Public policy in nutrition: a framework for action

Public policy in nutrition: a framework for action

Laura S. Sims

The nature of public policy is often enigmatic to those who do not understand the basic process. While researchers and practitioners in nutrition often profess to not knowing or caring about “policy” issues, a fundamental knowledge of the process and ways in which that process can be influenced may enhance those elements of nutrition with which both groups most closely identify: increased (or curtailed!) funding for research or programs in which nutritionists are employed, recognition of professional qualifications, oversight of patient care and/or research operations and the like.

THE NATURE OF PUBLIC POLICY

Policy provides a framework for making decisions, a guide for making choices among alternative courses of action. Public policy provides guidelines for governmental action, thus serving as the means by which modern societies seek to provide the greatest good for the greatest number. The effects of public policies are far-reaching; they exert significant impact beyond the entity making the decision.

Public policy evolves when a number of factors–among them science, economics, social and political circumstances–converge to focus attention on how government should be involved to meet an existing need or solve an identified problem. Setting policy always involves striking a balance between the scientific evidence and the values, priorities, needs and concerns of stake holders and constituents. Any enthusiasm for making new policy must be tempered by economic realities; maintaining the status quo, i.e., doing nothing’ is almost always less costly than changing policy or setting new policy directions. It requires a complex balancing act to satisfy scientific principles, consumer concerns, industry interests… and, budget realities (Chapman, 1987).

For policy to be set, a sound knowledge base must be coupled with a supportive political climate. The knowledge base is frequently derived from research data, program evaluation or demonstration project results. Such information usually includes a convincing presentation of the ‘facts’ behind the issue, i.e., a description of the nature of the problem, accompanied by a rationale of why government should be involved. However powerful the argument, a recitation of the facts alone will probably never result in policy changes. Therefore, a supportive political climate is needed to capture the attention of the general public and/or policy-makers, so that the facts become “alive” and people become convinced that laws or regulations need to be made or changed.

This is why all in the nutrition community need to be involved in the public policy process. Researchers can document scientific need or articulate rationale for policy formulation. Practitioners can personalize issues by sharing descriptive case studies or incidents so that a supportive “political climate” for the issue can emerge.

Policy-making is a dynamic, evolving process, resulting from the actions of certain individuals and structures at any given time in response to environmental forces and circumstances. In order to achieve a policy that is consistent with the views of most who try to influence its form, pace or direction, a number of “actors”–including influential organizations, interest groups, legislators-must work toward the goal of attaining mutually satisfactory goals by compromise and consensus. However rational the approach or lofty the goals, there is a constant ongoing struggle among conflicting values, vested interests and even ambitious personalities. Members of the nutrition community must be prepared to work with other professional organizations and interest groups with related agendas who, together with policy-makers, can develop a set of workable, coordinated policies.

POLICY STRUCTURES AND ACTIVITIES AFFECTING NUTRITION POLICY

Textbook explanations emphasize the “separation of powers” among the three branches of government. Constitutionally, the legislative branch, i.e., Congress, is given the responsibility for policy formation by the passing of laws. The executive branch, headed by the elected President, is mandated to “faithfully execute all laws.” In addition, the judicial branch is required to interpret the laws as disputes arise and are litigated through the court system. In reality, each of the three branches performs most of the functions of policy formulation, implementation and interpretation.

Legislative Branch. The Congress passes laws that initiate, modify, authorize and appropriate funds for all programs and services administered by the federal government. In any given year, between 10,000 and 15,000 bills are introduced. Because of the volume of work, most legislative activity is handled by the committees or subcommittees that have designated areas of jurisdiction. After referral of a bill by the chamber leader, the committee has the authority to review the bill, hold hearings, amend, “kill” or report out the bill for full chamber action.

Food, nutrition and health issues are considered by several committees in the Congress. In the Senate, those with primary jurisdiction over nutrition issues include the Committees on Agriculture, on Nutrition and on Forestry or on Labor and Human Resources. The Committees on Agriculture, on Education and Labor or on Energy and Commerce are primarily responsible for nutrition issues in the House of Representatives (Table 1). Select committees may be established for a limited and specific purpose, although they do not have the authority to authorize or appropriate funds for programs. The Senate Select Committee on Aging and the House Select Committees on Children, Youth, and Families and on Hunger are currently active.

The Federal Budget Process. Both the legislative and executive branches are integrally involved in the federal budget process at different points: executive branch development and proposal, congressional action and budget execution (Earl, 1990). Upon receiving the President’s budget, Congress can approve, modify or disapprove it. Authorizing committees in both chambers of Congress set general spending targets, within the limits set by the Balanced Budget and Emergency Deficit Control Act of 1985 (the Gramm-Rudman-Hollings Act). “Entitlement” programs– those for which persons qualify because of certain income or other eligibility requirements–are funded directly. Food Stamps and most other food assistance programs are entitlement programs.

Appropriation committees in both chambers determine spending policy; legislation must be passed to set specific funding levels to support federal programs and agencies for the fiscal year. Programs not considered entitlement-based compete for funds through the appropriation process; the Special Supplemental Food Program for Women, Infants, and Children (WIC) is a prime example of a program that depends on annual appropriations from Congress. The basic difference is that in an entitlement program all who are eligible are “guaranteed” to receive the program; in non-entitlement programs, there are eligibility requirements for participation, but when the funds are exhausted, no new participants can receive the program services regardless of their qualifications.

While the 1960s and 1970s witnessed expansion of government activity, the decade of the 1980s set a policy climate of consolidation and fiscal constraint. The series of laws called the Omnibus Budget Reconciliation Acts (OBRA) have an overarching influence on governmental activity primarily because these acts set financial constraints on all laws and regulations passed by the federal government. The 1981 OBRA combined a large number of categorical public health programs under several federal block grants and reduced levels of funding. Likewise, the OBRA in the early 1980s drastically affected the funding for food assistance programs by tightening eligibility requirements and reducing overall benefits. Medicaid benefits were also altered by the OBRAs of 1986 and 1987 by permitting states the option to expand coverage and to determine their own eligibility standards for certain groups of medically indigent pregnant women, infants and children.

The last stage in the federal budget process is budget execution.

The Office of Management and Budget (OMB) in the executive branch allocates funding to each federal agency over the fiscal year by activities to ensure the effective use of resources and to guard against the need for additional program funding. OMB has oversight responsibility for governmental spending as well as for how governmental activities are performed. For example, the OMB oversees and approves the type and manner of research that is performed by those inside the government, as well as those who receive governmental contracts.

Executive Branch. In most developed countries–and the United States is no exception–the major influences on nutrition policy are exerted by the agricultural (food production) and the health/medical sector. In this country, such interests are represented at the federal level primarily by the U.S. Departments of Agriculture (USDA) and Health and Human Services (DHHS). No clear policy guidelines have been published which designate each agency’s specific responsibilities vis-a-vis nutrition issues. USDA sees its role in food and nutrition policy as ensuring the availability of a sufficient, wholesome and nutritious supply of food and providing information by which all persons can select a healthful diet. In contrast, DHHS’ interest in nutrition is more directed toward dealing with the relationship between food and health and the ways in which dietary excesses and imbalances increase the risk for chronic diseases.

Regulations, described as the “final stage” in law-making, are the mechanism by which administrative (executive branch) agencies provide detailed restrictions and guidelines to the broad, less specific laws they are designed to implement. Regulations may address such specific matters as eligibility criteria of the target clientele, amount and type of benefits received and qualifications for service providers. Once they have passed through the rule-making process and are issued as “final rules, they are just as enforceable as the original law on which they were based. Interim regulatory activity is published in the Federal Register, the principal document that publishes proposed rules and notices. Final rules, or regulations, which guide the operation of federal programs are compiled in the Code of Federal Regulations (CFR), a document that is revised and published annually. On specific matters, technical reports, position papers or consensus statements also serve as policy statements. For example, the document, Dietary Guidelines for Americans, currently serves as a statement of dietary guidance policy for the federal government.

A CONCEPTUAL OVERVIEW OF NUTRITION POLICY

Nutrition policy, which serves as a unique example of linking scientific findings with governmental action, has been defined by the World Health Organization (WHO) as, a concerted set of actions, often initiated by government, to safeguard the health of the whole population through the provision of safe and healthy food (Helsing, 1989). The provision of wholesome food at affordable cost, however, is only one element of the nutrition policy picture. Health outcomes, as one result of nutrition policy, must also be considered. Indeed, nutrition is one means by which health promotion is incorporated into public policy because of its unique characteristics: nutrition is a major factor that influences health, involves both issues of individual choice and the social environment and is susceptible to modification through social policy changes (Spasoff, 1989).

Despite calls in the late 1970s to develop and implement a comprehensive nutrition policy in the United States, no single policy exists (Sims, 1988). Nutrition policy, in large measure, has emerged collectively as policy set in a number of separate arenas–by events in both the public and private sectors, by governmental actions in several departments and by response of the public in terms of their demands for particular foods and kinds of information. Rather than a coordinated, comprehensive set of policy directives, nutrition policy currently exists as mosaic of distinct, but related, health, social and food-related programs, each with its own set of objectives and expected outcomes. Therefore, because there is no coordinated nutrition policy, no single goal can be evaluated. Rather, we must examine the effectiveness of each program separately and seek to make sense out of often competing program goals, objectives and outcomes.

Nutrition policy exists as the nexus of a host of other policies– agricultural, health, medical, social, economic, educational–each of which is the product of its own set of influences, directives, actors and infrastructures. Likewise, the “nexus,” nutrition policy, is subject to its own set of external influences. Certainly, events outside the governmental arena, such as the media, advertising and the public’s demand for certain food products, have influenced the nutrition policy agenda in a variety of directions.

A “systems” model is helpful in showing the role of each component of the nutrition policy picture (Fig. 1). Figure 1 demonstrates both the simplicity, as well as the complexity, of nutrition policy. Input to the system takes the form of those sets of policies (mainly agricultural) that affect the quantity and quality of food available. Process is best conceptualized as all those events and situations that affect how the food supply will be used. The major process element in this scenario is food consumption, which in turn affects the output of the food system. The output of the system can be shown as a range of outcomes, including those related both to health outcomes of individuals as well as healthy, sustainable environments (McNutt, 1990).

Agricultural policy sets the stage by its influence on the quantity and quality of the food supply. We rely on the food production system to provide adequate quantities of food at reasonable prices for consumers, a basic tenet of nutrition policy. The types and amounts of food that are produced are directly affected by agricultural (i.e., farm) policy which, in turn, affects the types, supply and costs of foods available from which the public can make choices to consume.

While agricultural policy directly affects the food supply, both health/medical policy and environmental policy influence food consumption practices by means of a vast array of programs and services. Nutrition policy is no longer synonymous with food policy, nor solely in the domain of agricultural policy. Health policy, especially that segment which addresses health promotion and disease prevention, has embraced nutrition as a vital element of chronic disease prevention policy. Many think of nutrition as ‘an ideal arena in which to demonstrate the principles of health promotion and healthy public policy’ (Spasoff, 1989).

Science policy affects agricultural, health and environmental policies because of its role in setting funding priorities for research and new product development. Social-economic policy, in this context, mainly affects food consumption by means of its effect on food costs and on food assistance programs by setting eligibility standards for participation. Educational policy influences students’ literacy and numeracy abilities, thus affecting nutrition education programs and the capability of consumers to make informed food choices.

POLICY ELEMENTS IN NUTRITION

In order to understand and elucidate the complexity of nutrition policy, we must examine the components which together make up the whole. After extensive review of the literature and a number of policy documents, a consensus emerged about a limited number of policy options that can be considered in the realm of nutrition.

Nutrition policy includes a number of elements, ranging from the availability of safe, wholesome food, to provision of food security, to provision of services such as education and health care. Identified as the most salient policy components in nutrition are the following six elements:

1. Providing an adequate food supply at reasonable cost to consumers.

It is an overarching goal of agricultural policy, as it has evolved over the decades, to produce plentiful food at reasonable cost to consumers; simplistically, the policy has been described as, “cheap food for consumers; protection of farm income” (Rapp, 1988). The food supply, in turn, is directly affected by an elaborate system of policy instruments, such as price supports, marketing orders, commodity subsidies and processor incentives designed to encourage plentiful food production (and thus, lower food prices) and protect farm income. Charges have also been leveled that decades of agricultural chemical use, such as fertilizers, pesticides, herbicides, etc., have caused irreparable damage to the quality of the soil, ground-water and other environmental resources.

2. Ensuring the quality, safety and wholesomeness of the food supply.

Issues as varied as environmental contamination, pesticide residues, product tampering, microbial contamination, food additives, enrichment and fortification of food and inspection standards for meat, poultry and seafood affect the quality, safety and wholesomeness of the food supply. Given the divergent and often conflicting views on these issues among consumer advocates, the food industry and even government regulators, it is not surprising that some food safety concerns have become highly charged public policy issues.

Passage of the Federal Food and Drugs Act and the Federal Meat Inspection Act in 1906 were credited with ridding the U.S. marketplace of food fraud. More important, however, is the fact that these laws established that the federal government had a responsibility and a legal fight to ensure a safe and wholesome food supply. After the passage of the Federal Food, Drug and Cosmetic Act in 1938, Congress began taking a role in regulating the food supply in terms of its contribution to human nutrition. With the number of “processed” foods in the marketplace and the number of times nutrients are added to fortify or enrich products, Hutt (1986) has concluded that a major regulatory challenge affecting agencies such as the Food and Drug Administration (FDA) today is the overabundance, rather than under-supply, of nutrients in foods.

The present food safety policy presents unique challenges to revamp current laws and regulations so that they can adequately address issues such as the need for uniformity in approaches to controlling microbiological contamination in food, assessing the range of significant chemical hazards and communicating the relative risks from various food products to the public and addressing the regulation of new genetically engineered or formulated food products, such as ‘fat substitutes’ (Palmer, 1990).

3. Ensuring food access and availability to those lacking resources or the ability to obtain sufficient food.

Food insufficiency has become a chronic problem in the United States, directly attributable to poverty (Nestle and Guttmacher, 1992). More than any other aspect of food and nutrition policy, food assistance programs are a form of governmental action directly tied to the nation’s economic well-being.

Federal food assistance programs evolved as an outgrowth of farm support laws enacted during the Great Depression of the 1930s. The original goals of these programs were to improve the nutrition of low-income people, while providing an outlet for surplus agricultural commodities from the farm programs.

A number of federal food assistance programs exist–each designed to meet the needs of the economically disadvantaged, but using different strategies. Most programs supplement earnings and other types of assistance, including welfare and unemployment. Categories of food assistance are a) family nutrition programs, b) child nutrition programs, c) supplemental food programs and d) food distribution programs. Included under the family nutrition program category, the Food Stamp Program is the largest of all food assistance programs, with estimated funding for the program in 1992 over $22 million serving 25 million people, nearly one-tenth of the nation’s population.

Five child nutrition programs are offered: the National School Lunch Program (the largest and the one that has been in place the longest), the School Breakfast Program, the Child and Adult Care Food Program, the Special Milk Program and the Summer Food Service Program. The most notable supplemental feeding program is the Special Supplemental Food Program for Women, Infants, and Children, better known simply as ‘WIC.’ This program provides a monthly package of nutritious foods, selected to provide nutrients most likely to be missing from the diets of low-income women and children, nutrition education and health screening and referral. WIC is generally regarded as one of the most effective nutrition programs that exists. The food distribution programs, historically associated with the distribution of surplus commodities obtained through farm price supports, include the Temporary Emergency Food Assistance Program (TEFAP), the Nutrition Program for the Elderly and commodity distribution to charitable institutions.

The fundamental challenge facing food assistance policy-makers in the 1990s will be the need to hold down food program costs in the face of budget constraints while continuing to provide nutritional assistance to an ever increasing number of needy persons. Despite tighter program eligibility requirements and the creation of new program management systems in recent years, actual expenditures for all food assistance programs have continued to increase, even though the number of participants in the National School Lunch Program, School Breakfast Program and WIC has remained relatively constant.

4. Providing research-based information and educational programs to encourage the public to make informed food choices.

Dietary guidance policies have followed closely after related scientific discoveries in nutrition. In recent years, as the links between diet and chronic disease became well recognized, federal dietary guidance strategies, mainly in the form of the Dietary Guidelines for Americans (first published in 1980), were directed toward helping consumers make qualitative distinctions among food choices, rather than simply advising about the quantity of servings to be selected from certain “food groups.”

In addition to issuing dietary guidance, the government administers programs in nutrition education. With funding from federal, state and local sources, the Extension Service, USDA, administers a general food and nutrition education program for the public, which was originally established by the Smith-Lever Act in 1914. Also administered by the Extension Service is the Expanded Food and Nutrition Education Program (EFNEP), originally authorized in 1970. With instruction delivered by paraprofessionals from the community to clients usually in their own homes, this program is designed to teach low-income families, especially those with small children, the skills needed to choose and prepare an adequate and balanced diet.

The Nutrition Education and Training Program (NET) was authorized in 1977 to provide nutrition education and training to teachers and school food service personnel so that they, in turn, can teach children the relationship between food and health and can encourage good eating habits. Although not considered specifically as an educational program, providing nutrition information on the food label is a powerful tool for helping consumers make informed food choices. The ‘Nutrition Labeling and Education Act of 1990″ (NLEA) put the force of law behind a number of initiatives that will result in a new food label that will provide the consumer with accurate and useful information about the nutrient content of food products.

5. Supporting an adequate science/ research base in food and nutrition.

Through the use of tax dollars, government has the means–and the public responsibility–to conduct and/or support research in nutrition. The interactions between nutrition policy-making, nutrition monitoring and nutrition research (shown in Fig. 2) serve as the conceptual basis for The Operational Plan for the National Nutrition Monitoring System (DHHS/USDA, 1991 ), a document developed jointly by DHHS and USDA in response to the mandate of the National Nutrition Monitoring and Related Research Act of 1990. That report identified the type of research data needed for nutrition policy decisions on topics such as dietary guidance, food assistance programs, food labeling and the like. Research topics with policy relevance were identified, including nutrient requirements throughout the life cycle (and the establishment of the RDAs); research on the role of nutrition in etiology, prevention and treatment of chronic diseases and conditions; nutrient content of food, bio-availability and interactions; nutrition education research; economic aspects of food consumption; knowledge/attitudes’ relationships to dietary and health behavior; food composition analysis; and nutrition monitoring research.

The level and sources of federal support for nutrition research serve as surrogate indicators of the commitment of the government to the field. Ostenso (1988) has observed that,

Prior to 1950, the principal funding of human nutrition research was provided by three sources: the private sector, appropriate state funds, and USDA formula grants to agricultural experiment stations in land-grant colleges. Today, support for nutrition research has followed the public and congressional interest in issues related to health. She further reported that,

irrespective of the research focus, the federal contribution to nutrition research has kept pace neither with the rate of inflation nor with the percentage increase allocated by the government to basic research in most other disciplines.

The most recent data from the Human Nutrition Research and Information Management (HNRIM) system, a federally managed database created for the purpose of tracking human nutrition research activities, show an expenditure of $385 million for nutrition research and training in fiscal year 1988. Seventy-eight percent of these funds were expended by DHHS, 18 percent by USDA, 2 percent by the Agency for International Development (AID) and 1 percent each by the Department of Defense and the Department of Veterans Affairs. Of the total amount expended, 81 percent supported extramural research.

6. Improving access to and integrating nutrition services into preventive health care and medical services.

The delivery of food and nutrition services through the auspices of the health care system is an area of nutrition policy that has proven to be of great importance for the dietetics profession. Issues such as health care financing, credentialing of health services providers and standards of practice for nutrition professionals have attracted policy attention over the past few years.

The overwhelming emphasis in health policy in the United States today is the delivery of personal health services, which has been estimated to consume over 90 percent of Federal health spending (Milio, 1981). Within the federal bureaucracy, several DHHS agencies administer the majority of health and social service programs that do not include food assistance, such as Medicare (which provides insurance coverage for health services for older Americans) and Medicaid (which establishes cooperative federal and state funding of health care for economically disadvantaged individuals and the disabled).

As part of primary health care, nutrition services should be included in screening and diagnosis, health maintenance, health supervision and health promotion. Payment for nutrition services in primary health care has come, in part, through a series of federally financed ‘block grant’ mechanisms, such as the Maternal and Child Health (MCH) Block Grant and the Preventive Health and Human Services Block Grant, administered through DHHS.

Nutrition services, including screening and assessment, nutrition counseling and nutrition support, have long been provided by qualified dietitians and nutritionists as an integral component of appropriate medical care. Only lately have issues such as documenting the cost-effectiveness of nutrition services, pursuing third-party payment for nutrition services and credentialing of dietetics practitioners been of interest in the legislative and policy arenas.

THE INTERFACE BETWEEN NUTRITION POLICY ELEMENTS AND VARIOUS POLICY STRUCTURES

In order to initiate and implement policy in nutrition, a variety of institutional structures, actors, groups and processes must be actively involved. This section of the article is designed to show, for each policy element, those structures and groups most intimately involved in the issue. Undoubtedly a visualization, such as that provided in Table 1, can only be a selected snapshot of a very complicated, involved and dynamic process. But, it does serve to illustrate the complexity of the process and the magnitude of the number of units and persons–both inside and out of government–that are involved with nutrition policy-making. The chart is organized to depict initiating structures, primarily Congressional Committees; implementing structures, those administrative and regulatory agencies in the Executive Branch; and influencing structures, those groups such as advocacy organizations, interest groups, professional associations, trade associations and the like which converge to affect the direction of decisions in each element of nutrition policy.

Policy Element 1: Providing an adequate food supply at reasonable cost to consumers.

Food production issues are under the jurisdiction in Congress of the Agriculture Committee in the House and the Agriculture, Nutrition and Forestry Committee in the Senate. Implementation is primarily in the domain of the U.S. Department of Agriculture in the Executive Branch. A variety of farm, environmental and consumer groups have a role in influencing the direction of policy in this arena.

Policy Element 2: Ensuring the quality, safety and wholesomeness of the food supply.

Responsibility for food safety and quality activities are under the jurisdiction of the Agriculture and the Energy and Commerce Committees in the House and the Agriculture, Nutrition and Forestry and Labor and Human Resources Committees in the Senate. For issues dealing with food enrichment and fortification, the Science, and Space and Technology Committees in the House of Representatives also have some legislative responsibility. In addition to USDA implementation (mainly for meat and poultry products), the Food and Drug Administration (FDA) in DHHS and the Office of Pesticides and Toxic Substances in the Environmental Protection Agency (EPA) are also involved. Influencing groups include Public Voice for Food and Health Policy (which has been especially active in advocating for mandatory seafood inspection), several trade associations, such as the National Food Processors Association (NFPA), Grocery Manufacturers of America (GMA) and the Food Marketing Institute (FMI), as well as newer groups such as “Americans for Safe Food.”

Policy Element 3: Ensuring food access and availability to those lacking economic resources or the ability to obtain sufficient food.

Issues of domestic hunger and food assistance programs are primarily in the domain of the Education and Labor and Agriculture Committees in the House. These topics are under the jurisdiction of the Senate Committee on Agriculture, Nutrition, and Forestry, except for the Elderly Feeding Programs, which are under the Senate Committee on Labor and Human Resources. Implementation for nearly all food assistance programs at the federal level is handled by the Food and Nutrition Service of the U.S. Department of Agriculture, except for the Elderly Feeding Programs, which are administered by the Agency on Aging in DHHS. Influencing groups include anti-hunger advocacy groups such as the Food Action Research Center (FRAC) (which was instrumental in formulating the Medford Declaration against Hunger), the Children’s Defense Fund, the Center for Budget and Policy Priorities, Bread for the World, the Community Nutrition Institute (CNI) and associations such as the National School Food Service Association (NSFSA), the National Association of WIC Directors (NAWD), the National Association of Nutrition and Aging Service Providers (NANSP) and the National Association of Meal Programs (NAMP).

Policy Element 4: Providing research-based information and educational programs to encourage the public to make informed food choices.

The specific Congressional committee to which jurisdiction and oversight of educational programs is assigned depends on the agency that conducts the program. For example, for educational programs administered by the Extension service or dietary guidance programs in the Human Nutrition Information Service, both in USDA, the Committees would be Agriculture (in the House) and Agriculture, Nutrition and Forestry (in the Senate). However, for educational campaigns conducted by agencies in DHHS, the Committee assignments would be Education and Labor (in the House) and Labor and Human Resources (in the Senate). Labeling programs of the Food and Drug Administration, such as the law passed by the NLEA, are under the jurisdiction of the tatter two Committees, while meat and poultry labeling initiatives are under those Committees that oversee USDA efforts. Professional associations, such as the Society for Nutrition Education (SNE), the American Dietetic Association (ADA), the National Association of Extension Home Economists (NAEHE) and the American Home Economics Association (AHEA), have long influenced public policy for nutrition education. Recently the National Exchange for Food Labeling Education has been formed, which brings together trade associations such as FMI and NFPA, with voluntary health associations (such as the American Heart Association (AHA) and the American Cancer Society), professional associations and advocacy groups to coordinate efforts in food labeling education.

Policy Element 5: Supporting an adequate science/research base in food and nutrition.

Several House Committees have jurisdiction over research and nutrition monitoring programs–Agriculture, Science, Space and Technology, and Energy and Commerce. The Senate Committees are Governmental Affairs, Agriculture, Nutrition and Forestry and Labor and Human Resources. Within the Executive Branch, agencies such as the Agricultural Research Service (ARS), the Cooperative State Research Service (CSRS) and the Human Nutrition Information Service (HNIS) all conduct nutrition research/monitoring activities; in DHHS, these responsibilities are mainly assigned to the National Institutes of Health (NIH) and the National Center for Health Statistics (NCHS) within the Centers for Disease Control. Professional groups such as the American Institute of Nutrition, the American Society for Clinical Nutrition and “trade associations” such as the National Association of State Universities and Land Grant Colleges are keenly interested in oversight of these governmental activities and the budgets appropriated for research.

Policy Element 6: Improving access to and integrating nutrition services into preventive health care and medical services.

Various committees concerned with health care delivery, such as Education and Labor in the House and Labor and Human Resources in the Senate are directly involved with this policy element. This also is an issue specifically delegated to several agencies within DHHS, primarily the Health Care Financing Administration (HCFA) and units within the Public Health Service (PHS). A professional association, the American Dietetic Association (ADA), has taken the lead for influencing the policy discussion regarding the inclusion of nutrition services into health care delivery. Other groups of health care professionals, notably the American Medical Association (AMA), the American Public Health Association, the American Nurses Association (ANA) and the American Dental Association (ADA) are also directly involved with legislative activity in this area.

SUMMARY

It is urgent that all in the nutrition community become aware of and actively involved with the public policy process. There is indeed a role for all in our profession. The researcher can amass statistics and bring recent developments to the attention of those who are in a position to introduce or initiate policy; the practitioner has a role in creating a “positive political climate” so that matters of importance can gain widespread attention and support from policy-makers.

However, nutritionists working alone are probably not sufficient to influence the nutrition policy process significantly. We must team our efforts with those of economists, agriculturalists, epidemiologists and other political and biological scientists.

One of the most fundamental challenges of the 1990s for dietitians and nutritionists is to advocate for an integration of a number of disparate areas of nutrition policy in order to achieve common goals. As Ostenso (1988) has cogently pointed out, we as nutrition professionals must ‘responsibly educate policy-makers about the benefits to be gained by investments in nutrition. May we move forward with collective vision in this increasingly important task.

[TABULAR DATA OMITTED]

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Hutt PB. National nutrition policy and the role of the Food and Drug Administration. Currents 1986;2(2):2-11.

McNutt K. Integrating nutrition and environmental objectives. Nutr Today 1998;25(6):40-1.

Milio N. Promoting health through public policy. Philadelphia: F.A. Davis, 1981:189-92.

Milio N. Nutrition and health: patterns and policy perspectives in food-rich countries. Soc Sci Med 1989;29(3):413-23.

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Palmer S. Food and nutrition policy: challenges for the 1990s. Health Affairs 1990;9(2):94-108.

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Dr. Sims is a professor in nutrition at the University of Maryland at College Park. Her current research interests include the study of national nutrition policy, especially as it relates to the evaluation of the effectiveness of public nutrition and information delivery systems. Work on this paper was enhanced by Dr. Sims’ participation as a 1992 Leadership Fellow at the National Center for Food and Agricultural Policy, Resources for the Future.

GLOSSARY OF TERMS AND ACRONYMS

ADA American Dietetic Association

AIN American Institute of Nutrition

AMA American Medical Association

ANA American Nursing Association

APHA American Public Health Association

APHIS Animal and Plant Health Inspection Service (USDA)

ARS Agricultural Research Service (USDA)

ASCN American Society for Clinical Nutrition

ASFSA American School Food Service Association

CDC Centers for Disease Control (DHHS)

CNI Community Nutrition Institute

CSPI Center for Science in the Public Interest

CSRS Cooperative State Research Service (USDA)

DHHS Department of Health and Human Services

EPA Environmental Protection Agency

FASEB Federation of American Societies for

Experimental Biology

FDA Food and Drug Administration (DHHS)

FMI Food Marketing Institute

FNB Food and Nutrition Board, of Institute of Medicine/NAS

FNIC Food and Nutrition Information Center, part of

the National

Agricultural Library (USDA)

FNS Food and Nutrition Service (USDA)

FRAC Food Research and Action Center

FSIS Food Safety and Inspection Service (USDA)

GMA Grocery Manufacturers of America

HCFA Health Care Financing Administration (DHHS)

HNIS Human Nutrition Information Service (USDA)

NAS National Academy of Sciences

NAEHE National Association of Extension Home Economists

NASULGC National Association of State Universities and

Land Grant Colleges

NAWD National Association of WIC Directors

NCHS National Center for Health Statistics (CDC/DHHS)

NCA National Cattlemen’s Association

NCI National Cancer Institute, part of National Institutes

of Health (DHHS)

NFPA National Food Processors Association

NHLBI National Heart, Lung, and Blood Institute, part of

National

Institutes of Health (DHHS)

NIH National Institutes of Health (DHHS)

PHS Public Health Service (DHHS)

RISE Responsible Industry for a Sound Environment

USDA U.S. Department of Agriculture

COPYRIGHT 1993 Lippincott/Williams & Wilkins

COPYRIGHT 2004 Gale Group