Healthy People Consortium 2000 Meeting November 7, 1997

Summary Of Breakout Group Discussion Concerning Priority Area 2: Nutrition

Purpose and Objectives of Session

The proposed structure of the Year 2010 Objectives is to consider each of 27 focus areas, item by item, including new ones, to suggest changes, add new items, and delete items as necessary in order to meet projected needs for the 10-year period they will span. This meeting was an opportunity to offer comments on a face-to-face basis. The recommendations from this group will be compiled into a report that will be posted on the Healthy People 2010 homepage on December 1, 1997. All recommendations from this group will be considered, but participants are encouraged to submit comments officially either by mail or on the web site no later than December 15, 1997 (http://www.health.gov/healthypeople/). Comments offered on the web site are more likely to be read by the largest number of people.

The objectives are written with an emphasis on the fact that they will be implemented at the community level. Consideration must, therefore, be given to ways the communities can achieve the objectives. Objectives will range from global to particular issues that relate to nutrition. Consideration needs to be given on how some of the objectives will interface with other focus areas. Many objectives could fit into more than one area, but each objective will be given a "home" in the area that seems most appropriate and suggestions will be made for those who need to interface with other disciplines. Each focus area will be assigned to a lead agency where all comments will be considered and Year 2010 Objectives will be drafted. The Steering Committee and Workgroup Coordinators will meet on December 15, 1997, to begin this process.

Special Populations

The second goal of Healthy People 2010 is to eliminate health disparities between populations rather than just reduce these disparities. When writing objectives, all work groups are charged to have the same target for special populations as for the total population. The work groups are challenged to suggest ways for all special populations to meet the same objectives as the total population.

Duplicate Objectives

There will be no duplicate objectives in Healthy People 2010. Objectives may relate to more than one area, but they will only have one focus area "home." This was an area of interest to all members, as expressed by Gladys Block, that nutrition is cross-cutting and relates to all areas. The group wanted to ensure that nutrition would not be left out of any area if a particular objective found a "home" with another discipline. There was a consensus that cooperation among disciplines would be absolutely necessary and should be stated in the objectives. Richard L. Hanneman suggested that some goals reinforce those in other areas and should be referenced and strong attempts made to avoid conflicting messages.

The objectives that were determined to be so cross-cutting that they should not be assigned to one area only were osteoporosis, obesity/weight control, and coronary heart disease. These areas must involve physical activity along with nutrition. However, to assign them to physical activity alone would prevent nutrition programs at the local and State levels from developing initiatives to address the problem. Judy Rose reminded the group that local and State programs are designed around the Healthy People Objectives, within the program area to which they are assigned. This applies to State-funded programs as well as grant applications to government and private organizations. In order to ensure appropriate implementation at the community level, objectives that are cross-cutting need to be clearly associated with the relevant focus areas, even if more than one focus area is identified.

Measurable and Developmental Objectives

The Healthy People 2010 Objectives will contain measurable objectives that have baseline measures and developmental objectives that do not currently have a baseline, but will be monitored and a baseline will be developed for them by 2004. Linda Meyers explained "sentinel objectives" that internal government groups will be monitoring. A paper will be written and submitted to the Institute of Medicine to determine which will become "sentinel objectives". The matter will be open for comment. This will be done for objectives that can be measured in process. Linda Meyers said that two or three objectives from Healthy People 2000 were tracked in this manner, just not well publicized.

Not all objectives can be sentinels, which raised the concern that sentinel objectives would be given more importance because of their contribution to health, not because they are easily tracked. It was unsure whether these "sentinel objectives" were intended to tell something about the population or simply ease of reporting. Several participants emphasized that progress on nutrition objectives is slow and therefore not measurable within the 10-year timeframe of the Healthy People 2010 Objectives. Specific concern was expressed about objectives related to osteoporosis (calcium intake, physical activity) and the objectives related to cancer prevention and obesity (fiber, fruit and vegetables).

Another concern was that if no nutrition objectives were chosen as "sentinel objectives", nutrition would be ignored. Just because a goal is not measurable within the time frame of the objectives does not mean that progress is not being made. Several members suggested ways to measure accountability without appearing to fail at achieving objectives. Elaine Frank suggested that objectives be written in an incremental way that could show progress rather than all-or-nothing goals. This would allow goals to be more audacious than in the past so that each discipline would be forced to "stretch" to reach them. She suggested use of an upside-down pyramid with the most important goals on the point branching out to broader goals to represent progress.

Because nutrition goals interact with other health objectives, it becomes impossible to separate them from other areas such as physical activity or mental health and self esteem. Gladys Block suggested that perhaps objectives that cross several disciplines should not be placed under nutrition or the other discipline, but under a neutral area that could coordinate all the disciplines and prevent it from being limited to any one discipline. Richard Hanneman suggested measuring behavior patterns of 10 year olds as indicators of progress that predict long-term health benefits. Interaction between adults and children often educate across the generation gap. Susan Davidson suggested using behavioral objectives.

Objectives Suggested for Deletion

1. Gladys Block suggested eliminating Objective 2.3 on obesity for several reasons: 1) we are not achieving them; 2) we are pushing people into more bizarre dieting behaviors; 3) some data say that obesity does not always lead to health problems. Gladys Block expressed concern that people who are constantly on weight-loss diets become deficient in micronutrients, which causes other health problems. You can be healthy even if you are fat. Perhaps in objective 2.7 we can say that if you are overweight, be physically active and eat well. Elaine Frank suggested saying that obesity alone is not a health risk factor. Paul Coates said that in the last few years as the prevalence of obesity has risen, some of the comorbidities have decreased.
2. There was a general consensus that this group would be unable to eliminate the obesity objective and adequately explain it to our agencies. The obesity objective fits equally well in the physical activity area and in nutrition and tends to be one of the objectives that is tracked. It still needs to be covered in both disciplines. Perhaps this is an area where step-wise, attainable goals would be helpful. Perhaps measuring healthy food choices and physical activity would show progress toward better health.
3. Richard Hanneman suggested eliminating objective 2.9, which recommends reduction in salt and sodium intake. He said that this was included in the Healthy People 2000 objectives in order to be consistent with the Dietary Guidelines for Americans, which no longer contain this objective and that new studies only show an effect in older people with hypertension and no benefit in Myocardial Infarction incidence. Also, he stated that removal of sodium from the diet increases food intake. Most agreed that anything that interferes with eating well should be eliminated. Elaine Frank was hesitant to ignore sodium, but agreed that perhaps we have gone overboard. The direction of the group seemed to be that with a normal, healthy population sodium consumption isn't an issue, but those with hypertension, coronary artery disease, etc., should check with their physician.

Suggested New Objectives

1. On behalf of the American Dietetic Association, Margaret Tate suggested an objective on food insecurity. This was also suggested by ASTPHND. Food insecurity was not included in the Year 2000 Objectives because it had not been defined and measured. Linda Meyers said that food insecurity is currently being defined and measured by the Office of Science and Technology Policy. Judy Rose will have ASTPHND send a suggested objective to the web site.
2. Gladys Block suggested an objective on serum levels of folate and vitamin C. These are easily monitored as "sentinels" and could predict outcomes. NHANES has baseline data and time sequence. Folate dietary reference intakes are due in late March, 1998. Gladys Block will write up this proposed objective and post it on the web site.
3. ASTPHND requests that the breastfeeding initiative be placed in the nutrition section instead of with maternal and infant health. Most of the public health nutritionists work in the WIC program, which contacts approximately one-half of the babies born in the United States. The mothers on the WIC program are the ones who have the lowest rate of breastfeeding and would benefit most from promotion of breastfeeding. The group members were surprised to learn that WIC impacted so many mothers and infants. Margaret Tate added that there had been nothing mentioned about prenatal nutrition.
4. ASTPHND requested that the obesity objective be expanded to include children. This needs to be taken into consideration along with the previous discussion on the future of the obesity objective. Elaine Frank added that childhood obesity influences self esteem. Gladys Block suggested that we may need to approach obesity from another angle such as increasing fruit & vegetable consumption, decreasing TV time, increasing activity, etc. Margaret Tate suggested that these come under parental responsibility. Susan Davidson asked if we can leave the obesity issue in the physical activity area and focus nutrition campaigns on decreasing fat consumption, increasing fruit and vegetable consumption and other positive messages.
5. Group consensus expressed the desire to do positive things, not negative things, such as concentrate on education and behavior change. Several channels were suggested for these initiatives, including day care centers and child/adult food programs.
6. ASTPHND suggested separating the objectives on fruits and vegetables from grain. This was another area that could be related to obesity - increasing fruits and vegetables, increasing fiber, increasing physical activity, appropriate food availability, etc.
7. Objective 2.15 on decreasing fat and saturated fat, add ". . .and calories".
8. Objective 2.16. The group questioned the value of this objective, concluding that food offered reflects public demand.

Closing Comments

Gladys Block commented that all these comments are being funneled into a few staff and questioned how it will be sorted out and decisions made on what to include. Paul Coates said that working groups will sort them out.

Participants

Paul Coates, Facilitator, National Institutes of Health
Judy Rose, Recorder, Indiana State Department of Health, Association of State and Territorial Public Health Nutrition Directors
Gladys Block, University of California Berkeley
Susan Davidson, National Osteoporosis Foundation
Elaine Frank, American Institute for Preventive Medicine
Richard L. Hanneman, Salt Institute
Linda Meyers, Office of Disease Prevention and Health Promotion
Margaret Tate, American Dietetic Association
Christina Verni, American Association for World Health
Martina Vogel-Taylor, National Institutes of Health, Office of Disease Prevention

Breakout Session List