Health Education & Behavior

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Environmental and Policy Approaches to Cardiovascular Disease Prevention

Through Nutrition: Opportunities for State and Local Action
Karen Glanz, Becky Lankenau, Susan Foerster, Sally Temple, Rebecca Mullis and
Thomas Schmid
Health Educ Behav 1995; 22; 512
DOI: 10.1177/109019819502200408

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 Environmental and Policy
Approaches to Cardiovascular
Disease Prevention Through Nutrition:
Opportunities for State and Local Action
Karen Glanz,
PhD, MPH
Becky Lankenau, MS, RD, MPH, DrPH
Susan Foerster, RD, MPH
Sally Temple, RD, MS
Rebecca Mullis, PhD, RD
Thomas Schmid, PhD

This article reviews environmental and policy intervention approaches to cardiovascular disease prevention
through nutrition and recommends opportunities for state and local health departments to initiate and participate
in environmental and nutrition policy initiatives. By addressing these complementary aims, the authors hope to
stimulate further efforts to achieve progress in nutrition promotion among state and local health-related
organizations. Key categories of opportunity to develop new or expanded nutrition policies and environmental
strategies include economic incentives, food assistance and feeding programs, regulations for institutional food
service operations, and nutrition services in health care. Environmental strategies to reduce barriers to following
dietary guidelines, such as point-of-choice programs and school nutrition programs, should be tailored for local
communities and widely disseminated. In addition, current federal policy efforts, notably nutrition labeling
rules, will provide a valuable focal point for state and local advocacy, education, and monitoring.

The association of nutrition with cardiovascular disease (CVD) occurs principally

through the role of diet in several primary and secondary CVD risk factors, including
high blood cholesterol, high blood pressure, obesity, and diabetes mellitus.I,2 These risk
factors affect one-eighth to one-half of all American adults and can often be prevented or
controlled through diet. 3,4 The consequences of these risk factors are reflected in high
disease rates, premature death, disability, reduced productivity, and increased use of
medical care.I,6 Good nutrition can reduce some of these costs and consequences in the
short run and can affect others through population-wide declines in disease rates and in
disease severity over the longer term. 3,1,11

Karen Glanz is a professor (researcher) at the Cancer Research Center of Hawaii, University of Hawaii,
Honolulu. Becky Lankenau is a visiting scientist, Health Interventions and Translation Branch, Division of
Chronic Disease Control and Community Intervention, National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. Susan Foerster is the chief of
the Nutrition and Cancer Prevention Program, California Department of Health Services. Sally Temple is the
director of the Division of Cardiovascular Health, Center for Health Promotion, South Carolina Department of
Health and Environmental Control. Rebecca Mullis was formerly the assistant director for program develop-
ment, Division of Nutrition, National Center for Chronic Disease Prevention and Health Promotion, Centers

Health Education Quarterly, Vol 22 (4)- 512-527 (November 1995)

0 1995 by SOPHE
512

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 513

Scientific consensus and national guidelines for cardiovascular nutrition have become
possible through the convergence of scientific and social forces during the past decade
CVD prevention guidelines from the American Heart Association and the National
Cholesterol Education Program are consistent in their recommendations on limiting total
dietary fat consumption to 30% or less of total calories and consuming no more than 10%
of calories from saturated fatty acids and no more than 300 mg of cholesterol per day.’,15
The American Heart Association’ also advises limiting sodium to no more than 3000 mg
daily to reduce risk for hypertension. Recommendations for initial diet therapy for adults
with elevated blood cholesterol levels are similar to the primary prevention guidelines.’6

NUTRITION PRACTICES AND POLICIES:

STATUS AND POTENTIAL

Public awareness of the impact of nutrition on CVD, particularly of the role of fats
and the risks associated with elevated blood cholesterol, has improved substantially.l’-’9
However, this increased awareness has not consistently translated into healthy eating
patterns because of the convenience of high-fat food choices, food preferences, and
economic, social, cultural, and informational factors.’o As the role of state health agencies
evolves away from a direct service model toward a role of assurance, policy development,
and environmental modification, these barriers will have to be addressed. Some progress
has been made; food industry and food service operations have initiated changes to supply
healthier foods in response to consumer demand. Opportunities exist for public health
advocates to systematically encourage both producers and consumers to shift toward
eating patterns that can reduce CVD risk.
Several historical and structural obstacles have hampered the evolution of a unified
nutrition policy to reduce the prevalence of CVD. These include the recency of scientific
consensus and guidelines; diversity of opinion among experts and special interest groups

(i.e., food producers and marketers, food industry lobbyists); pressure from meat and
dairy producers on federal policymakers; and multiagency involvement in nutrition
programs. 21-23 Future initiatives need to incorporate effective environmental and policy
approaches and to establish cooperative relationships between private, public, and
voluntary sector partners.
Improved nutrition for CVD prevention involves a goal of community-level preven-
tion and thus cannot be reached one case at a time?4-27 Market forces such as supply and
demand influence health behavior change. Environmental effects on nutrition practices
include social norms, policies, access to food, and promotion.&dquo; Thus nutrition policy to

for Disease Control and Prevention. Currently, she is a professor in and the chair of the Department of Nutrition
and Dietetics, College of Health Sciences, Georgia State University, Atlanta. Thomas Schmid is a senior
evaluation specialist, Health Interventions and Translation Branch, Division of Chronic Disease Control and
Community Intervention, National Center for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention.
Address reprint requests to Becky Lankenau, MS, RD, MPH, DrPH, Health Interventions and Translation
Branch, Division of Chronic Disease Control and Community Intervention, National Center for Chronic Disease
Prevention and Health Promotion, 4770 Buford Highway, NE, Mailstop K-46, Atlanta, GA 30341-3724.
Telephone: (404) 488-5520; fax: (404) 488-5964.
This article was presented as a paper at the workshop on Environmental and Policy Approaches to
Cardiovascular Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, September
8-10, 1993.

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514

prevent CVD can only occur through interaction among various sectors and policy arenas:
health, social, economic, and agricultural. Contemporary health promotion strategies
need to go beyond education and communication activities to include organizational
change efforts, economic development, advocacy, and policy development. 21-10

ENVIRONMENTAL AND POLICY INTERVENTIONS:

DEFINITIONS AND OPPORTUNITIES

Environmental and policy interventions aim to improve the health of all people in
defined populations through nutrition, not just small groups of motivated or high-risk
individuals. Specifically, environmental interventions are those that do not require
self-selection into a defined educational program (i.e., class, group, or counseling
situation). They reach populations through influencing the availability of healthy foods,
access to information for making food choices, and the accessibility, consistency, and
attractiveness of nutrition education experiences.&dquo; Examples include mass media and
information in the general consumer marketplace, advocacy, and changes in nutrition
services in the health care system.&dquo;,3’ In contrast, policy approaches are specific types of
environmental interventions that involve establishing formal social, economic, or legal
structures within a formal organization or by a local, state, or federal government unit.32
Environmental and policy interventions to encourage adoption of healthful eating patterns
can be planned and delivered in a variety of governmental, institutional/organizational,

and community situations. Settings where food is provided, prepared, sold, or served are
especially suitable for environmental nutrition interventions. Six major settings and
channels are particularly relevant to planned change efforts for promoting good nutrition:
health care settings, schools, worksites, community groups (e.g., churches, clubs), the
consumer marketplace, and mass media. These settings also overlap; for example, health
care settings are also worksites and worksites may have employee health clinics within
their facilities.
Environmental and policy interventions are often combined with other intervention
strategies, such as those involving counseling, group education, and high-risk programs.
Policy interventions can be established wherever there is a formal structure in which
social, legal, or economic rules can be created, implemented, and enforced.
Nutrition promotion has several unique features that warrant consideration in devel-
oping environmental and policy strategies and that distinguish it from tobacco and other
drug control initiatives.33,3a For example, food, unlike tobacco, is essential for human
health. Desirable changes in eating patterns are both qualitative and quantitative and are
more complex than merely limiting intake or &dquo;cessation.&dquo; No single food product can be

justifiably implicated as unequivocally dangerous or toxic, as can tobacco and some other
drugs.35 Also, no sidestream food or &dquo;passive eating&dquo; issues are present.

TYPES OF ENVIRONMENTAL AND POLICY

INTERVENTIONS FOR CVD PREVENTION THROUGH NUTRITION

Environmental and policy interventions for CVD prevention through nutrition include
those related to dietary guidance policy, nutrition information policy and strategies, food
access strategies, economic strategies, health service policies, cholesterol control strate-

gies, and media advocacy (see Table 1). Several of these areas overlap; in this article,

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 515

Table 1. Types of Nutrition Policy and Environmental Interventions

descriptions are organized to highlight strategies clearly rather than to provide a definitive
typology of interventions.

Dietary Guidance Policy

Dietary guidance policy includes developing dietary guidelines to support chronic

disease risk reduction and health and educational interventions as well as designing
strategies to convey the guidelines to the general population. The National Cholesterol
Education Program (NCEP) population report includes dietary guidelines for CVD
prevention. &dquo; The NCEP Adult Treatment Guidelines I and II are risk-reduction guidelines
calling for dietary change as the first line of treatment. 16,36 These and other national
guidelines provide state health agencies with an opportunity to develop local policies and
guidelines. For instance, the state of California is in the process of establishing and
implementing a state dietary guidance policy, which will call for consistency of menu
standards in all relevant state-supported nutrition and food programs.
Assessing the impact of dietary guidance policy per se is difficult partly because it is
intended as a foundation, with initial activities focusing on raising professional and public
awareness. Subsequent activities that include mass media, educational programs, and

community-based and environmental approaches involve applications of dietary guid-

ance policy; thus their effects cannot be fully attributed to the policy itself.

Nutrition Information Policy and Strategies

Three key nutrition information and policy strategies are nutrition labeling, regulation
of health claims, and point-of-purchase (POP) or point-of-choice nutrition information.
These strategies are considered from three perspectives: (1) At what level or levels are
these strategies controlled and carried out? (2) From a policy standpoint, has it been
established that people want or have a right to information and food choices that promote
health and prevent CVD? and (3) From a behavioral standpoint, do these strategies result
in better food choices? The first issue is discussed for the three approaches together, and
the others are covered as they apply to each approach.
The federal government has legal jurisdiction over the labeling of foods, the use of
health claims on food packages and in advertising, and the use of health-related nutritional
descriptors in the consumer marketplace (i.e., supermarkets, restaurants, and other retail

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516

food vendors). Most of the policy activity for food and nutrition labeling occurs at the
federal level, and concerns about health claims have been addressed at both federal and
state levels.37.38 Although regulation of health-related nutritional descriptors, or POP
nutrition information, is the responsibility of the Food and Drug Administration (FDA),
interventions using these strategies have been initiated in research programs, the private
sector, and through voluntary health agencies such as the American Heart Association. 31
State and local health agencies can foster private efforts. For instance, organizations such
as the California Table Grape Commission and the Prune Board have adopted a related

strategy by deciding that a specific proportion of all their advertisements will promote
statewide nutrition programs by carrying a &dquo;5 A Day for Better Health&dquo; tagline.
Nutrition labeling on food packages provides consumers with a reliable and consistent
source of information. However, assessments of the quality, use, and impact of nutrient
label information are contradictory. Reviews of numerous published reports show that
although many consumers want nutritional information on food packages and labels,
many neither comprehend nor use it.31.40 Individuals on medically restricted diets and
those with higher education and income are most likely to use labels.&dquo; Studies of
consumer comprehension of various label formats are equivocal. Additional consumer

testing and education are needed to help consumers understand and apply label informa-
tion to food choices.
Health claims that link specific foods and disease prevention benefits are the focus of
regulations that are now being released, although they have been used previously with
variable levels of enforcement. The best studied example of this type of claim was the
Kellogg Company’s advertising campaign for All-Bran cereal, undertaken as a partner-
ship with the National Cancer Institute. (The campaign was controversial because it
ignored existing regulations about the use of health claims and involved a government-
industry partnership.) The campaign used print and broadcast media and information on
cereal boxes to state that dietary fiber could help prevent cancer and that All-Bran was
an excellent source of fiber.38 The campaign greatly raised awareness of the link between

dietary fiber and cancer, and the increased awareness appeared among minorities and
low-income groups as well. 41 In California, the health agency policy to use consistent
nutrition education messages and materials statewide is analogous to this widespread
campaign.
POP nutrition interventions in restaurants and supermarkets provide consumers with
information, reminders, and reinforcements guide them toward more informed food
to
selections. These strategies are based on the premise that information, cues, or incentives
at the point of decision making will increase awareness, help people apply general
nutrition concepts, and remind them to choose more healthful foods.&dquo; POP strategies are
potentially cost-effective for reaching large numbers of people and satisfying consumers’
desires for information. Point-of-choice interventions include a variety of strategies.
Restaurant and cafeteria programs generally use labels and posters and may include
games and incentives. Supermarket programs use shelf labels, posters, brochures, tasting
demonstrations, and audiovisual and print media. States have made good use of POP
programs. The South Carolina Cardiovascular Disease Prevention Project, for example,
included nutrition education activities in both restaurants and grocery stores to increase
the availability of heart-healthy foods and to guide consumer choice.42
Controlled studies in cafeterias, restaurants, and supermarkets have demonstrated
positive behavioral effects on the selection of &dquo;more nutritious&dquo; foods and on nutrition
knowledge and attitudes, but the effects varied in magnitude, duration, and consistency.3’
Point-of-choice nutrition information programs are becoming widely adopted in com-

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 517

mercial food-marketing operations. As with nutrition labeling, this is partly a response to

patrons’ desire for information.

Food Access Strategies

An increase in the quantity and accessibility of healthy food products can contribute
to wider adoption of good nutrition habits. Proactive efforts to increase the availability
of heart-healthy foods date back about a decade. Most have stressed institutional-level
changes in food preparation or offerings in supermarkets, restaurants, school, and
worksite food services and vending areas.43 Nationally, voluntary health organizations
like the American Heart Association have been instrumental in promoting healthy-food
initiatives in restaurants, worksites, and schools. At the state level, California is using the
state’s volume purchasing power to promote wider use of foods that are low in fat, whole
grain, and/or fresh processed.
There is a paucity of data regarding the effects of introducing changes in food
availability on total consumption. Few controlled studies have tested the impact of food
supply changes outside of point-of-choice nutrition interventions or comprehensive
educational programs. Studies by Ellison et al. that were conducted in boarding schools
suggest that nutrient intake can be altered merely by systematically reducing the fat
content of foods served in the cafeteria. 44.4’ However, examples in free-living populations
are rare.
Some organizations where food is served are beginning to establish and enforce
catering policies. These policies specify guidelines for food purchase, preparation, and
provision within an organization and at organization-sponsored functions. Catering
policies are beginning to emerge in the United States in worksites and in the professional
meeting and conference planning of some health-oriented professional associations.35,43
For example, at least one state unit of the American Cancer Society has adopted
health-promoting guidelines for foods served at meetings, award ceremonies, and fund-
raising events.
Most reported food access strategies were designed to increase opportunities for
healthful choices and reduce barriers to nutritious eating patterns, rather than to restrict
access to high-fat, high-calorie, or high-sodium foods. However, catering policies also
have the potential to include some restrictive measures. Restrictions need not be absolute,
but could limit variables such as total fat, the frequency with which some foods could be
served, or portion size.
Supermarkets, food service establishments, and worksites offer state health agencies
promising settings for environmental nutrition initiatives. Grocery stores can be encour-
aged to participate in substantive and sustained health promotion initiatives that will
assure access to identifiable, affordable, attractive, and healthful food options in all food

categories. The Georgia Department of Health has collaborated closely with the Georgia
Affiliate of the American Heart Association to conduct HeartFest, a POP nutrition
information program conducted in grocery stores, worksites, and schools.
In the food service sector, restaurants and other food service establishments can be
urged to provide and promote healthy menu options and remove barriers to choice. This
could be done by increasing cues to positive action and reducing cues to negative actions,
encouraging competitive pricing of the healthy options, and creating norms for healthy
eating. Other strategies might include establishing &dquo;deep-fat-fry-free zones,&dquo; supporting

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518

mandatory disclosure of ingredients and nutrients, and adopting a socially responsible

stance in developing and promoting menu offerings.
At worksites, state health agencies might encourage and assist in developing policies
to ensure the availability and accessibility of healthy foods, information, incentives, and
support. Opportunities for such support are available through food services and vending
operations; collaboration with unions, voluntary agencies and health insurers; physical
activity release time; and other activities positioning CVD prevention as a worksite issue.
The local government in Contra Costa County, California has established standards for
foods served at cafeterias, vending machines, and snack stands on city/county property
and in government buildings. In addition, state and local health agencies themselves could
serve as model worksites.

Economic Strategies

There have been few initiatives to develop widely disseminated economic strategies
to promote nutrition, although small-scale demonstrations have been used as part of
multicomponent programs. Three types of explicit economic strategies to encourage or
discourage consumption of certain types of foods are available: (1) monetary incentives
and disincentives through taxation, pricing policies, price supports, and price reductions;
(2) insurance risk rating; and (3) payment or other economically valued support for health
promotion programs to improve nutrition.
In California, monetary disincentives were proposed in the form of a 2-year sales tax
on certain nonnutritious snacks; however, this component of the state budget bill was
passed but not enacted. Incentives have also been tried within some multicomponent
nutrition interventions, using coupons or special reduced pricing for healthy food options,
or to promote consumption of locally grown fruits and vegetables. Producers and

marketers of fruits and vegetables could be given tax incentives. Restaurants and food
services might be offered incentives for adhering to dietary guidelines. Colleges, work-
sites, hospitals, and businesses often have contractual relationships with local, state, or
federal governments. Requiring these institutions to follow health-promoting food prepa-
ration and serving guidelines and to train their personnel to plan and prepare heart-healthy
meals would have a broad effect on the health quality of the menu offerings.
There is some evidence that the public would support selective regulatory policies to
discourage high-fat food consumption. A survey of 821 residents of seven upper mid-
western communities revealed popular support for proposals such as limiting advertising
of high-fat foods on children’s television and requiring warning labels on high-fat foods.
Taxing high-fat foods received less support than regulatory controls on alcohol and
tobacco products. Not surprisingly, those who reported the least personal use of high-fat
foods were most in favor of restrictive policies.46.47
Insurance risk rating is a method recently introduced by health insurance providers
and employers to reduce insurance premiums for individuals or groups based on risk
profiles that include lifestyle and chronic disease risk factors or to charge extra premiums
for those at high risk.48 Among the nutritional risks included or proposed for risk rating
are obesity and elevated blood cholesterol. How well including diet-related factors will
be accepted in this type of plan is unclear; most insurers have accepted risk rating based
on smoking habits. 48
Payment and other support for health promotion programs to improve nutrition have
been offered in some worksite health promotion programs, in which employers provide

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 519

work-release time to attend nutrition and weight control classes, cover the cost of
participating in these programs, and even offer economic incentives for behavior change
or weight loss.49 Incentives for weight loss appear effective but only for short-term

change.8Other economic support for participation in nutrition improvement programs

sometimes comes from health insurers and health maintenance organizations, which
either directly provide these programs or reimburse subscribers for participation. An
innovative motion in California proposed a law establishing a fund into which taxpayers
could designate a portion of their tax refund for the 5-A-Day campaign. Tax incentives
are a popular way that government fosters change. States are establishing empowerment
zones to foster local economic health; could state health agencies use the same type of
incentives and policies to designate health promotion zones? Although few evaluations
have assessed the impact of economic strategies, they do appear to have some short-term
impact and may encourage patrons to try new foods or dishes. 11,50

Nutrition Services in Health Care

Nutrition services for primary prevention in health care could be promoted by example
through governmental health-financing agencies and professional education standards.
Improved nutrition education training for physicians and other health professionals could
be advanced by including requirements in government funding for health professions
training and continuing education.13,21,23,43.51 State health agencies can work with state
medical societies and boards to encourage or require that continuing education includes
preventive nutrition concepts and practices. Institutional review boards can include
considerations for health promotion services in the service delivery mix of private and
state hospitals. New York State considers the applicant’s community and preventive
health promotion efforts when issuing certificates of need for new or expanded medical
care units such as coronary artery bypass surgery facilities. Health services policies offer

the possibility of extending the benefits of chronic disease prevention through dietary
change by promoting their widespread use in the clinical practice of medicine, particularly
in primary care delivery. Preventive services guidelines, the Healthy People 2000 objec-
tives, and recommendations for the implementation of dietary guidelines call for preven-
tive nutrition education as a part of routine health care and for better training of health
professionals in promoting healthful nutrition practices. 3,52-54
Significant obstacles to the widespread availability of effective nutrition interventions
still exist, both among health care providers and in health care delivery and financing.&dquo;,&dquo;
Surveys indicate that more physicians now believe that diet can have a preventive effect.’9
However, studies that used chart audits and patient surveys reveal substantial discrepan-
cies between current guidelines and actual practice for detection and management of
elevated cholesterol and do not show trends toward improved practice over the past
decade. 14 States can provide leadership and foster improved preventive nutrition services
by organizing and publishing recommendations for clinical preventive services. For
instance, the state of Colorado, through its Cardiovascular Disease Coalition, fostered the
development of the &dquo;Colorado CVD Screening Guide,&dquo; which summarizes the various
preventive health services recommendations, including nutrition-related CVD risk fac-
tors. Companion guides were developed for medical and public health professionals and
are used in continuing education workshops.
Policies that encourage the routine provision of quality preventive nutrition services
in health care are a necessary component of environmental approaches to CVD prevention

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520

through nutrition.&dquo;,&dquo; Health care financing and reimbursement has long been tied to
patterns of disease diagnosis and treatment, and thus preventive nutrition intervention is
not generally covered by existing health care financing mechanisms.56 Although we know
of no such state policies at present, there is precedent for them in states that require health
insurers to cover the cost of early-detection tests for breast, cervical, and prostate cancer.
It appears that states will be taking an increasing role in determining how (and to whom)
many medical and nutrition services are provided. As managed care and other approaches
to Medicare, Medicaid, and food distribution programs evolve, state health agencies will
have an opportunity to include polices that require or reward service providers for
preventive nutrition and related CVD risk factor services.

Mass Media Communications

Through broadcast and print channels, mass media can reach wide audiences, raise
awareness about issues, and affect public opinion. Media advocacy is the strategic use of
mass media to stimulate changes in public policy and corporate actions. 57 This social
action approach has been used widely in tobacco control efforts and was recently used
on a limited basis to promote healthy eating patterns. It helped to change the composition
of processed food products and to hasten the development of new food labeling legisla-
tion. The HeartSavers campaign initiated by Philip Sokoloff was a nearly single-handed
effort to persuade food processors to replace tropical oils used in cookies and crackers
with vegetable oils. The campaign consisted of taking out full-page advertisements in
major national newspapers (e.g., USA Today, Wall Street Journal) that accused the food
industry of unnecessarily poisoning consumers by using saturated fats where unsaturated
oils could be used.43 This unconventional but powerful use of mass media also has
potential to spur nutrition action for other changes.
Several other types of strategies can be viewed as environmental or policy approaches
to CVD prevention through nutrition. They include mass media, school programs,
surveillance, and public-private partnerships.
As discussed previously, mass media communications can reach wide audiences and
thus may be useful in the primary prevention of CVD. A small number of organized mass
media campaigns have sought to influence nutrition practices for chronic disease preven-
tion. Mass media was a prominent component of the community heart health programs
in Rhode Island, Minnesota, California, and Finland and was effective in increasing
awareness of health issues. However, it is difficult to isolate the effects of mass media on
behavior. Future media efforts might be better focused on explaining the ramifications of
various policy or environmental options, stimulating discussion and setting the agenda
for public debate, rather than on attempting to foster individual behavior change.
The media campaign of the National Cholesterol Education Program (NCEP) initially
used &dquo;Know your cholesterol number&dquo; as its primary theme. Public service an-
nouncements and other media publicity also encouraged people to choose more foods
low in saturated fat and cholesterol. A series of national and state cross-sectional surveys
suggest an impact on cholesterol-screening activity, and increases in beliefs in the
preventive impact of diet and reported efforts at self-initiated dietary change.18,19.58
Mass media was a key strategy in Project LEAN (Low-Fat Eating for America Now),
a social marketing campaign initiated by the Kaiser Family Foundation with a coalition
of national health and consumer organizations involved in nutrition. 59 In California, the
&dquo;5 A Day for Better Health&dquo; campaign uses mass media as a central component to increase

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 521

intake of fruits and vegetables as part of a low-fat, high-fiber diet. Mass media monitoring
showed that both these campaigns yielded widespread recognition among consumers.60
However, impact data are not presently available for these projects.
Comprehensive school health education programs are multiple risk factor, primary
prevention efforts that include programs to teach children and adolescents about nutrition
and health and to encourage healthy diets. School-based nutrition interventions use one
or more approaches: classroom teaching, skill development, teacher preparation, parental
involvement, and food service changes.6’ Recently, programs with behavioral goals
related to CVD prevention were evaluated. About a dozen such school-based nutrition
programs for various grade levels were reported; they used multiple components and
included strategies such as modeling desired behaviors, self-monitoring, and rewards.
Although these programs have been inconsistent in the magnitude and duration of their
impacts, they have generally had positive effects. 61
School food services provide an opportunity to use the educational environment to
encourage lower fat meals and more fresh fruit and vegetables. Cafeteria-based strategies
that have been tried in schools include analyzing and modifying menus (e.g., reducing
fat and sodium), changing how foods are prepared, and training food service personnel.6’
In studies in two New England boarding schools, Ellison et al. worked with food service
staff to reduce fat and sodium in the foods served.44,45 They found that meals consumed
by students contained significantly less sodium and saturated fat, even without including
direct education for the students.
State health agencies should work with statewide educational infrastructures to
establish and implement policies to assure provision of healthy food choices and a school
environment where such choices are the norm. This goal can be accomplished by targeting
school meals, vending machine items, and other foods served in school; classroom-based
curriculum; teacher and food service staff training; parent participation; community
involvement; fund-raising events and products for school activities; and by tying fiscal
and other support to improved nutrition patterns. Several states are actively involved in
working with state and local school boards. South Carolina is working on policy and
environmental interventions in schools. These include policies that require healthy food
choices in the school setting, including changes in the food service program, vending and,
canteen operations, and a comprehensive health education curriculum.

LIMITATIONS AND EVALUATION NEEDS

A number of limitations deserve mention as environmental and policy approaches to

CVD prevention move forward. There are many issues about which little is presently
known, and many things will be best learned through experience. The cost of many of
these approaches, realistic time lines, and expectations about impact are relative un-
knowns. The skills and roles needed by leaders in environmental programs, and their lay
and professional collaborators, may vary widely. Little is known about the relative merits
of short-term versus long-term implementation of interventions. Industry resistance can
be anticipated for some strategies but cooperation can be obtained for others.
Most policy interventions require educational support to be properly implemented and
to be successful. Policy and environmental strategies may be harder to implement in
high-need or low-income communities, and attention should be given to ways of reaching
disadvantaged groups. One way to coordinate healthful eating strategies for disadvan-
taged communities involves encouraging or mandating the coordination of state-

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522

administered food programs such as Food Stamps, WIC, Senior Meals, and school lunch
programs with nutrition education for CVD prevention.
Evaluation of policy and environmental interventions is essential to help build a base
of knowledge about what works, how well, and for whom. Practical evaluation method-
ologies are needed but they must also have sufficient methodological rigor to permit an
understanding of change processes.62 Databases for tracking development of valid and
reliable environmental indicators and practical and community-oriented evaluation
strategies will help meet this challenge.63-66 Better state- and community-level data on
nutrition practices are needed. For example, the Behavioral Risk Factor Surveillance
System (BRFSS) surveys could include brief, validated measures of food purchasing and
eating habits. To date, limitations on the length of BRFSS interviews have constrained
the usefulness of state-level nutrition information.
In addition to evaluating the impact of various strategies, some other important
evaluation questions should be explored to advance our understanding of environmental
and policy interventions in nutrition:

~ What is the incremental impact of environmental and policy interventions when they
are added to, or combined with, other nutrition and health promotion strategies?
~ Which elements of multicomponent interventions, individually and in combination,
are most effective in stimulating environmental change and dietary change?
~ What is the relative impact of different strategies on various racial and ethnic
minorities, different gender groups, different age groups, and people of lower
income and education levels?
~ How do secular trends in the food supply and nutrition awareness interact with
planned interventions?
~ How cost-effective are various approaches, compared with clinical and educational
strategies, and relative to other preventive or therapeutic modalities to prevent
disease, prolong life, and/or improve the quality of life?

OPPORTUNITIES AND RECOMMENDATIONS FOR ACTION

States and municipalities have important roles and opportunities for designing and
implementing nutrition policy and environmental intervention programs for CVD pre-
vention. Local governments have a major role in ensuring that nutrition programs and
policies are implemented and appropriate for their populations and settings. Responsibil-
ity for nutrition policy and programs cuts across many sectors, including health, agricul-
ture, commerce, education, and social welfare. The examples described above demon-
strate the broad range of possible approaches.
The relative contributions and roles of organizations and of state, local, and federal
government will differ depending on the specific initiative. Current federal policy efforts,
most notably the advent of new nutrition labeling rules, require advocacy, education, and
monitoring at the state and local levels. Environmental strategies to reduce barriers to
following dietary guidelines, such as point-of-choice programs and school nutrition
programs, should be tailored to individual communities’ needs and disseminated.
There is considerable room for expansion of state and local health departments’ roles
in CVD prevention through nutrition. The recommendations described in this article
provide a starting point for developing actions for community programs for environ-

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mental and policy efforts in CVD prevention through nutrition. State and local health
departments are ideally situated to assume leadership in creating supportive policies and
environments for heart health, targeting minority, low-income, and underserved groups
in their regions, and building coalitions to carry out new initiatives. 67-70 Coordination of
CVD nutrition initiatives and policies should be carefully coordinated with other risk
factor programs such as physical activity and tobacco control. Some key categories for
opportunity to develop new or expanded nutrition policies and environmental strategies
are economic incentives, food assistance and feeding programs, regulations for institu-
tional food service operations, and nutrition services in health care (see Table 2).

Economic incentives. Local producers and marketers of fruits and vegetables could be
given tax incentives to compensate for low profit margins. Coupons to promote consump-
tion of locally grown fruit and vegetables might be used. Restaurants and food services
might be offered incentives for adhering to dietary guidelines.
Food assistance and feeding programs. State agencies currently feed, purchase food
for, or provide food assistance to major sectors of the population. These include food
services for state employees, school lunch and breakfasts, older adult programs, day care
centers, and assistance to food stamp recipients and low-income mothers and children.
Nutrition policies for these programs should be developed to be consistent with the
Dietary Guidelines for Americans.54 Environmental changes should be implemented to
improve or assure access to appropriate food.
Regulations for institutional food service operations. Colleges, worksites, hospitals,
and businesses often have contractual relationships with local, state, and/or federal
governments. Requirements that these institutions implement health-promoting food
preparation and serving guidelines would have a broad effect.
Nutrition services in health care. Nutrition services for primary prevention in health
care could be promoted through governmental health-financing agencies and professional
education standards. As mentioned above, licensure requirements for continuing educa-
tion and criteria for certificates of operation can be designed to foster preventive nutrition
services.

BARRIERS AND ACTIVATION NEEDS

Several barriers to increased policy and environmental initiatives and important needs
to enhance these efforts must be addressed. Concrete barriers are narrow profit margins
in the food industry, competing priorities, lack of reimbursement for preventive nutrition
services, lack of a clear public message, and the lack of specific &dquo;how-to&dquo; steps. Other
barriers in professional roles and resources include ill-defined agency and professional
roles and responsibilities; lack of a literature base on what programs and initiatives work
(with much work remaining unpublished); and the need to resolve the &dquo;good food/bad
food&dquo; debate among professionals, which leads to conflicting messages. Obstacles related
to consumer factors and services are gaps in consumer knowledge versus behavior, gaps
in services that create negative perceptions (such as poor hospital food services), values,
and access.
Among the priority needs to be addressed are a national communications network to
include an inventory of policy and environmental initiatives, information sharing, and a

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Table 2. Opportunities for New or Expanded Cardiovascular Disease Nutrition Policies and
Environmental Strategies

technical assistance system and consistent, unified, and simple messages that are true to
the science but also tap into emotion and values for various audience segments and
communication channels. Further, in adapting several ideas from the tobacco movement,
nutrition should be framed as a majority concern and an important local health issue, and
state and local health departments should develop model policies and reshape the issue
with help from market research with grassroots and decision maker input. There are also
important opportunities to capitalize on cross-cutting issues with tobacco and physical
activity, particularly at the worksite and in schools.
Health professionals need to better understand the impact of industry issues on healthy
eating, including competition, responsible business practices (advertising, promotion),
incentives, price supports, and politics. At the national level, clarifying roles and respon-
sibilities among national, state, and local agencies and organizations should be a priority,
as should building a consensus regarding translation of science into action. Finally, the

importance of building capacity to undertake new initiatives, enhancing evaluation and

surveillance, and building more effective partnerships with industry, voluntary groups,
and other sectors should be emphasized to broaden program impact at all levels. Progress
and success in this area will require support from and partnerships between local, state,
and federal agencies, as well as other health, education, and food-related organizations,
that are willing to include primary prevention of CVD among their priorities.

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