines
Into Consumer Behaviors
Consumers need to have the dietary
guidance translated into consumer
behaviors or actions. Consumers want
directions; they want to know what to
do.
Dietary Guidelines are not consumer
behaviors. Dietary concepts such as fat
reduction and consumption of fruits and
vegetables are not necessarily relevant
to how consumers live their lives. They
do not communicate in terms that defme
consumers' actions.
"Everybody knows you should
eat more vegetables and fruits.
It's in the media. We know that.
But it's about doing it. Helpful
hints about how you can do it."
[Food Stamp--female]
"Show us what 300 mg [of choles­terol]
looks like. Is it half an egg?
Is that a full egg? Is that one and
one-half eggs? Because when you
see 300 mg, you think, what's 300 mg?"
[General public-male]
Family Economics and Nutrition Review
"To be perfectly honest, I have
never considered how many
calories I eat in a day. 2,000 is
just as arbitrary as saying 5,000.
/' m going to eat what I want
to eat."
[General public- male]
"They keep throwing [the advice]
to eat vegetables at you-vegetables
as a group. But a lot of people don't
know things like avocados are
very fattening. There are different
vegetables that people should
watch out for-instead of just
having vegetables in general."
[Food Stamp-male]
"Just don't tell me not to do
something. What is [the fat]?
Where do I find it? "
[Overweight group-male]
Nutrition concepts and desired nutrition
outcomes (e.g., reduce fat, increase con­sumption
of grains, watch total calories)
are not consumer behaviors. Consumers
don't reduce fat content; they remove
the skin on their chicken. They don't
choose a diet with plenty of grain products;
they eat spaghetti. We need to translate
the Dietary Guidelines into actual
consumer steps-much more in line,
for example, with the 5 A Day program
where "eat more fruits and vegetables"
becomes "keep fruits visible" or "micro­wave
your carrots in 2 minutes."
It is clear that if the public is to follow
the Dietary Guidelines, the Dietary
Guidelines will need to be translated
into consumer-based message strategies
and specific behaviors that consumers
can carry out. They do not want to do
the math.
1996 Vol. 9 No.2
4. Express Consumer Behavior
in Consumer Talk
The last general theme that emerged
from the focus groups was the need to
speak in a language that consumers
understand. Consumers want specifics­clear,
easy, meaningful information­on
what they should do. They do not
have the time, energy, or background
to move from nutrition science and
recommendations to a healthy diet.
"I want a sample dietary plan.
Show me the foods [I} should
eat and how much fat or grams
of fat each food has, so I can
visualize [it and] follow this
type of diet."
[General public-male]
"I think that people are eating
them (fruits and vegetables); it's
just that they're not eating them
properly. It doesn't say don't cook
this way. Or they don't give you
suggestions of different ways of
preparing them."
[Food Stamp group-female]
"They're talking about saturated
and unsaturated fats, and mono­unsaturated
and polyunsaturated.
And what are they? What are these
things they are telling me about?"
[Overweight group-male]
Information that is matter of fact to
nutritionists may not be credible or
understandable to the consumer. For
example, nutritionists know that it is the
total diet that counts, not an individual
food. But how does that message play
with the consumer? Is it perceived as
meaningful? Believable? Achievable?
These questions must be answered in
order to craft a "total diet message."
"Like I said before, I believe that
if you're going to put out advice
you should have do's and don'ts and
not "political correctness"
so that everything is positive."
[Older Americans group-male]
"My thing is that I don't count
calories. I know that I eat food
that's lower in fat. I used to make
the mistake of counting calories
and it didn't work because that
meant I ate all the macaroni and
cheese that I wanted and stuff
like that. I still maintained or
gained weight."
[African American-female]
It must also be recognized that consumers
are not all alike. Messages must be
tailored to varying informational and
motivational needs. One bulletin or
brochure will never do the entire job.
This is shown by these two consumer
comments to the same brochure:
"I knew that from before, but
it's pretty clear in here."
[African American-male]
"Well, [this is clear] if you
know Greek."
[Overweight group-female]
19
20
Knowledge of what
consumers believe,
value, need, and
do is as important
as our knowledge
of basic human
nutrition.
Implications for
Nutrition Promotion
The insight gained from the focus groups
reinforced the Dietary Guidelines
Advisory Committee's recommendation
for a two-pronged approach. USDA's
renewed vision for nutrition education
must meet two significant challenges:
• Continue to advance national
dietary guidance based upon the
preponderance of scientific
evidence, and
• Promote this guidance to consumers
in a way that will lead to behavior
change and ultimately improved
health and well-being.
Moving from traditional issuance of
dietary guidance to consumer-based
nutrition promotion will require the
following:
• A focus on behavior change.
The ultimate purpose of dietary
guidance and promotion is to
improve dietary behavior. Behavior
change cannot occur unless it is
purposefully targeted for change.
If changes in knowledge and
attitude are the end points, then
improvements will not be achieved.
• A strong consumer orientation.
Understanding and emphasizing
the nutrition behavior from the con­sumer's
point of view is essential.
Knowledge of what consumers
believe, value, need, and do is as
important as our knowledge of
basic human nutrition. Speaking
in a language that the consumer
understands, in a way that is lively,
appealing, and entertaining, is just
as critical as communicating the
nutritional facts.
• Segment and target consumers.
There must be recognition that one
message will not meet the needs of
the entire public. We must have a
clear and vivid picture of who the
target is and focus the message in
a personal and meaningful way on
precise audience segments to create
the most impact.
• Use multiple, reinforcing,
interactive channels that actually
reach consumers. Various, inte­grated,
new technologies exist
today that can reach the target
audience to deliver the message
through multiple and reinforcing
media. Again, these channels must
be selected from the consumer's
viewpoint: Where will they be open
to the message? When will they be
thinking about nutrition? Based on
a thorough understanding of the
audience-TV advertising, radio
advertising, cable programming,
talk shows, newspaper editorials,
lifestyle sections, food columns,
consumer magazines, direct
promotions, point of purchase
programs, promotions, interpersonal/
intermediary partnerships-all can
be useful to deliver and reinforce
the message.
• Continually refine the consumer
messages. What works today may
be ineffective tomorrow because of
the changes in our consumers, the
marketplace, the competition, and
the consumer benefits.
Family Economics and Nutrition Review
References
I. The American Dietetic Association and International Food Information Council. 1994. How
Are Americans Making Food Choices?-1994 Update. Prepared by The Gallup Organization.
2. Balch, G.l. 1995. Expert Advice on the Direction of Nutrition Education and Promotion.
Final Report to the Center for Nutrition Policy and Promotion. Unpublished.
3. Dietary Guidelines Advisory Committee. 1995. Report of the Dietary Guidelines Advisory
Committee on the Dietary Guidelines for Americans, 1995, to the Secretary of Health and
Human Services and the Secretary of Agriculture. U.S. Department of Agriculture, Agricultural
Research Service.
4. Food Marketing Institute. 1995. Trends in the United States, Consumer Attitudes and the
Supermarket, 1995. Conducted by Opinion Research Corporation.
5. Food Marketing Institute and Prevention Magazine. 1995. Shopping for Health 1995. New
Food Labels, Same Eating Habits?
6. Frazao, E. 1995. The American Diet: Health and Economic Consequences. U.S. Department of
Agriculture, Agriculture Information Bulletin No. 711.
7. McDowell, M.A., Briefel, R.R., Alaimo, K., Bischof, A.M., Caughman, C.R., Carroll,
M.D., Loria, C.M., and Johnson, C.L. 1994. Energy and macronutrient intakes of persons
ages 2 months and over in the United States: Third National Health and Nutrition Examination
Survey, Phase 1, 1988-91. Advance Data No. 255. National Center for Health Statistics.
8. National Live Stock and Meat Board and MRCA Information Services, Inc. 1994. Eating
in America Today: A Dietary Pattern and Intake Report. Edition II.
9. The National Nutrition and Related Research Act. 1990. 7 U.S.C. 5341.
10. 1995 Farm Bill: Guidance of the Administration. Section 5: Food and Nutrition, pp. 67-73, 1995.
11. Popkin, B.M., Haines, P.S., and Reidy, K.C. 1989. Food consumption trends of U.S. women:
Patterns and determinants between 1977 and 1985. American Journal of Clinical Nutrition
49:1307-1319.
12. Prospects Associates. 1995. Dietary Guidelines Focus Group Report. Unpublished report
prepared for the U.S. Department of Agriculture, Center for Nutrition Policy and Promotion.
13. Research Triangle Institute. 1991. Estimating the Benefits of Nutrition Label Changes.
14. Sutton, S.M., Balch, G.l., and Lefebvre, C. 1995. Strategic questions for consumer-based
health communications. Public Health Reports 110(6):725-733.
15. U.S. Department of Agriculture and U.S. Department of Health and Human Services. 1995.
Nutrition and Your Health: Dietary Guidelines for Americans. 4th ed. Home and Garden Bulletin
No. 232.
16. U.S. Department of Health and Human Services. 1990. Healthy People 2000, National
Health Promotion and Disease Prevention Objectives. DHHS Publication No. (PHS) 91-50212.
17. Wheats Food Council and American Bakers Association. 1995. What America Thinks
About Eating Right. A Gallup opinion survey.
1996 Vol. 9 No.2 21
22
Healthy People 2000 Midcourse
Review and 1995 Revisions
Summarized by Joanne F. Guthrie
Nutritionist
Center for Nutrition Policy and Promotion
hen the Dietary Guidelines
for Americans was first
published in 1980 as a state­ment
of Federal nutrition
policy and a summary of the best knowl­edge
of how diet can promote health,
the Federal Government was also
considering new ways of directing
and monitoring its health promotion
and disease prevention activities in
order to increase their effectiveness.
In Promoting Health/Preventing
Disease: Objectives for the Nation,
published in 1980, the U.S. Department
of Health and Human Services adopted
a management-by-objectives planning
process borrowed from the business
world: to set measurable objectives for
improvements in health status and risk
reduction for Americans. These objectives
were broad in scope, encompassing
such areas as nutrition, substance abuse,
cardiovascular risk factor reduction, and
many others. Several of the nutrition
objectives were consistent with the
recommendations or goals of the Dietary
Guidelines for Americans. Measurable
levels of improvement (target outcomes)
in each area were established for
achievement in 1990.
In 1990, Healthy People 2000: National
Health Promotion and Disease Prevention
Objectives was published. The Year
2000 objectives built upon those estab­lished
in 1980, with some modification
and expansion. For example, such
health problems as lllV infection and
cancer were added as priority areas.
As in 1990, a key aspect of the project
was the development of measurable
objectives for monitoring improvement.
Again, the nutrition objectives frequently
paralleled the Dietary Guidelines for
Americans. For example, Year 2000
nutrition objectives include decreased
consumption of total fat, saturated fat,
and sodium; increased consumption of
fruits, vegetables, and grains; and reduc­tion
in the prevalence of overweight,
all recommendations of the Dietary
Guidelines for Americans.
The Healthy People 2000 Midcourse
Review and 1995 Revisions provides a
mid-decade report on progress on these
objectives. The rnidcourse review also
prompted development of new objectives
in response to changes in health knowl­edge
and health concerns. The box on
pp. 24-25 presents nutrition objectives
for the year 2000 plus six objectives
from other priority areas that have been
added to the Nutrition priority area in
1995.
The findings presented here are a summary
of those reported in the Healthy People
2000 Midcourse Review and 1995
Revisions. The data reported are taken
from the review itself, although the
original data used to evaluate progress
Family Economics and Nutrition Review
toward objectives were obtained from
a wide range of public and private
sources and compiled for the review.
Three overarching goals have been
established for the Healthy People 2000
initiative. These are to: (1) increase the
span of healthy life for Americans, (2)
reduce health disparities among
Americans, and (3) achieve access to
preventive services for all Americans.
Priority areas for health improvements
that would lead to the achievement of
these goals have also been established.
There are 22 priority areas, which fall
into three broad categories-health ·
promotion, health protection, and
preventive health services.
Within each priority area, objectives
have been set for improvement. The
objectives are designed to achieve three
major types of outcomes--changes in
health status, changes in risk reduction
factors, and changes in health care
service and protection. Health status
objectives assess progress toward
reduction of death, disease, and disability
and enhancement of functional status,
including physical, mental, and social
functioning. Risk reduction objectives
target the reduction of physical, environ­mental,
social, or behavioral risks to
health (e.g., cigarette smoking, use of
safety belts). Services and protection
objectives are aimed at increasing the
comprehensiveness, accessibility, and/
or quality of preventive services and
protective interventions (e.g., blood
pressure and cholesterol screening,
testing for lead-based paint in older
homes).
1996 Vol. 9 No.2
For each objective, baseline data have
been obtained whenever possible and
measurable target figures established
for accomplishment of the objective.
In addition to objectives that address
the total population, more than 200
objectives or subobjectives address
needs of special population groups.
In all, there are more than 500 specific
objectives and subobjectives for which
targets have been established.
Summary of Progress
Halfway to the year 2000, a review of
the available data indicates that progress
is being made in accomplishing many
but not all of the Healthy People 2000
goals and objectives. Since 1990, average
life expectancy has increased by about
three-quarters of a year, reaching a new
high of almost 76 years. The infant
mortality rate declined to a new low of
8.5 per 1,000 live births in 1992. How­ever,
international data indicate that
there is still room for improvement:
compared with other industrialized
nations, the United States ranks 24th
in infant mortality rates.
Progress toward meeting established
targets has been made on about 50
percent of the objectives. For 18 percent,
however, the situation has worsened,
with available data indicating movement
further away from the target; 3 percent
show no change from the baseline; and
for the remaining 29 percent, evaluation
data are not yet available.
To provide a broad perspective on the
overall progress of the initiative, 47
"sentinel" objectives were selected
for particular examination (see table,
pp. 26-27). There are sentinel objectives
for each of the 22 priority areas, allowing
assessment of progress in each area.
Progress ... has been
made on about
50 percent of the
objectives. For
18 percent. .. the
situation has
worsened ... 3 percent
show no change ...
and for the remaining
29 percent, evaluation
data are not yet
available.
23
Nutrition Objectives
Health Status
• Reduce coronary heart disease deaths to no more than 100 per 100,000 people.
• Reverse the rise in cancer deaths to achieve a rate of no more than 130 per 100,000 people.
• Reduce overweight to a prevalence of no more than 20 percent among people aged 20 and older and no more than 15
percent among adolescents aged 12-19.
• Reduce growth retardation among low-income children aged 5 and younger to less than 10 percent.
Risk Reduction
• Reduce dietary fat intake to an average of 30 percent of calories or less and average saturated fat intake to less than
10 percent of calories among people aged 2 and older. In addition, increase to at least 50 percent the proportion of
people aged 2 and older who meet the Dietary Guidelines' average daily goal of no more than 30 percent of calories
from fat, and increase to at least 50 percent the proportion of people aged 2 and older who meet the average daily goal
of less than 10 percent of calories from saturated fat.
• Increase complex carbohydrate and fiber-containing foods in the diets of people aged 2 and older to an average of 5 or
more daily servings for vegetables (including legumes) and fruits, and to an average of 6 or more daily servings for
grain products. In addition, increase to at least 50 percent the proportion of people aged 2 and older who meet the
Dietary Guidelines' average daily goal of 5 or more servings of vegetables/fruits, and increase to at least 50 percent
the proportion who meet the goal of 6 or more servings of grain products.
• Increase to at least 50 percent the proportion of overweight people aged 12 and older who have adopted sound dietary
practices combined with regular physical activity to attain an appropriate body weight.
• Increase calcium intake so at least 50 percent of people aged 11-24 and 50 percent of pregnant and lactating women
consume an average of 3 or more daily servings of foods rich in calcium, and at least 75 percent of children aged 2-10
and 50 percent of people aged 25 and older consume an average of 2 or more servings daily.
• Decrease salt and sodium intake so at least 65 percent of home meal preparers prepare foods without adding salt, at least
80 percent of people avoid using salt at the table, and at least 40 percent of adults regularly purchase foods modified or
lower in sodium.
• Reduce iron deficiency to less than 3 percent among children aged 1-4 and among women of childbearing age.
• Increase to at least 75 percent the proportion of mothers who breastfeed their babies in the early postpartum period and
to at least 50 percent the proportion who continue breastfeeding until their babies are 5-6 months old.
• Increase to at least 75 percent the proportion of parents and caregivers who use feeding practices that prevent baby bottle
tooth decay.
• Increase to at least 85 percent the proportion of people aged 18 and older who use food labels to make nutritious food selections.
24 Family Economics and Nutrition Review
Services and Protection
• Achieve useful and informative nutrition labeling for virtually all processed foods and at least 40 percent of ready-to-eat
carry-away foods. Achieve compliance by at least 90 percent of retailers with the voluntary labeling of fresh meats,
poultry, seafood, fruits, and vegetables.
• Increase to at least 5,000 brand items the availability of processed food products that are reduced in fat and saturated fat.
• Increase to at least 90 percent the proportion of restaurants and institutional food service operations that offer identifiable
low-fat, low-calorie food choices, consistent with the Dietary Guidelines for Americans.
• Increase to at least 90 percent the proportion of school lunch and breakfast services and child care food services with
menus that are consistent with the nutrition principles in the Dietary Guidelines for Americans.
• Increase to at least 80 percent the receipt of home food services by people aged 65 and older who have difficulty in
preparing their own meals or are otherwise in need of home-delivered meals.
• Increase to at least 7 5 percent the proportion of the Nation's schools that provide nutrition education from preschool to
12th grade, preferably as part of comprehensive school health education.
• Increase to at least 50 percent the proportion of worksites with 50 or more employees that offer nutrition education and/or
weight management programs for employees.
• Increase to at least 7 5 percent the proportion of primary care providers who provide nutrition assessment and counseling
and/or referral to qualified nutritionists or dietitians.
In 1995, six objectives from other priority areas have been added to the Nutrition priority area, recognizing
that diet can contribute to the prevention of these diseases.
Health Status
• Reduce stroke deaths to no more than 20 per 100,000 people.
• Reduce colorectal cancer deaths to no more than 13.2 per 100,000 people.
• Reduce diabetes to an incidence of no more than 2.5 per 1,000 people and a prevalence of 25 per 1,000 people.
Risk Reduction
• Reduce the prevalence of blood cholesterol levels of 240 mg/dL or greater to no more than 20 percent among adults.
• Increase to at least 50 percent the proportion of people with high blood pressure whose blood pressure is under control.
• Reduce the mean serum cholesterol level among adults to no more than 200 mg/dL.
1996 Vol. 9 No.2 25
Healthy People 2000: Progress on 47 sentinel objectives
Year
2000 Right Wrong No No
Objective Baseline a Updateg targets direction direction change data
Health promotion
1. Physical activity
- more people exercising regularly 22%c 24o/d 30% X
- fewer people never exercising 24%c 24%j 15% X
2. Nutrition
- fewer people overweight 26%b 34%h 20% X
- lower fat diets 36%b 34%h 30% X
3. Tobacco
- fewer people smoking cigarettes 29% 25% 15% X
- fewer youth beginning to smoke 30% 27% 15% X
4. Alcohol and other drugs
- fewer alcohol-related automobile
deaths (per 100,000) 9.8 6.8 8.5 X
- less alcohol use among youth age 12-17 years 25.2%e 18.0% 12.6% X
- less marijuana use among youth age 12-17 years 6.4%e 4.9% 3.2% X
s. Family planning
- fewer teen pregnancies (per 1 ,000) 71.1 c,r 74.3i,r so.or X
- fewer unintended pregnancies 56%e NA 30% X
6. Mental health and mental disorders
- fewer suicides (per 100,000) 11.7 11.2 10.5 X
- fewer people reporting stress-related problems 44.2%c 39.2% 35% X
7. Violent and abusive behavior
- fewer homicides (per 100,000) 8.5 10.3k 7.2 X
- fewer assault injuries (per 100,000) 9.7d 9.9k 8.7 X
8. Educational and community-based programs
- more schools with comprehensive school
health education NA NA 75% X
- more workplaces with health promotion programs 65%c 81%k 85% X
Health protection
9. Unintentional injuries
- fewer unintentional injury deaths (per 100,000) 34.7 29.6 29.3 X
- more people using automobile safety restraints 42%e 67%1 85% X
10.0ccupational safety and health
- fewer work-related deaths (per 100,000) 6m 5 4 X
- fewer work-related injuries (per 100,000) 7.7m 7.9 6.0 X
ll.Environmental health
- no children with blood lead 25 j.!g/dl 234,000° 93,000h 0 X
- more people with clear air in their communities 49.7%e 76.5% 85% X
- more people in radon-tested houses 5o// 11.4% 40% X
12.Food and drug safety
- fewer salmonella outbreaks nt 63 25 X
13. Oral health
- fewer children with dental caries 54% 52% 35% X
- fewer older people without teeth 36%d 30% 20% X
26 Family Economics and Nutrition Review
Healthy People 2000: Progress on 47 sentinel objectives
Year
2000 Right Wrong No No
Objective Baseline a Update& targets direction direction change data
Preventive services
14.Maternal and infant health
- fewer newborns with low weight 6.9% 7.1%k 5% X
- more mothers with first trimester care 76.0% 77.7%k 90% X
15.Heart disease and stroke
- fewer coronary heart disease deaths
(per 100,000) 135 114k 100 X
- fewer stroke deaths (per 100,000) 30.4 26.4 20.0 X
- better control of high blood pressure 11%b 21%h 50% X
- lower cholesterol levels 213 mg/dlb 205 mg/dlh 200mg% X
16.Cancer
- decrease cancer deaths (per 100,000) 134 133 130 X
- increase screening for breast cancer (age> 50) 25% 55% 60% X
- increase screening for cervical cancer (age>18) 88% 95% 95% X
- increase fecal occult blood testing (age> 50) 27% 30o/} 50% X
17.Diabetes and chronic disabling conditions
- fewer people disabled by chronic conditions 9.4% 10.6% 8% X
- fewer diabetes-related deaths (per 100,000) 38d 38k 34 X
18. HIV infection
- slower increase in HIV infection (per I 00,000) 400f NA 400 X
19.Sexually transmitted diseases
- fewer gonorrhea infections (per 100,000) 300f 172 225 X
- fewer syphilis infections (per 100,000) 18.lf 10.4 10.0 X
20.Immunization and infectious diseases
- no measles cases 3058e,q 312q 0 X
- fewer pneumonia and influenza deaths (per 100,000) 19.9° 23.JP 7.3 X
- higher immunization levels (age 19-35 months) 54-64% 67% 90% X
2l.Clinical preventive services
- financial barriers to recommended preventive
services 16%f 17% 0 X
Surveillance and data systems
22.Surveillance and data systems
- common and comparable health status
indicators in use across States 0 States 48 States 40 States X
Total 33 9 2 3
a 1987 unless otherwise noted f 1989 k 1992 P 1987-88 through 1989-90 influenza seasons
b 1976-80 g 1993 unless otherwise noted I 1994 q Data are expressed as measles cases
c 1985 h 1989-91 m 1983-1987 r Rate per 1,000
d 1986 i 1990 n 1984
e 1988 j 1991 0 1979-80 through 1986-87 influenza seasons
NA = not available
1996 Vol. 9 No.2
27
28
... the prevalence of
overweight among
adults 20-74 years
of age has increased
from 26 percent in
1976-80 to 34 percent
in 1988-91. Over the
same period, the
prevalence of
overweight among
adolescents
increased from
15 to 21 percent.
Physical Activity and Fitness. Progress
on physical activity and fitness objectives
appears to be mixed. Objectives moni­toring
prevalence of regular moderate
and vigorous physical activity among
adults have shown a slight increase.
However, there has been no change in
the percentage of adults who state that
they never exercise. Unfortunately, little
information is available on the physical
activity levels of children. Two objectives
for which there are data, the percentage
of students in grades 9 to 12 engaged in
daily school physical education and the
proportion of time that students spend
being physically active, show declines,
however.
Nutrition. Data indicate that the preva­lence
of overweight among adults 20-74
years of age has increased from 26 per­cent
in 1976-80 to 34 percent in 1988-91.
Over the same period, the prevalence of
overweight among adolescents increased
from 15 to 21 percent. This substantial
movement away from the Year 2000
target indicates that action is needed
both to improve diets and to promote
physical activity.
The average intake of dietary fat has
declined from 36 percent of calories
in 1976-80 to 34 percent in 1988-91.
Numerous changes have taken place
that may promote further dietary
improvement. Since implementation of
the Nutrition Labeling and Education
Act in 1994, more understandable and
useful food labels appear on most pack­aged
foods. More lowfat foods are now
available to consumers, a Healthy People
objective for which the original target
has now been surpassed. An increasing
number of worksites now offer nutrition
education, weight management, and/or
physical fitness programs for employees.
Tobacco. Progress continues to be made
in reducing cigarette smoking. The
prevalence of cigarette smoking among
the general adult population dropped
to 25 percent in 1993. It continues to
be considerably higher among some
special population groups, including
American Indians/Alaska Natives, blue­collar
workers, and military personnel,
however, indicating that special attention
needs to be paid to these groups. The
prevalence of smoking among adults
20-24 years of age, a proxy measure
of youth initiation to smoking, dropped
from 30 percent in 1987 to 27 percent in
1993. One objective in which there was
movement in a negative direction was the
percentage of female cigarette smokers
who quit during pregnancy. Compared
with 39 percent who quit in 1985, only
31 percent quit in 1991.
Alcohol and Other Drugs. One of the
most dramatic areas of improvement is
the reduction of alcohol-related automo­bile
deaths. The reduction by 1993 to
6.8 deaths per 100,000 people exceeded
the Year 2000 target of 8.5 deaths per
100,000. Major factors in achieving
this success have been the passage and
enforcement of stricter laws regulating
alcohol-related driving issues by many
States.
In general, alcohol use appears to be on
the decline. Annual per capita alcohol
consumption in the United States dropped
from 2.54 gallons in 1987 to 2.31 gallons
in 1991. Alcohol and marijuana use
declined by 29 and 23 percent respec­tively
between 1988 and 1993 among
adolescents ages 12-17 years, based on
data from the National Household
Survey of Drug Abuse.
Family Economics and Nutrition Review
Family Planning. No recent data are
available on the reduction of unintended
pregnancies in the general female popu­lation.
Among adolescents, a high-risk
group identified for special attention,
the movement appears to be away from
Year 2000 targets. Despite prevention
efforts such as sex education, abstinence
education, life skills education, and
contraceptive services programs, adoles­cent
pregnancies continue to increase,
rising from 71.1 per 1,000 females in
1985 to 74.3 per 1,000 in 1990. Sexual
activity among young teens also continues
to increase. Among 15-year-old females,
36 percent reported being sexually \!Ctive
in 1991 compared with 27 percent in
1988, based on data from the Youth
Risk Behavior Surveillance System.
Mental Health and Mental Disorders.
Suicide rates have declined from 11.7
per 100,000 people in 1987 to 11.2 per
100,000 in 1993. One contributing
factor may be the increase in persons
seeking treatment for depression (one
of the strongest risk factors for suicide)
and other mental problems. More
employers are offering worksite programs
to reduce employees' stress. The per­centage
of adults who report experiencing
adverse health effects from stress has
declined from 44.2 percent in 1985 to
39.2 percent in 1993.
Violent and Abusive Behavior. The
United States ranks first among industri­alized
nations in violent death rates, and
unfortunately, recent data indicate that
the trend to increasing mortality and
morbidity resulting from violent behavior
is continuing. Deaths from homicide
have increased from 8.5 persons per
100,000 in 1987 to 10.3 per 100,000 in
1992. The Centers for Disease Control
have predicted that if current mortality
trends continue, the death rate from
firearms will surpass that from motor
1996 Vol. 9 No.2
vehicle crashes in the United States
by the year 2003. Injuries from assault
have also increased from 9.7 persons
per 100,000 in 1986 to 9.9 per 100,000
in 1992.
Educational and Community-Based
Programs. A major area of success
has been the rise in workplaces offering
health promotion programs on such topics
as physical fitness, stress management,
and nutrition and weight management.
The proportion of workplaces offering
programs has risen from 65 percent in
1985 to 81 percent in 1992, almost
reaching the Year 2000 target of 85 per­cent.
For schools, another potential site
for health promotion, there are currently
no data on the number offering compre­hensive
health education.
Unintentional Injuries. Deaths from
unintentional injuries have dropped
from 34.7 per 100,000 in 1987 to 29.6
per 100,000 in 1993, approaching the
Year 2000 target. One major factor in
this decline has been the decrease in
motor vehicle traffic fatalities, which
may, in tum, be partly attributable to
increased use of automobile safety
restraints. Currently, two-thirds of
Americans use automobile safety
restraints, and one State, Hawaii, has
met the Year 2000 target of 85 percent
of individuals using safety restraints.
Occupational Safety and Health.
While work-related injury deaths have
been reduced to 5 per 100,000 workers
in 1993, nonfatal injuries at work have
increased slight! y. In particular, repeti­tive
trauma injuries, such as carpal
tunnelsyndrome,haveincreased. This
increase may reflect the changing nature
of the workplace-a rise in automation­as
well as heightened awareness and
improved reporting.
Environmental Health. One of the
most important improvements in envi­ronmental
health has been the reduction
in the number of children with elevated
blood lead levels from 234,000 in 1984
to 93,000 in 1989. Factors contributing
to this improvement include increased
use of unleaded gasoline, virtual elimi­nation
of U.S. manufactured food and
drink cans containing lead solder, a ban
on leaded paint and lead-containing
solder for residential use, and the imple­mentation
of lead poisoning prevention
programs by several States and cities.
Implementation of the Clean Air Act of
1990 has helped increase the proportion
of people living in counties that meet
EPA standards for air pollution from
49.7 percent in 1988 to 76.5 percent in
1993. Some progress has been made on
reducing exposure to radon, with the
percentage of people whose homes have
been tested for radon increasing from
less than 5 percent in 1989 to 11.4
percent in 1993.
Food and Drug Safety. Progress has
been made in reducing Salmonella
outbreaks from 77 during 1989 to 63
in 1993. National data for tracking
infections caused by E. coli 0157:H7,
the bacteria responsible for a multi-State
outbreak of food poisoning in 1993, are
not currently available. The 1992-93
Food and Drug Administration Food
Safety Survey found improvements in
household practices such as promptly
refrigerating perishable foods.
Oral Health. The oral health of Americans
continues to improve. The percentage
of children with dental caries declined
from 54 percent in 1987 to 52 percent
in 1993. The proportion of people 65
years and over with complete tooth loss
declined from 36 percent in 1986 to 30
percent in 1993.
29
Maternal and Infant Health. Although
infant mortality rates have improved,
the prevalence of low birthweight has
increased, with 7.1 percent of babies
born weighing less than 5.5 pounds in
1992. The number of babies born with
Fetal Alcohol Syndrome has also in­creased,
from 0.22 per 1,000 live births
in 1987 to 0.67 per 1,000 in 1993,
although this may be at least partly a
function of changes in reporting.
More mothers are receiving prenatal
care in the first trimester, although Black,
ative American, and Hispanic mothers
are less likely than other mothers to receive
care in the fust trimester. The percent
of mothers breastfeeding has increased-
56 percent in 1993, compared with 54
percent in 1988.
Heart Disease and Stroke. Over the
past 25 years, death rates from coronary
heart disease and stroke have declined
by 49 percent and 58 percent, respectively,
and current data indicate that the decline
in mortality is continuing. Improvements
in control of cardiovascular risk factors
have accompanied this decline. Blood
cholesterol levels have dropped and
control of high blood pressure has
improved. These changes seem to be
attributable, at least partly, to dietary
and lifestyle change, as well as earlier
screening, detection, and treatment.
Cancer. Cancer deaths have declined
slightly from 134 per 100,000 people in
1987 to 133 per 100,000 in 1993. One
major area of improvement has been
increased screening for detection of such
common types of cancer as breast cancer,
cervical cancer, and colon cancer (fecal
occult blood testing).
30
Diabetes and Chronic Disabling
Conditions. The proportion of people
disabled by such chronic conditions as
back problems, asthma, and hearing or
visual impairment has increased from
9.4 percent in 1987 to 10.6 percent in
1993. There has been no change in the
prevalence of diabetes-related deaths or
of most diabetes-related complications,
although there has been a reduction in
lower extremity amputations among
people with diabetes.
HIV Infection. Data are not currently
available to evaluate progress on the
Year 2000 target of slowing the increase
in HIV infection. In general, the nature
of the HIV disease-with its relatively
long incubation period between infection
and symptoms--creates problems for
tracking the progress of AIDS preven­tion
efforts: most of the people who will
be diagnosed as having AIDS between
now and the year 2000 already have been
infected. Some prevention-oriented
objectives show progress, including
increased condom use by sexually
active unmarried people, the increased
percentage of injecting drug users in
drug abuse treatment or using uncon­taminated
drug paraphernalia, and the
increased safety of blood supply.
Sexually Transmitted Diseases. Rates
of nearly all sexually transmitted diseases
are declining. Both gonorrhea and syphilis
are declining in prevalence, with syphilis
rates almost meeting the Year 2000
target. The rate of decline, however,
is not as great among minorities.
Immunization and Infectious Diseases.
The number of reported measles cases
declined from 3,058 in 1988 to 312 in
1993. The prevalence of numerous other
infectious diseases, including mumps,
rubella, diphtheria, and poliomyelitis,
has declined, and the proportion of
young children who have received age­appropriate
immunizations has increased.
The introduction of a new vaccine
reduced the incidence of Haernophilus
influenza meningitis by 95 percent.
Deaths from pneumonia and influenza
among adults 65 years and over have
increased from 19.9 per 100,000 people
in 1979-87 to 23.1 per 100,000 in 1987-
90, despite increased immunization
levels for these illnesses among older
adults. Another area of concern is the
rise in the prevalence of tuberculosis,
especially among minorities, as well as the
decline in the proportion of tuberculosis
patients who complete therapy to pre­vent
further spread of the disease.
Clinical Preventive Services. This
area encompasses such services as
immunizations, screening tests for
early detection of disease, and patient
education and counseling. In addition
to being clinically effective and having
a positive impact on quality of life,
preventive services have a strong prob­ability
of being cost-effective. There­fore,
the increase in the percentage of
people under 65 years old without
health care coverage-from 16 percent
in 1989 to 17 percent in 1993-is a
concern.
Surveillance and Data Systems. One
problem in assessing the health status
of Americans and progress toward
improvement has been shortcomings
in available data and the lack of compa­rable
data across States. In 1991, CDC/
NCHS released a consensus set of 18
health status indicators. Forty-eight
States were using the indicators in 1993,
thus allowing comparability of informa­tion
across States.
Family Economics and Nutrition Review
New Objectives
As a part of the midcourse review
process, new objectives that reflect
scientific developments, changes in
health concerns, or new strategies for
health promotion have been added to
the existing Healthy People 2000
objectives. Some of these changes
reflect advances in knowledge that
make it possible to prevent or control
health problems that previously were
less amenable to treatment.
Several major studies published since
1990 have demonstrated that adequate
intake of folic acid by women of child­bearing
age was associated with reduced
risk of giving birth to a child with neural
tube defects (e.g., spina bifida or
anencephaly). Therefore, the Public
Health Service published a recommen­dation
in 1992 that all women capable
of becoming pregnant consume 400
micrograms of folic acid daily. Because
of this new information on how neural
tube defects may be reduced, a new
Maternal and Infant Health objective to
reduce the incidence of spina bifida and
other neural tube defects has been
added.
Two new objectives reflecting new
scientific knowledge have been added
to the Diabetes and Chronic Disabling
Conditions priority area. With the identi­fication
of the bacterium Helicobacter
pylori as a cause of recurrent and chronic
peptic ulcer disease, effective therapies
have been developed to eradicate the
bacteria and prevent the recurrence of
peptic ulcer disease. Consequently, a
new objective to reduce the prevalence
of peptic ulcer disease by preventing its
recurrence has been added. Other recent
studies indicate that about 90 percent of
1996 Vol. 9 No.2
diabetes-caused blindness could have
been avoided through improved detection
and treatment. Therefore, a new objective
to increase the number of people with
diabetes receiving annual eye exams
that would detect treatable retinopathy
has been added.
The growth of homicide as a leading
cause of fatal injury to workers has
prompted the addition of an objective
to reduce deaths from work-related
homicides to the Occupational Safety
and Health Priority Area. In the area
of Violent and Abusive Behavior, an
objective calling for all States to enact
laws requiring proper storage of firearms
has been added.
Several new objectives seek to employ
new strategies to control health problems.
In the Tobacco Priority Area, new ob­jectives
have been added that advocate
increasing taxes on tobacco products to
discourage smoking and increasing the
proportion of health plans that offer
treatment for nicotine addiction. In the
Unintentional Injuries priority area, one
new objective calls for extending, to all
States, laws requiring helmets for bicycle
riders; and a second objective aims to
increase the number of States having a
graduated driver licensing system for
drivers and motorcycle riders under
the age of 18. In the area of controlling
HlV Infection, a new objective has
been added to increase the proportion
of businesses offering an HIV/AIDS
workplace program.
In the area of Food and Drug Safety, a
new objective has been added that takes
advantage of MedWatch, the FDA
Medical Products Reporting Program
developed in 1993. It seeks to increase
the proportion of adverse event reports
voluntarily sent to FDA by health
professionals via this program. A
second drug safety objective would
increase the proportion of people
receiving information on new prescrip­tions
from prescribers or dispensers.
In addition to these completely new
objectives, several pre-existing objec­tives
have been modified to include a
new emphasis on population subgroups
of particular concern. These changes
reflect both the ongoing concern about
health disparities in America and the
growth of more detailed information
on health characteristics of specific
population subgroups.
Continuing Progress
At the mid-point of the Healthy People
2000 initiative, appropriate strategies
for continuing progress toward the Year
2000 goals and objectives must also be
considered. The initiative has employed
a broad-based approach toward accom­plishment
of its aims, with State and
local communities, as well as private
organizations, playing important roles
in the development and implementation
of intervention programs and strategies.
Today, most States have developed
their own disease prevention and health
promotion objectives as a means of
setting public health priorities and as
a framework for developing and
supporting legislation. To continue
making progress toward the Year 2000
targets, this broad-based approach­with
interventions at the family, school,
worksite, and community levels-must
be continued.
Source: U.S. Department of Health and Human
Services, Public Health Service, Healthy People
2000 Midcourse Review and 1995 Revisions.
31
32
Research Summaries
Total and Per
Capita Personal
Income by State
and Region
In 1994, total personal income in the
Nation increased 5.9 percent after in­creasing
4.4 percent in 1993. Earnings
increased faster in 1994 than in 1993 in
all major industries except the Federal
Government.
Per capita personal income in the
Nation increased 4.9 percent in 1994
after increasing 3.3 percent in 1993 and
4.9 percent in 1992. The increases in
per capita income have exceeded the
increases in U.S. prices (as measured
by the fixed-weighted price index for
personal consumption expenditures)
for 3 consecutive years. In 1994, prices
increased 2.4 percent, the smallest in­crease
since 1966. By State, increases
in per capita income in 1994 exceeded
or equaled 2.4 percent in all 50 States.
In 12 States (indicated in dark gray in
the figure), increases in per capita
personal income were at least 1.0 per­centage
point higher than the national
average. Eleven of these States had
below-average increases in population
(see table).
Per capita personal income: Percent change, by State and region,
1993-94
• ,_.. . •
• Fastest income growth
• Slowest income growth
All other
Source: Tran, D.O. and Friedenberg, H.L., 1995, Total and per capita personal income by State
and region, Survey of Current Business 75(4):58-61 .
Family Economics and Nutrition Review
Per capita personal income for selected States and the United States,
1993-94
Rank
Fastest growing States:
Iowa
2 South Dakota
3 North Dakota
4 Michigan
5 Mississippi
6 Minnesota
7 West Virginia
8 Ohio
9 Louisiana
10 Wisconsin
11 Indiana
12 Missouri
United States
Slowest growing States:
43 Colorado
44 Washington
45 Texas
46 Wyoming
47 Alaska
48 Montana
49 California
50 Hawaii
Above-average increases in farm
income, earnings in both durables and
nondurables manufacturing, and in
retail trade boosted personal income
growth in Iowa, South Dakota, North
Dakota, Minnesota, and Missouri.
1996 Vol. 9 No.2
Percent change
Per capita
personal income Population
10.9 0.3
9.5 .7
8.6 .2
8.5 .4
7.4 1.1
7.0 .9
6.4 .2
6.3 .4
6.3 .6
6.1 .7
6.1 .8
5.9 .8
4.9 1.0
3.9 2.6
3.8 1.6
3.7 2.0
3.6 1.3
3.1 1.4
2.8 1.8
2.7 .7
2.4 1.1
In Michigan, Ohio, Wisconsin, and
Indiana, personal income growth was
boosted by above-average increases in
earnings in durables manufacturing, in
transportation and public utilities, in
retail trade, and in government.
In Mississippi, West Virginia, and
Louisiana, above-average increases in
earnings from farm income, construc­tion,
mining, transportation and public
utilities, services, and government led
to above-average increases in per capita
personal income.
In eight States (indicated in light gray
in the figure), increases in per capita
personal income in 1994 were at least
1.0 percentage point less than the U.S.
average. Seven of these States had
below-average increases in personal
income; seven had above-average
increases in population (see table).
In Washington, Texas, Wyoming, and
Montana, personal income growth was
slowed by declines in farm income.
In Alaska, California, and Hawaii,
declines in nondurables manufacturing,
private service-type industries except
retail trade, and government caused
personal income growth to lag behind
national figures. Cutbacks in defense­related
industries in California and earn­ings
declines in the construction and
finance/insurance/real estate industries
in Hawaii were responsible.
Source: Tran, D.J?. and Friedenberg, H.L., 1995,
Total and per capita personal income by State and
region, Survey of Current Business 75(4):58-61.
33
Home Health Care
Home health care has become the
fastest growing segment of the health
services industry. Expansion of medi­care
benefits, lower costs for care at
home relative to hospital care, and
modem technology have contributed
to this growth. Although home health
care is not a replacement for all hospital
services, it has become an important
setting for delivering preventive, diag­nostic,
therapeutic, rehabilitative, and
long-term maintenance services.
According to employment data from the
Current Employment Statistics survey,
one in five jobs created in the nonfarm
economy since January 1988 has been
in the health services industry. Within
health services, employment in home
health care has risen by 168 percent (or
345,000 additional jobs). In contrast,
employment in hospitals has increased
by 18 percent-580,000 additional jobs
(see table). Since health services are
always in demand, the health care
industry is recognized for its strength in
bad times as well as good. For example,
during the most recent employment
recession, June 1990 through February
1992, employment in the health services
industry grew 7.5 percent while employ­ment
in the total nonfarm economy fell
1. 7 percent. During the first 3 years of
the recovery period following this
recession, home health care had the
third largest increase of all industries,
following mortgage bankers and
brokers and title insurance.
34
Employment change in health services, 1988 and 1994
Percent of health
services employment Employment change
January October
Industry 1988 1994 Percent Level
Total
Hospitals
Physicians
Nursing and personal
care facilities
Home health care
Practitioners
Dental offices
Osteopaths and n.e.c.
Laboratories
Note: Data are seasonally adjusted.
n.e.c. - not elsewhere classified.
100.0
46.3
16.9
18.6
3.0
3.1
6.9
3.3
2.0
100.0
41.6
17.3
18.1
6.0
4.4
6.6
3.7
2.3
31
18
35
27
168
88
25
48
45
(thousands)
2,163
576
406
350
345
187
121
109
64
Source: Freeman, L., 1995, Horne-sweet-home health care, Monthly Labor Review 118(3) :3-11.
Home Health Care Profile
Home health care services, as defined in
the Standard Industrial Classification
Manual 1987, are "establishments pri­marily
engaged in providing skilled
nursing or medical care in the home,
under the supervision of a physician."
Services range from helping with basic
activities of daily living to caring for
patients needing specialized care for
AIDS or cancer chemotherapy. Time
with the patient can range from 1 hour
a week to around-the-clock care.
According to the Occupational Employ­ment
Statistics survey, home health
aides 1 are the most common providers
of care to individuals at home, account­ing
for 31 percent of the industry.
Various professional health providers
make up 32 percent, of which 20 percent
are registered nurses, and 7 percent are
licensed practical nurses. Personal and
home care aides2 account for 13 percent,
and the remainder is comprised of other
specialized personnel such as physical
therapists, social workers, and speech
pathologists.
1Home health aides have been defined by the
Occupational Employment Statistics survey as
those who care for elderly, convalescent, or handi­capped
persons in the home of the patient. They
perform duties for patients such as changing bed
linens, preparing meals, assisting in and out of
bed, bathing, dressing, and grooming, and adminis­tering
oral medications under a doctor's orders or
at the direction of a nurse.
2Personal and home care aides have been defmed
by the Occupational Employment Statistics survey
as those who perform a variety of tasks at places
of residence. Their duties include keeping a house
and advising families with problems such as
nutrition, cleanliness, and household utilities.
Family Economics and Nutrition Review
The Impact of Medicare
During the early 1980's, the Health
Care Financing Administration imposed
restrictions on coverage of home health
care by medicare. Reimbursement for
home care that was provided for more
than 4 days a week-no matter how
little time was involved-was denied.
A lawsuit was filed and the care was
certified as a class action suit, requiring
the government to reopen all medicare
claims from patients whose benefits
were denied-estimated to number
hundreds of thousands of individuals.
As a result of the decision, medicare
now allows payment of part-time (fewer
than 8 hours a day) or daily (7 days-a­week)
home health care services for as
long as the patient requires such care.
The change in medicare benefits allows
more individuals to be covered by home
health care services. Before the lawsuit,
approximately 1.5 million enrollees
received home health services from
medicare-certified agencies. By the
end of 1993, about 3.5 million received
these benefits, an increase of more than
218 percent.
Employment in home health services
grew 21 percent in 1990, the first full
year in which the new guidelines were
in effect. Since 1990, the gains in the
industry have averaged 16 percent
annually. The number of medicare­certified
home health agencies has
increased by nearly 22 percent over
the past 5 years; most of the increase
occurred in 1993 when nearly 7,000
medicare-certified home health agencies
and a little more than 6,000 noncertified
agencies provided service. Agencies
that have remained outside of medicare
may not be providing skilled nursing
care or they may choose to restrict
business to private-pay patients.
1996 Vol. 9 No.2
Cost Effectiveness
For fmancial reasons, hospitals find it
expedient to discharge patients as soon
as medically possible. The services pro­vided
immediately following discharge
have become an increasingly significant
component of patient care. Cost savings
result from the lower overhead expenses
and flexible staffmg practices of the
home health care company. High-cost
institutional care is replaced by profes­sional
care and personal care, which is
often provided by family or friends.
Data from the Current Employment
Statistics survey show that the average
hourly earnings for workers in the home
health care industry is more than $3 less
than that for those in the hospital industry,
$10.67 compared with $14.
Also, in an institutional setting, a
registered nurse or doctor may visit all
patients three times a day, while home
care rounds are based on the needs of
the patient and his or her family. The
frequency of the visits is determined by
the patient's condition and the ability of
the patient and the family to learn how
to provide care themselves, with the
goal being self-sufficiency.
Technological Advances
When planning for home health care, a
major concern is whether the treatment
at home will be comparable to institu­tional
care. Recent technological ad­vances
have made complex medical
equipment more compatible with the
home environment. Lab tests are now
available curbside from vans that
perform lab work on site.
One of the most rapidly growing areas
of medical technology is the engineering
and production of medical equipment
tailored for use in the home. Such
equipment includes blood glucose moni­toring
for the diabetic, computerized
equipment for the disabled, and mini­intensive
care units with ventilators and
central venous lines. Employment in the
medical instruments and supplies industry
has increased by 17 percent since January
1988.
A new generation of hardware, software,
and fiber-optic, digital cable networks
is attracting attention from hospitals,
physicians, and clinics in both urban
and rural areas. This technology en­hances
home health care by enabling
hospital staff and physicians to monitor
patients in their homes via telephone
lines.
Increased Public Awareness
Recently, the public has become more
aware of the home health care industry.
Change in the structure of families has
contributed to this awareness. With
increasing numbers of women in the
work force-59 percent, up from 56
percent in 1988-fewer family members
are at home to help sick or elderly
patients who may need sophisticated care.
Use of home health care services is
dependent on many factors including
the patient's health care needs, the
type of reimbursement plan, and the
physician's willingness to prescribe
home care. Home health care cannot be
obtained without a physician's prescrip­tion,
so the physician, who makes
specific recommendations and referrals,
plays a significant role in deciding
whether to use home care services.
A 1991 study, "Physicians' Attitudes
and Behaviors Toward Home Health
Care Services," addressed the impor­tance
of physicians' insights into the
strengths and weaknesses of the home
35
health care industry. The survey con­cluded
that 90 percent of the physician
sample regarded home health care
services and programs favorably, while
3 percent regarded them unfavorably.
As physicians become more involved
with home care, they will require wider
use of technological improvements and
other forms of innovation and education.
Approximately 82 percent of all accred­ited
medical schools offered home
health care in their 1992 curricula.
The Future
The expansion of medicare benefits
brought about by policy changes in
the late 1980's had a major impact on
employment in the home health care
industry. In the absence of other policy
changes, this trend will most likely
continue. Improved cost-effectiveness,
advancing technology, and increased
public awareness will continue to
strengthen the industry.
Employment in the home health industry
is projected to increase by more than
500,000 jobs, or 128 percent, between
1992 and 2005. This compares with an
expected increase of only 30 percent in
the hospital industry and 43 percent for
total health services.
The need for personal assistance and
health care-specifically home health
care-increases with age. As the size
of the elderly population increases, the
numbers requiring home health care
should greatly increase, also. Aging
baby boomers will cause the elderly
population to expand from 39.7 million
in 2010 to 69.8 million in 2030, when
more than 20 percent of the population
will be 65 years and older.
Source: Freeman, L., 1995, Home-sweet-home
health care, Monthly lAbor Review 118(3):3-11.
36
Health Needs of
Young Children in
Foster Care
Foster children are among the most
vulnerable individuals in the welfare
population. Of particular concern is the
health of young foster children since
conditions left untreated during the first
3 years of life can influence functioning
into adulthood and impede a child's
ability to become self-sufficient later
in life. Yet, little comprehensive infor­mation
is available about the provision
of health-related services to meet the
needs of young foster children. This
report provides information on (1) the
health-related services needed and
received by young children in foster
care, (2) the relationship between the
receipt of health-related services and
foster care placements with relatives
versus placements with nonrelatives,
and (3) what responsible agencies are
doing to ensure that these children are
receiving needed health-related services.
To develop this information, the General
Accounting Office (GAO) reviewed
foster care programs in California,
New York, and Pennsylvania-the
States with the largest average monthly
foster care populations in 1991. In addi­tion,
random samples of case files from
Los Angeles County, New York City,
and Philadelphia County from a com­bined
population of 22,755 young foster
children were analyzed. These locations
cared for a substantial portion of each
State's young foster children. Findings
reported here are based on cases from
only these three locations.
Results indicated that a significant
proportion of young foster children in
Los Angeles County, New York City,
and Philadelphia County did not receive
critical health-related services. Despite
State and county foster care agency
regulations requiring comprehensive
routine health care, an estimated 12
percent of young foster children received
no routine health care, 34 percent
received no immunizations, and 32 per­cent
had at least some identified health
needs that were not met. Furthermore,
an estimated 78 percent of young foster
children were at high risk for human
immunodeficiency virus (HIV) as a
result of parental drug abuse, yet only
an estimated 9 percent of young foster
children were tested for it.
Case files did not always reflect the
exact nature or extent to which services
were provided. Thus, children noted as
having received routine medical care
may have received as little care as one
visit with a physician for treatment of a
minor illness rather than comprehensive
or ongoing medical care.
States must offer Early and Periodic
Screening, Diagnosis, and Treatment
(EPSDT) services to medicaid-eligible
children. EPSDT services are specific,
comprehensive medical examinations
and follow-up treatment; however, only
an estimated 1 percent of the young foster
children in the locations reviewed
received them.
Children with no known health problems
were less likely to receive routine care
than children who were at risk for or
had serious health problems. Of the
children with no known serious health
problems, an estimated 28 percent did
not receive any health-related services.
Family Economics and Nutrition Review
By comparison, only 6 percent of children
who were at high risk for serious health
problems because of prenatal drug
exposure and 2 percent of children with
serious physical health problems did not
receive any health-related services.
Although young foster children received
a wide variety of services from health
care providers, many children had iden­tified
health-related needs that were not
met. GAO used information collected
from case files to identify the health­related
needs of each child and to match
them with the services received. About
one-third of the children had some iden­tified
needs that were not met. These
unmet needs included pulmonary and
speech therapy; psychotherapy; develop­mental
assessments; infant stimulation
services; cardiological, urological, and
neurological examinations; and testing
for sickle cell anemia, syphilis, and HN.
Young foster children placed with
relatives were less likely than children
placed with nonrelatives to receive
health-related services of all kinds.
Also, children placed in kinship care
were nearly three times as likely as
those placed in traditional foster care
to have received no routine health care.
Since studies indicate that children in
kinship care remain in foster care longer,
and they receive a lower level of service,
these children are likely to go without
needed services for longer periods.
More and more, young foster children
are being placed with relatives. In
California and New York-the States
where placement data were available­the
number of young children placed
with relatives increased by 379 percent
between 1986 and 1991, while the number
1996 Vol. 9 No.2
of young children placed with non­relative
foster parents increased by
54 percent. Consequently, whereas 20
percent of young foster children were
placed with relatives in 1986, 43 per­cent
of them were placed with relatives
in 1991.
Young children placed in kinship care
in Los Angeles County and New York
City were three times more likely than
those placed in traditional foster care to
be at risk for future problems because
of prenatal drug exposure. Furthermore,
because drug-exposed children are more
likely to be at risk for illV and develop­mental
delays, the need for health­related
services for children in kinship
care is even more critical. Yet, only 11
percent of children placed exclusively
in kinship care received specialized
examinations, such as developmental
evaluations, compared with 42 percent
of those placed exclusively in traditional
foster care.
The Department of Health and Human
Services (HHS) recently contracted for
10 National Resource Centers to assist
its Administration for Children and
Families (ACF) in responding to States'
questions and in providing free techni­cal
assistance. None, however, is desig­nated
to assist States with health-related
programs for foster children. Further­more,
while ACF audits States for
compliance with federally mandated
safeguards for foster children, these
audits omit review of compliance with
health-related safeguards. Therefore,
when a State has passed its compliance
audit, it is entitled to receive the full
Federal child welfare funding available
by law; because health-related safeguards
are not included in the audit, States
have no Federal financial incentive to
comply with them.
Local foster care agencies continue to
revise health-related policies, regulations,
and programs in efforts to improve the
delivery of health care to foster children.
Given the importance of health care
during the first 3 years of life, an
improved response to the health needs
of this vulnerable population is vital.
Source: U.S. General Accounting Office, 1995,
Foster Care: Health Needs of Many Young
Children Are Unknown and Unmet, Report to
the Ranking Minority Member, Subcommittee
on Human Resources, Committee on Ways and
Means, House of Representatives, GAO/HEHS-
95-114.
37
Effects of
Intermittent Labor
Force Attachment
on Women's
Earnings
Women who interrupt their careers
and leave the labor market for family
responsibilities often return to fmd that
their wages lag behind those of women
at comparable stages in their careers
who did not leave the labor force. Many
reasons account for this lag. First, women
who leave the labor force and later
re-enter do not build up seniority, with
associated higher wages. Second, women
who return to the labor force are less
likely to receive on-the-job training to
increase their productivity and thereby
raise their pay. Third, when women are
not in the work force, their job skills
may decline. Finally, employers may
view gaps in work history as an indica­tion
that women may leave again. Some
employers would, therefore, hire them
for less important, lower paying jobs to
limit the impact of a future leave.
This study calculates the cost of taking
a break from work in terms of the wage
difference between women who work
continuously and women who take one
or more leaves. Because those who do
not leave the work force tend to be
younger and better educated than those
who do, a straight-forward comparison
cannot be made-foregone earnings
would be overestimated.
38
Characteristics of women who remained in the labor force (no gaps)
and women who left the labor force (1 or more gaps)
Women who remained Women who left
in the work force the work force
Item (no gaps) (1 or more gaps)
Number of people 696 1,730
Age 39 45
Years of education 14 12
Total years worked 17 17
Percent
Education
No high school diploma 6 21
High school diploma 33 47
Some college 27 19
College degree 15 7
Graduate work 19 6
Occupation
Professional/executive 38 21
Service occupations 10 17
Craft occupations 2 3
Pink collar/blue collar 50 59
Marital status
Married 58 70
Widowed 3 5
Divorced 21 21
Never married 18 4
Number of children ever born
None 39 9
1 18 14
2 24 33
3 or more 19 44
Source: Jacobsen, J.P. and Levin, L.M., 1995, Effects of intermittent labor force attachment on women's
earnings, Monthly Labor Review 118(9):14-19.
Family Economics and Nutrition Review
Previous studies of gaps in labor force
participation have found that these gaps
affect earnings. One hypothesis is that
women returning to the work force who
fmd their wages lower than they had
expected are quite likely to leave again;
and over time only the relatively high­earning
women who have had a break
in labor force participation will be left
in the work force. Another hypothesis
is that earnings will rebound soon after
women re-enter the work force.
This study tests for the rebound effect
by restricting the sample of women
with labor force breaks to those women
who display continuous labor force
attachment for an extended period after
a break. Findings indicate that when
women re-enter the labor market, their
earnings are much lower than those of
a comparable group of women who did
not leave the labor market. Over time,
that difference diminishes (due to the
rebound effect) but never disappears,
even after as long as 20 years.
Data used were from the 1984 panel
of the Survey of Income and Program
Participation. Each individual in the
data set was interviewed eight times
at 4-month intervals. Participants were
asked in each interview about their
labor force participation in the previous
4 months. Thus, data for 32 consecutive
months for each individual (June 1983
to Aprill986) were collected. Only
women ages 30 to 64 at the start of the
sample period were included.
Only women who worked relatively
continuously during the 32 months of
the sample were included in the "no
gap" group; women must have reported
earnings in the 1st, 6th, 12th, 18th, 24th,
and 32d months of the sample. Thus,
1996 Vol. 9 No.2
To illustrate the cost of taking an employment gap for a particular case,
assume a woman with the following characteristics: graduates college at
age 21, immediately begins full-time work (40 hours a week, 50 weeks a
year) in a pink-collar occupation in a city outside the South. She leaves
work at age 25 for 7 years and re-enters full-time work in 1984 at age 32.
The difference between her earnings for the 20 years after she re-enters
and what they would have been had she remained constantly employed is
$52,000. Part of this is caused by her fewer years of experience; part is
due to her decision to leave the labor force. This amount is equal to 15
percent of her prospective earnings had she worked constantly-or about
3 years of wages. Thus, the cost of taking a 7 -year gap is 10 years of earnings.
women were included only if their gaps
were shorter than 6 months. In this
way, the majority of women who have
seasonally intermittent work schedules,
such as teachers, participated in the
"no gap" group.
To be included among the sample of
women with labor force breaks ("gaps"),
a woman must have taken at least one
break from work, lasting 6 months or
longer, between the year she received
her last educational degree and the
beginning of the survey. 1
Total work experience was the same
for the two groups (see table), which
reflects the higher age and lower educa­tional
attainment of the women who
left the work force. These women were
much more likely to be working part
time and were more heavily represented
in less skilled and service occupations­both
blue- and pink-collar positions.
1Lncludes women who worked before taking a
break, and women who had an initial gap between
the year of their last degree and the year in which
they started working.
Women who left the work force were
more likely than their counterparts
who remained in the work force to
be married and to have children. The
reason mentioned most often for taking
leave from the work force was family
reasons (85 percent gave this response).
Other reasons included poor health and
inability to find a job; leaving work to
attend school was not counted as a gap.
Regression analysis was used to show
the direct effects on wages of gaps
occurring at different times in the past
and to calculate wage ratios that control
for differences in age, education, work
experience, and other factors between
those who had left the work force and
those who remained at work. The re­gression
equation was estimated at three
different times during the sample period:
the 1st, 18th, and 32d months. The
dependent variable was the natural loga­rithm
of the hourly wage. Independent
variables controlled for individual
characteristics (age, geographic location,
occupation class, and human capital)
and also a set of dummy variables for
number of years since a worker ended
her last absence from the labor force
(measured from the beginning of the
survey). Thus, the wages of the same
39
group of women could be measured and
examined to determine what changes
occurred over the duration of the survey.
A lasting negative effect and a gradual
rebound effect resulted from the period
out of the labor force. For any particular
length of time out of the labor force,
2-1/2 years of continuous labor force
attachment will, on average, diminish
the difference in wages between those
who have left the work force and those
who remained. For example, in the in­itial
period, women whose gaps ended
less than 1 year ago had wages that
were 33 percent lower than those of
women who did not leave the labor
force. By the third year (when they
would have returned to the work force
more than 3 years ago), these women's
wages were only 20 percent lower than
those of women who remained in the
labor force.
Although there is strong evidence for
a partial rebound effect, the wages of
women who have taken a leave from
the labor market never catch up to the
wages of women who never left. Even
women whose labor force gap occurred
more than 20 years ago still earn between
5 and 7 percent less than women who
never left the labor force and have
comparable levels of experience.
The effect of a gap on a woman's life­time
earnings is significantly larger than
just her foregone wages during the time
away from work. This finding has
significant implications for the way in
which compensation between husband
and wife is calculated in divorce
proceedings.
Source: Jacobsen, J.P. and Levin, L.M., 1995,
Effects of intermittent labor force attachment on
women's earnings, Monthly Labor Review
118(9):14-19.
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