Dietary Guidance and Nutrition Promotion: USDA’s Renewed Vision of Nutrition Education

Dietary Guidance and Nutrition Promotion: USDA’s Renewed Vision of Nutrition Education – United States Department of Agriculture

Sharyn M. Sutton

The United States has a proven process for continually developing national dietary guidance. This guidance, as reflected in the bulletin Nutrition and Your Health: Dietary Guidelines for Americans, represents the Federal Government’s policy on nutrition. Over the last 15 years, a consensus on diet and its effect on health has developed among U.S. nutrition and health experts. This paper addresses the relationship between the expert consensus on “nutrition, diet, and health” and the consumer. It distinguishes between dietary guidance and nutrition promotion: nutrition promotion uses the Consumer-Based Health Communications process to translate the science-based dietary guidance into consumer-oriented messages that facilitate behavior change. The implications for USDA’s dietary guidance and nutrition education efforts are discussed.

The United States has an established procedure for updating national dietary guidance. Title III of the National Nutrition Monitoring and Related Research Act of 1990 (7 U.S.C. 5341) requires the Secretaries of Agriculture and Health and Human Services to publish jointly every 5 years a report entitled Dietary Guidelines for Americans.

An appointed Dietary Guidelines Advisory Committee reviews the most up-to-date research and makes recommendations to the U.S. Department of Agriculture (USDA) and the U.S. Department of Health and Human Services (DHHS). After the recommendations are approved and accepted by the Departments, the recommended Dietary Guidelines and explanatory text are issued in a bulletin called Nutrition and Your Health: Dietary Guidelines for Americans (15). The Dietary Guidelines for Americans constitutes the basis of the Federal Government’s policy on nutrition.

Over the last 15 years, a remarkable degree of consensus on diet and its effect on health has developed among U.S. nutrition and health experts. The fourth edition of the Dietary Guidelines for Americans (15), released by USDA and DHHS in 1995, provides nutritional and dietary information and guidelines for the general public, based on current scientific and medical knowledge (9).

Consensus on the relationship between diet and health is critical to improving public health since diet has been linked to many chronic and preventable diseases:

* Four of the leading causes of death in the United States are nutrition-related (16). Heart disease, cancer, stroke, and diabetes account for more than 1.4 million deaths annually, nearly two-thirds of the U.S. total (16).

* Diet also plays a role in other health conditions such as overweight, hypertension, and osteoporosis, which can reduce the quality of life and productivity and contribute to premature death (16).

Taken together, these seven diet-related health conditions cost society an estimated $250 billion each year in medical costs and lost productivity (6). Improved dietary behavior might prevent at least 20 percent of the annual deaths from heart disease, cancer, stroke, and diabetes (6). Even small improvements in average dietary intakes towards the Dietary Guidelines for Americans can be valuable If intakes in fat, saturated fat, and cholesterol improved in the range of 0.1 to 1.4 percent, the Food and Drug Administration (FDA) estimates between $4.4 to $26.5 billion would be saved over 20 years (13).

This paper addresses the relationship between the expert consensus on “nutrition, diet, and health,” as reflected in the Dietary Guidelines, and the consumer. It examines how the state of dietary knowledge is transferred to the consumer and its effect on consumer eating behaviors. The implications for USDA’s dietary guidance and nutrition education efforts are discussed.

Nutrition, Health, and the Consumer

The Dietary Guidelines for Americans is supported by a rich history of science-based research and analysis. The guidelines are scientifically sound and have been remarkably consistent over the past 20 years.

While we have achieved success in developing science-based dietary guidance, we have been much less successful in translating this guidance for consumers in a way that educates and motivates changes in behavior leading to improved health status.

There is a serious gap between the experts’ agreement on dietary guidance and the consumer’s understanding of what constitutes a healthy diet. It is ironic that while scientific consensus has never been stronger, the consumers we seek to serve through this consensus remain very confused about dietary advice. Several recent national surveys highlight current consumer perceptions.

* Almost 50 percent of Americans say that there is too much conflicting information about what foods are good for them, and they are uncertain about what to eat (5).

* The Dietary Guidelines for Americans emphasize the importance of balance, variety, and moderation in the total diet–meaning that any food can fit into a healthful diet. But 70 percent of consumers think that they must eliminate favorite foods to improve their diets (1). The percent of consumers concerned about getting a balanced diet dropped from 11 percent in 1988 to 2 percent in 1995 (4).

* Dietary guidance is presented in a manner that is frequently misinterpreted by consumers in their attempt to build a healthy diet. For instance, “consumer unfriendly” advice on limiting total calories from fat to 30 percent is often interpreted by consumers to mean that they should not eat individual foods with more than 30 percent calories from fat (1, 5, 8).

* In addition, old perceptions and past nutrition advice linger in the minds of consumers. For example, whereas today’s nutritionists are urging greater consumption of breads and grains, 40 percent of Americans still think that bread is fattening, and 35 percent say starches should be avoided (17).

Consumer confusion and frustration over nutrition does not mean that they have given up or are incapable of changing their eating patterns. On the contrary, there are numerous examples that reflect the changes in the national nutrition agenda.

The increasing focus on fat in the American diet over the past decade is related to significant changes in consumer awareness, concern, and consumption. Consumer concern over fat content in foods has escalated dramatically. When asked:

“What is it about the nutritional content of the foods you eat that

concerns you most?”

the number of consumers who responded “fat content” jumped from 27 percent in 1988 to 65 percent in 1995 (4). Likewise, the mean percent of calories from fat has declined from 36 percent to 34 percent of total calories, although these levels are still above dietary recommendations (7).

The fact is that many consumers do change their dietary behavior–but the changes reflect their understanding and interpretation of dietary advice. The ability of consumers to improve their health depends upon how successfully they can translate the science-based dietary guidance into appropriate patterns of eating behaviors that lead to improved nutritional status. For example, an attempt to reduce intake of dietary fat by decreasing consumption of red meat will be successful only if meat consumption is not replaced by an equally high–fat substitute (e.g., high-fat salad dressings) (11).

Dietary Guidance and Nutrition Promotion

Changing diet-related behaviors is more complicated than once thought. Although it is possible to improve people’s knowledge and attitudes about food and nutrition, this does not necessarily result in the needed behavior change. There is now serious concern whether providing consumers with dietary guidance is sufficient to support behavior changes that lead to improved health.

A recent discussion among nutrition education leaders from various national organizations revealed strongly held beliefs that dietary guidance is not the best message for consumers, particularly if the goal is behavior change. “Consumers do not even have to see the [Dietary] Guidelines” (2). This contrasts greatly with the traditional nutrition education efforts surrounding the Dietary Guidelines. These efforts centered on the publication of a consumer bulletin, Nutrition and Health: Dietary Guidelines for Americans, that outlined seven guidelines and provided explanatory text. The focus was the nutrition science-base, not the needs of the consumer. The nutrition education leaders conceded that we currently know more about what a healthy diet is than about how to get it across to consumers. These professionals stated that consumer needs and behavior must play a central role in driving nutrition education programs to produce behavior change (2).

This consumer perspective is the foundation of USDA’s renewed vision for nutrition education. In May 1995, the Secretary of Agriculture announced a new comprehensive nutrition promotion effort to develop consumer-based messages. USDA’s recommitment to nutrition as one of six key mission areas is reflected in the establishment of the Center for Nutrition Policy and Promotion (CNPP) (10) “to improve the nutritional status of Americans by serving as the focal point within USDA for linking scientific research and the consumer.”

The term “nutrition promotion” is used to differentiate this new concept from past definitions of “nutrition education.” Nutrition promotion is defined as the translation of science-based dietary guidance into consumer-oriented messages that facilitate the appropriate eating behaviors. Nutrition promotion is based on consumer research. It follows the Consumer-Based Health Communications approach, which combines the science base with the consumer’s reality to create a message strategy that is meaningful and motivating to the consumer. The outcome of nutrition promotion is a consumer-based message strategy that will lead consumers to follow science-based dietary guidance (14).

Consumer Perceptions of Dietary Guidance

Traditionally, the actual Dietary Guidelines, as suggested by the Dietary Guidelines Advisory Committee and approved by USDA and DHHS, have been issued in a bulletin called Nutrition and Your Health: Dietary Guidelines for Americans (15).

The Dietary Guidelines Advisory Committee recognized the difficulty of having a single dietary guidance bulletin to address the needs of consumers, policymakers, and health professionals. The Committee felt it was important to investigate consumers’ reaction to the guidelines and their understanding of nutrition concepts in the Dietary Guidelines bulletin as a first step, preceding the focus on nutrition promotion to improve dietary behavior (3).

The Advisory Committee encouraged USDA and DHHS to continue to conduct consumer research to determine understanding of selected dietary guidance messages proposed for the 1995 Dietary Guidelines for Americans bulletin (15). The Committee also urged the Departments to use consumer research to design more meaningful messages to consumers.

In response to the Committee’s recommendation, CNPP/USDA, in consultation with DHHS, sponsored focus group research to gauge consumer reactions to specific design and content elements of an early draft of the 1995 bulletin as published in the Technical Report (3). The following section describes the methodology and research objectives (12).

Focus Groups on Dietary Guidelines

A series of 12 focus groups was conducted between May 31 and June 8, 1995. To obtain some geographic dispersion, four groups were conducted in each of three cities–Richmond, VA; Chicago, IL; and San Francisco, CA. Half of the 12 groups were conducted with women and half with men. A total of 107 consumers participated. In addition, four of the groups were conducted with general consumers representing a variety of respondents–within broad age, income, and education restrictions–while still maintaining enough homogeneity so the groups could discuss the issues in a coherent fashion.

The remaining eight groups were conducted with four target audiences: African Americans, older consumers, overweight consumers, and food stamp recipients. These target audiences were selected because of their potentially different perspectives on the Dietary Guidelines reflecting different health and diet attitudes, practices, and needs.

During the group discussions, participants were presented with three versions of a mocked-up Dietary Guidelines bulletin. Throughout the sessions, participants were asked to read and respond to various sections and formats of the mock-ups.

Specific research objectives included: Assessing consumer perceptions and understanding of selected dietary concepts and key terms such as moderation; assessing perceived barriers in following the Dietary Guidelines; and assessing consumer reaction to the actual presentation of the consumer bulletin.

As a qualitative research methodology, focus groups are not projectable to any population. However, they provide valuable insight into how the consumer views the world and what the consumer thinks–in this case–about nutrition and eating.

Emerging Consumer Themes

Findings from this focus group research can be presented under four general themes with illustrative quotes. All quotes from individuals participating in the focus groups are taken from the unpublished report prepared by Prospects Associates for USDA (12).

1. Distinguish Between Dietary Guidance AND Nutrition Promotion

The focus group research found strong support for making the distinction between dietary guidance and nutrition promotion. Reactions from the participants made it very clear that there is a difference between dietary guidance–what is known about nutrition–and nutrition promotion–what is needed by consumers to actually follow the dietary guidance. Both are critical.

Dietary guidance or nutrition knowledge does not necessarily give consumers the information and/or motivation to change their behavior. Nutrition knowledge does not in itself help consumers to act. However, it must be acknowledged that consistent consumer-based messages leading to behavior change must be based on dietary guidance. We need both dietary guidance and nutrition promotion.

“I think it’s [the Dietary Guidelines brochure] good for a brief overview

… I’m going to need something that’s going to give me more about what I

want to know.” [African American male]

“It would have no bearing for me. I wouldn’t even know how to begin

controlling it [fat intake]…. They need to say that you need to eat these

items that are lower in fat.” [General public–male]

“I just know that there are a lot of fats, and they are bad.” [General

public–male]

2. Effective Nutrition Promotion Must Communicate Consumer Benefits

The focus group discussions showed that participants were not motivated by the health consequences that underpin the Dietary Guidelines. Consumer benefits, as perceived by the consumer, were what mattered most. Therefore, we need to identify and promote benefits for healthy eating that have meaning in the mind of the consumer.

“What’s in it for me? … What would I get out of it?” [General

public–male]

“What’s the pay-off for doing this? That’s what I want to know.” [General

public–male]

If we don’t offer meaningful, motivating consumer benefits, we will lose our audience:

“And after a while, you get so discouraged, you say the heck with it. I’m

just going to eat it and see what happens.” [General public–female]

3. Translate Dietary Guidelines Into Consumer Behaviors

Consumers need to have the dietary guidance translated into consumer behaviors or actions. Consumers want directions; they want to know what to do.

Dietary Guidelines are not consumer behaviors. Dietary concepts such as fat reduction and consumption of fruits and vegetables are not necessarily relevant to how consumers live their lives. They do not communicate in terms that define consumers’ actions.

“Everybody knows you should eat more vegetables and fruits. It’s in the

media. We know that. But it’s about doing it. Helpful hints about how you

can do it.” [Food Stamp–female]

“Show us what 300 mg [of cholesterol] looks like. Is it half an egg? Is

that a full egg? Is that one and one-half eggs? Because when you see 300

mg, you think, what’s 300 mg?” [General public–male]

“To be perfectly honest, I have never considered how many calories I eat in

a day. 2,000 is just as arbitrary as saying 5,000. I’m going to eat what I

want to eat.” [General public–male]

“They keep throwing [the advice] to eat vegetables at you–vegetables as a

group. But a lot of people don’t know things like avocados are very

fattening. There are different vegetables that people should watch out

for–instead of just having vegetables in general.” [Food Stamp–male]

“Just don’t tell me not to do something. What is [the fat]? Where do I find

it?” [Overweight group–male]

Nutrition concepts and desired nutrition outcomes (e.g., reduce fat, increase consumption of grains, watch total calories) are not consumer behaviors. Consumers don’t reduce fat content; they remove the skin on their chicken. They don’t choose a diet with plenty of grain products; they eat spaghetti. We need to translate the Dietary Guidelines into actual consumer steps–much more in line, for example, with the 5 A Day program where “eat more fruits and vegetables” becomes “keep fruits visible” or “microwave your carrots in 2 minutes.”

It is clear that if the public is to follow the Dietary Guidelines, the Dietary Guidelines will need to be translated into consumer-based message strategies and specific behaviors that consumers can carry out. They do not want to do the math.

4. Express Consumer Behavior in Consumer Talk

The last general theme that emerged from the focus groups was the need to speak in a language that consumers understand. Consumers want specifics–clear, easy, meaningful information–on what they should do. They do not have the time, energy, or background to move from nutrition science and recommendations to a healthy diet.

“I want a sample dietary plan. Show me the foods [I] should eat and how

much fat or grams of fat each food has, so I can visualize [it and] follow

this type of diet.” [General public–male]

“I think that people are eating them (fruits and vegetables); it’s just

that they’ re not eating them properly. It doesn’t say don’t cook this way.

Or they don’t give you suggestions of different ways of preparing them.”

[Food Stamp group–female]

“They’re talking about saturated and unsaturated fats, and monounsaturated

and polyunsaturated. And what are they? What are these things they are

telling me about?” [Overweight group–male]

Information that is matter of fact to nutritionists may not be credible or understandable to the consumer. For example, nutritionists know that it is the total diet that counts, not an individual food. But how does that message play with the consumer? Is it perceived as meaningful? Believable? Achievable? These questions must be answered in order to craft a “total diet message.”

“Like I said before, I believe that if you’re going to put out advice you

should have do’s and don’ts and not “political correctness” so that

everything is positive.” [Older Americans group–male]

“My thing is that I don’ t count calories. I know that I eat food that’s

lower in fat. I used to make the mistake of counting calories and it didn’t

work because that meant I ate all the macaroni and cheese that I wanted and

stuff like that. I still maintained or gained weight.” [African

American–female]

It must also be recognized that consumers are not all alike. Messages must be tailored to varying informational and motivational needs. One bulletin or brochure will never do the entire job. This is shown by these two consumer comments to the same brochure:

“I knew that from before, but it’s pretty clear in here.” [African

American–male]

“Well, [this is clear] if you know Greek.” [Overweight group–female]

Implications for Nutrition Promotion

The insight gained from the focus groups reinforced the Dietary Guidelines Advisory Committee’s recommendation for a two-pronged approach. USDA’s renewed vision for nutrition education must meet two significant challenges:

* Continue to advance national dietary guidance based upon the preponderance of scientific evidence, and

* Promote this guidance to consumers in a way that will lead to behavior change and ultimately improved health and well-being.

Moving from traditional issuance of dietary guidance to consumer-based nutrition promotion will require the following:

* A focus on behavior change. The ultimate purpose of dietary guidance and promotion is to improve dietary behavior. Behavior change cannot occur unless it is purposefully targeted for change. If changes in knowledge and attitude are the end points, then improvements will not be achieved.

* A strong consumer orientation. Understanding and emphasizing the nutrition behavior from the consumer’s point of view is essential. Knowledge of what consumers believe, value, need, and do is as important as our knowledge of basic human nutrition. Speaking in a language that the consumer understands, in a way that is lively, appealing, and entertaining, is just as critical as communicating the nutritional facts.

* Segment and target consumers. There must be recognition that one message will not meet the needs of the entire public. We must have a clear and vivid picture of who the target is and focus the message in a personal and meaningful way on precise audience segments to create the most impact.

* Use multiple, reinforcing, interactive channels that actually reach consumers. Various, integrated, new technologies exist today that can reach the target audience to deliver the message through multiple and reinforcing media. Again, these channels must be selected from the consumer’s viewpoint: Where will they be open to the message? When will they be thinking about nutrition? Based on a thorough understanding of the audience–TV advertising, radio advertising, cable programming, talk shows, newspaper editorials, lifestyle sections, food columns, consumer magazines, direct promotions, point of purchase programs, promotions, interpersonal/ intermediary partnerships–all can be useful to deliver and reinforce the message.

* Continually refine the consumer messages. What works today may be ineffective tomorrow because of the changes in our consumers, the marketplace, the competition, and the consumer benefits.

References

(1.) The American Dietetic Association and International Food Information Council. 1994. How Are Americans Making Food Choices?–1994 Update. Prepared by The Gallup Organization.

(2.) Balch, G.I. 1995. Expert Advice on the Direction of Nutrition Education and Promotion. Final Report to the Center for Nutrition Policy and Promotion. Unpublished.

(3.) Dietary Guidelines Advisory Committee. 1995. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 1995, to the Secretary of Health and Human Services and the Secretary of Agriculture. U.S. Department of Agriculture, Agricultural Research Service.

(4.) Food Marketing Institute. 1995. Trends in the United States, Consumer Attitudes and the Supermarket, 1995. Conducted by Opinion Research Corporation.

(5.) Food Marketing Institute and Prevention Magazine. 1995. Shopping for Health 1995. New Food Labels, Same Eating Habits?

(6.) Frazao, E. 1995. The American Diet: Health and Economic Connsequences. U.S. Department o Agriculture, Agriculture Information Bulletin No. 711.

(7.) McDowell, M.A., Briefel, R.R., Alaimo, K., Bischof, A.M., Caughman, C.R., Carroll, M.D., Loria, C.M., and Johnson, C.L. 1994. Energy and macronutrient intakes of persons ages 2 months and over in the United States: Third National Health and Nutrition Examination Survey, Phase 1, 1988-91. Advance Data No. 255. National Center for Health Statistics.

(8.) National Live Stock and Meat Board and MRCA Information Services, Inc. 1994. Eating in America Today: A Dietary Pattern and Intake Report. Edition II.

(9.) The National Nutrition and Related Research Act. 1990. 7 U.S.C. 5341.

(10.) 1995 Farm Bill: Guidance of the Administration. Section 5: Food and Nutrition, pp. 67-73, 1995.

(11.) Popkin, B.M., Haines, P.S., and Reidy, K.C. 1989. Food consumption trends of U.S. women: Patterns and determinants between 1977 and 1985. American Journal of Clinical Nutrition 49:1307-1319.

(12.) Prospects Associates. 1995. Dietary Guidelines Focus Group Report. Unpublished report prepared for the U.S. Department of Agriculture, Center for Nutrition Policy and Promotion.

(13.) Research Triangle Institute. 1991. Estimating the Benefits of Nutrition Label Changes.

(14.) Sutton, S.M., Balch, G.I., and Lefebvre, C. 1995. Strategic questions for consumer-based health communications. Public Health Reports 110(6):725-733.

(15.) U.S. Department of Agriculture and U.S. Department of Health and Human Services. 1995. Nutrition and Your Health: Dietary Guidelines for Americans. 4th ed. Home and Garden Bulletin No. 232.

(16.) U.S. Department of Health and Human Services. 1990. Healthy People 2000, National Health Promotion and Disease Prevention Objectives. DHHS Publication No. (PHS) 91-50212.

(17.) Wheats Food Council and American Bakers Association. 1995. What America Thinks About Eating Right. A Gallup opinion survey.

Sharyn M. Sutton(1)

President Sutton Social Marketing

William Layden

Director, Nutrition Promotion Staff Center for Nutrition Policy and Promotion

Jackie Haven

Nutritionist Center for Nutrition Policy and Promotion

(1) Formerly Director, Nutrition Marketing and Education, Center for Nutrition Policy and Promotion.

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