The Changing Face of Nutrition Education

The primary emphasis of Extension nutrition education programs is in the area of "normal nutrition." Historically, home economists have concentrated on disseminating information about balanced nutrition and food preservation methods designed to maintain optimal nutritional composition of foods. These continue to be important program objectives.

However, changes in American society have created new information needs of consumers in foods and nutrition. An increasing awareness of the relationship between diet and health exists in America today. For example, the Department of Health and Human Services reports that 63% of American adults are trying to reduce or eliminate dietary salt.

The Good Housekeeping Institute recently reported the results of a consumer survey on foods and nutrition conducted on 200 women in 20 major urban areas.1 Their respondents reported cutting down on salt (74%), white sugar (63%), cholesterol (57%), saturated fats (57%), and calories (53%). Fifty percent of respondents felt that foods have both short term and long-term effects on health. Long-term health problems were described as heart disease, weight gain, diabetes, and cancer. The Wall Street Journal has called us a nation of grazers, partially because of a 25% increase in the consumption of fruits and vegetables, a dramatic decrease in consumption of animal products, and a great increase in take-out and snack items.2

Extension programming is designed to respond to new needs of consumers and families. While fundamental food and nutrition education is the responsibility of home economists, the scope of "normal nutrition" is changing along with other social trends. Furthermore, a modified "normal diet" is being advocated by federal agencies and reputable health organizations as a preventive measure against chronic illness. The American Heart Association, the Committee on Diet, Nutrition, and Cancer of the National Research Council/National Academy of Sciences (NRC/NAS), The American Cancer Society, and the National Cancer Institute recommend that the general population, including children, consume a diet containing only 30-35% of fat to reduce the incidence of heart disease and cancer.3

Disputing this, the Food and Nutrition Board of the National Academy of Sciences (FNB/NAS) and the American Academy of Pediatrics are two prominent groups recommending diet modification based entirely on individual need.4 Consensus of policymaking groups regarding national dietary recommendations isn't expected in the near future. Dietary modification is increasingly being used as an adjunct to medication in such chronic disorders as diabetes, hypertension, and arthritis. Also, many consumers wish to make dietary changes as a part of a more health-conscious lifestyle.

How can Extension home economists alter their food and nutrition programs to meet the changing needs of the public, while at the same time maintaining the original Extension mandate? In Florida, the initial step taken was to determine the extent of the requests Extension home economists received for information on diet modification for health maintenance.

Study Intent and Design

A questionnaire was developed and sent to 68 Extension home economists in all Florida counties. It documented the role of county agents as resources for information on modified diets and consumer referral. Eighty-eight percent of the questionnaires were returned. All respondents didn't answer all questions, however, so the percentages presented represent only total responses to any particular item. The survey asked 13 questions in the areas of demographic information, agents' educational backgrounds, nature of consumer questions received, and agents' referral capabilities. Results were compiled and analyzed by computer using the Statistical Analysis System (SAS) program.5

Results

The respondents were evenly divided between living in rural, urban, or mixed rural-urban counties, representing the general population distribution of Florida. Forty-seven respondents had earned at least two college degrees, the majority having a bachelor's plus master's degree. Five percent were registered dietitians (R.D.), and 25% had taken a course in diet therapy in the past. The majority of respondents knew of a dietetic association in their local area, and 79% routinely interacted with R.D.'s.

Ninety-three percent received questions on modified diets. It's not unusual for a patient to be sent home from the hospital or clinic with an order for dietary modification, but little, if any, patient nutrition education. Often the only nutrition educator known to the patient is the county home economist.

The majority of modified diet questions coming to agents are in the area of calorie-controlled diets. Similar to national trends described in the literature, Florida residents are interested in ways to reduce salt in their diets. The agents surveyed received an average of six calls monthly about sodium/salt restriction. The respondents who were R.D.'s indicated confidence in their ability to answer 90-95% of consumer questions on dietary modification, but only 28% of the non-R.D. agents felt similarly wellprepared. Nearly two-thirds (62%) of the agents with master's degrees didn't feel adequately prepared to answer most questions on modified nutrition. This isn't surprising, however, since academic majors in this group ranged from guidance/counseling to clothing/textiles. Even a master's degree in nutrition doesn't always ensure expertise in dietary modification.

The survey asked, "Do you perceive a need for continuing education for yourself regarding modified diets?" Eighty percent of those responding said yes. Agents recognized that competence in dietary modification wasn't expected of them, yet the survey revealed that agents wanted more information on diet modification and interagency referral. Eightyone percent of the respondents with master's degrees desired more training in this area. Surprisingly, 93% of those respondents who had taken a diet therapy course in the past indicated a need for more education on modified diets, whereas only 74% of the agents who had never taken a diet therapy course felt this same need.

Further delineation of curriculum content areas such as labeling regulations, food shopping, preservation and preparation, eating out, and dietary rationale is needed. The important point to emphasize is that the home economists are resource people in this and other foods/nutrition areas. They are neither the nutrition counselor as are the R.D.'s, nor primary care providers, as are the M.D.'s. They do have a role as information providers to consumers, as evidenced by the fact that nearly all respondents received questions on modified diets.

Responding to the question "I would like to know more about the types of allied health professionals or organizations that exist in my county for referral of consumers' questions regarding modified diet," 9% strongly disagreed, 21 % moderately disagreed, 47% moderately agreed, and 23% strongly agreed. Many agents noted that they were already knowledgeable in interagency referral and therefore disagreed with the statement. They valued and used their interagency referral capabilities.

Seventy-two percent of the urban respondents used Public Health nutritionists as resource people, whereas 61% of mixed and only 53% of rural agents did so. Seventy-two percent of the agents from mixed rural-urban counties went to R.D.'s for referral, as did 44% of urban and 42% of rural agents. Medical doctors were rarely contacted by agents.

The state nutrition specialist was cited as the most used resource for questions on modified diets.

Eighty-three percent of urban respondents, 79% of mixed rural-urban, and 67% of rural respondents used the state-level nutritionists. Over half of all respondents used literature from reputable healthrelated organizations. This is particularly interesting in light of the fact that few of these organizations can agree on nutrition advice to the public.

Table 1 details the types of resources used by the home economists when consumer requests are received.

Summary and Conclusion

State Extension Services are seeing changes in consumer expectations for foods and nutrition programming. The national diet includes less salt, less saturated fat, and fewer calories than ever before.6 Consumer demand for ways to alter diet to prevent or treat chronic illness is increasing. There's evidence that the majority of home economists in Florida receive consumer questions about management of modified diets, but agents often feel illequipped to answer these questions or to refer consumers to appropriate professional resources.

About 80% of the respondents to the survey wanted continuing education in the area of modified diets. It's possible that content material could be identified such that the home economists maintain their viability as a community nutrition resource without encroaching on the professional area of registered dietitians or physicians.

Natural liaisons between dietitians and home economists could emerge for community education programs focusing on shopping, label reading, home preservation, and preparation of foods. Important consumer groups would include older and/or single citizens, businesspeople, young mothers, adolescents, and athletes. In addition, with home economists in every county prepared to appropriately answer selected questions or refer consumers, it's possible that progress can be made against nutrition faddists who are all too willing to provide information (and misinformation) to the interested, but undiscerning, public.

Footnotes

1. A. Elizabeth Sloan and others, "Changing Consumers' Lifestyles," Food Technology, XXXVIII (November, 1984), 99-103.
2. Fergus M. Clydesdale, "Culture, Fitness, and Health," Food Technology, XXXVIII (November, 1984), 108-11.
3. American Heart Association, Nutrition Committee and the Council on Arteriosclerosis, Circulation, LVIIX (1984), 1065A; Committee on Diet, Nutrition and Cancer, Assembly of Life Sciences, National Research Council, Diet, Nutrition and Cancer (Washington, D.C.: National Academy Press, 1982); American Cancer Society, Nutrition and Cancer: Cause and Prevention, Special Report (New York: American Cancer Society, 1984); and National Cancer Institute, Cancer Prevention, NIH Publication No. 84-2671 (Washington, D.C.: U.S., Department of Health and Human Services, Public Health Service, National Institute on Health, 1984).
4. Food and Nutrition Board, Division of Biological Sciences, Assembly of Life Sciences, National Research Council, Toward Healthful Diets (Washington, D.C.: National Academy of Sciences, 1980) and Committee on Nutrition, American Academy of Pediatrics, "Toward a Prudent Diet for Children," Pediatrics, LXXI (1983), 78.
5. SAS Institute, SAS User's Guide: Basics (Cary, North Carolina: SAS Institute, Inc., 1982).
6. National Center for Health Sciences, National Health and Nutrition Examination Survey (Rockville, Maryland: National Center for Health Sciences, 1974).