from the association                                                                                   ADA REPORTS        ...
ADA REPORTSnutrients within calorie needs. This      for Americans, but limited quantities       SUCCESSFUL COMMUNICATIONi...
ADA REPORTSsituation such as a tempting food (eg,       and growth. To avoid this confusion,       sumption of savory, hig...
ADA REPORTSfoods are not readily accessible at        control diets is a preoccupation with       the great influence of pa...
ADA REPORTSeconomic factors were the most im-         When Kellogg’s high-fiber cereals          promoting healthful behavi...
ADA REPORTS                                                                                                      terms of ...
ADA REPORTSimprovements at the broader organi-              it is important to stress that a diet   Effective Communicatio...
ADA REPORTS 3. Food Marketing Institute. SuperMarket Re-               cians, registered in health promotion and          ...
ADA REPORTS      gene map: The 2005 update. Obesity Res.                188. Agriculture Information Bulletin No.         ...
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  1. 1. from the association ADA REPORTS Position of the American Dietetic Association: Total Diet Approach to Communicating Food and Nutrition Information messages that emphasize the total half of food shoppers strongly agreeABSTRACT diet approach promote positive life- that eating healthfully is a better wayIt is the position of the American Di- style changes. to manage illness than medication.etetic Association that the total diet J Am Diet Assoc. 2007;107: Unfortunately, this trend toward in-or overall pattern of food eaten is the 1224-1232. creasing awareness has been accom-most important focus of a healthful panied by widespread confusion witheating style. All foods can fit within complaints that nutrition educationthis pattern, if consumed in modera- POSITION STATEMENT is focused on what NOT to eat, in-tion with appropriate portion size and It is the position of the American Die- stead of what TO eat (1). These con-combined with regular physical activ- tetic Association that the total diet or flicting messages make it difficult toity. The American Dietetic Associa- overall pattern of food eaten is the know what to do.tion strives to communicate healthful most important focus of a healthful Eating is an important source ofeating messages to the public that eating style. All foods can fit within pleasure. As food and nutrition pro-emphasize a balance of foods, rather this pattern, if consumed in modera- fessionals strive to improve the qual-than any one food or meal. tion with appropriate portion size and Public policies that support the to- ity of Americans’ dietary and lifestyle combined with regular physical activ- choices, challenges are exacerbatedtal diet approach include the Dietary ity. The American Dietetic AssociationGuidelines for Americans, MyPyra- by the widespread perception that in- strives to communicate healthful eat-mid, the DASH Diet (Dietary Ap- dividuals must choose between good ing messages to the public that em-proaches to Stop Hypertension), Di- taste and nutritional quality. In fact, phasize a balance of foods, ratheretary Reference Intakes, and no single food or type of food ensures than any one food or meal.nutrition labeling. The value of a food good health, just as no single food orshould be determined within the con- type of food is necessarily detrimental O ver the past 4 decades, Ameri-text of the total diet because classify- cans have become more con- to health. Rather, the consistent ex-ing foods as “good” or “bad” may foster scious of diet and nutrition (1). cess of food, or absence of a type ofunhealthful eating behaviors. Alter- Although nearly all consumers be- food over time, may diminish the like-native approaches may be necessary lieve that body weight, diet, and phys- lihood of a healthful diet. For exam-in some health conditions. Eating ical activity influence health, diet sur- ple, habitual, excessive consumptionpractices are dynamic and influenced veys suggest that their food habits of energy-dense foods may promoteby many factors, including taste and are not always commensurate with weight gain and mask possible under-food preferences, weight concerns, knowledge and beliefs (2). Only half consumption of essential nutrients.physiology, lifestyle, time challenges, describe their diet as healthful, and Yet small quantities of energy-denseeconomics, environment, attitudes 14% eat five or more servings of fruits foods on special occasions have no dis-and beliefs, social/cultural influences, and vegetables per day. One third cernible influence on, food technology, and food classify themselves as sedentary and In most situations, nutrition mes-product safety. To increase the effec- do not engage in physical activity. sages are more effective when focusedtiveness of nutrition education in pro- Even though more than half of con- on positive ways to make healthfulmoting sensible food choices, food and sumers say they are making dietary food choices over time, rather thannutrition professionals should utilize changes to improve their health, ap- individual foods to be avoided (4,5).appropriate behavioral theory and ev- proximately two thirds are over- Unfortunately, the current mix of re-idence-based strategies. A focus on weight or obese. It is clear that prac- liable and unreliable information onmoderation and proportionality in the tical guidance by food and nutrition diet and nutrition from a variety ofcontext of a healthful lifestyle, rather professionals is needed to promote sources is confusing to the public andthan specific nutrients or foods, can positive lifestyle changes that are elicits negative feelings such as guilt,help reduce consumer confusion. Pro- sustainable. worry, helplessness, anger, fear, andactive, empowering, and practical According to the Shopping for inaction. Health 2004 study, nearly six in 10 The total diet approach is based on consumers are trying hard to eat overall eating patterns that have im- 0002-8223/07/10707-0021$32.00/0 healthfully so they can avoid health portant benefits and health conse- doi: 10.1016/j.jada.2007.05.025 problems later in life (3). More than quences and that provide adequate1224 Journal of the AMERICAN DIETETIC ASSOCIATION © 2007 by the American Dietetic Association
  2. 2. ADA REPORTSnutrients within calorie needs. This for Americans, but limited quantities SUCCESSFUL COMMUNICATIONincludes the concept that foods are would be acceptable, provided that CAMPAIGNS AND PROGRAMSnot inherently “good” or “bad.” Over nutrient-dense foods comprise the Teaching consumers to make wisethe years, the American Dietetic As- bulk of the day’s choices. This mes- food choices in the context of the totalsociation has consistently recom- sage of the total diet approach must diet is not a simple process. Depend-mended a balanced variety of nutri- be communicated to consumers by ing on the audience and the situation,ent-dense foods eaten in moderation food and nutrition professionals. a variety of nutrition information,as the foundation of a health-promot- communication, promotion, and edu-ing diet (5,6). cation strategies may be needed for Nutrition Labels an appropriate and effective nutrition Nutrition labels are a third tool that intervention. It may be necessary toFEDERAL NUTRITION GUIDANCE consumers can use to choose and com- suggest a change to a more healthfulSUPPORTS THE TOTAL DIET APPROACH pare foods. The Nutrition Facts label lifestyle in terms of small steps thatThe Dietary Guidelines for Americans was developed by the Food and Drug are achievable in increments, so that(7), which are the centerpiece of fed- Administration and its collaborating these can build to broader successeseral food, nutrition education, and in- agency partners as a consumer infor- in improving fitness or dietary qualityformation programs, are based on a mation system. Food and nutrition (17). In addition, successful cam-total diet approach to food guidance. professionals have found the label to paigns often include the coordinatedThe DASH (Dietary Approaches to be an effective educational tool that efforts of a number of agencies andStop Hypertension) Eating Plan from helps consumers plan their diets. For organizations with similar healththe US Department of Health and example, 48% of survey respondents promotion goals (4,17-19).Human Services is one of many re- reported that they had changed their A growing body of evidence sup-sources that are available to assist minds about buying or using a food ports the recommendation to designconsumers in implementing these product after reading the nutrition la- behavior-oriented food and nutritionrecommendations (8-11). bel in 1995, as compared with 30% in programs that are targeted to help The MyPyramid Food Guidance 1990 (15). learners adopt a total diet approachSystem is another example of a di- that is sustainable and fits individualetary pattern that uses a total diet preferences. Nutrition education re-approach to ensure nutritional ade- Nutrient Intake Recommendations search supports the identification ofquacy and healthful food choices. My- The Dietary Reference Intakes (DRIs) components that are effective acrossPyramid was released in 2005 as an are reference values that are used to various types of interventions (17,20).updated graphic to replace the Food plan and assess diets for healthy pop-Guide Pyramid. The developers of the ulations. The DRIs replaced the Rec-Dietary Guidelines for Americans and ommended Dietary Allowances, PSYCHOSOCIAL CONSEQUENCES OF GOODMyPyramid found that consumers which had been revised periodically AND BAD FOOD MESSAGESand educators preferred dietary guid- since 1941. The new dietary stan- Categorizing foods as good or bad pro-ance that enables consumers to eat in dards emphasize the prevention of motes dichotomous thinking. Dichot-a way that suits their individual chronic diseases and promotion of op- omous thinkers make judgments intastes and lifestyles (8,12,13). The timal health (16). A positive emphasis terms of either/or, black/white, all/concept of monitoring discretionary was implemented, rather than “focus- none. or good/bad and do not incorpo-calories (solid fats, added sugars, al- ing solely on the prevention of nutri- rate abstract or complex options intocohol) was introduced to allow con- tional deficiencies.” In addition to the their decision strategies.sumers to choose small amounts of Recommended Daily Allowancesless-nutrient-dense foods while meet- (RDAs), DRI categories include Esti-ing nutrient needs within caloric lim- mated Average Requirements The Magic Bullet Approachits (14). For example, consumers can (EARs), Adequate Intakes (AIs), and Thinking in terms of dichotomous orbalance a small amount of low-nutri- Tolerable Upper Intake Levels (Uls). binary (either/or) categories is com-ent or high-energy-density food or Each type of DRI refers to average mon in childhood. Almost all elemen-beverage (eg, fried food, butter/mar- daily intake over time—at least 1 tary-age and half of middle schoolgarine, jelly, alcohol) with nutrient- week for most nutrients. For macro- children believe that there are gooddense foods (vegetables, whole grains, nutrients, recommendations are and/or bad foods (21). Although thenonfat milk) to achieve an overall stated as Acceptable Macronutrient ability to think in more abstract andhealthful dietary pattern (13). How- Distribution Ranges (AMDRs). The complex modes is prevalent amongever, the discretionary calorie values AMDRs show that there is not just adolescents and adults, consumers ofcan be quite low (150 kcal/day), such one acceptable value, but rather a all ages tend to rely on dichotomousthat if an individual ate a fried broad range within which an individ- thinking in certain situations (22).chicken entree, it would be impossible ual can make diet choices based on An example of dichotomous think-to stay within the recommended lim- their own preferences, genetic back- ing is the quick fix or “magic bullet”its with the addition of other high- grounds, and health status. This con- approach to weight control. As long asenergy foods. Thus, large servings of cept of adequacy of nutrient intakes one stays on the diet (target behavior)foods or beverages high in solid fats, over time supports the need to help the person feels a sense of perceivedadded sugars, or alcohol are not com- consumers understand the impor- control (self-efficacy). However, whenpatible with the Dietary Guidelines tance of the total diet approach. an individual encounters a high-risk July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1225
  3. 3. ADA REPORTSsituation such as a tempting food (eg, and growth. To avoid this confusion, sumption of savory, high-fat snacksa cookie), loss of control may occur, the Food and Drug Administration was associated with poor diet qualitydepending on the individual’s emo- has excluded the naturally occurring (33). In addition, three national sur-tional state, interpersonal conflict, trans fat that is in a conjugated sys- veys of the US population have docu-and social pressure (23). tem from its definition of trans fat for mented that portion sizes and energy In this scenario, a cookie would be nutritional labeling (26). intakes have increased substantiallyregarded as a forbidden food and a Conversely, even foods associated over time both inside and outside thedieter who yields to a desire for a with a healthful diet such as egg household (34). Nutrition education iscookie would tend to say, “I ate the whites and soybeans should not be critical because individuals tend tocookie. I have blown my diet. I might oversimplified as being perfect. Egg eat more calories when served largeas well finish the rest of the box.” This whites are low in cholesterol and high portions of foods, especially energy-pessimistic approach becomes self- in protein, yet they are also so low in dense foods (35). Yet foods low in nu-fulfilling, as the subject believes that zinc that they can induce a zinc-defi- trient density can fit as part of thethere is not much that can be done ciency when used as a primary or sole total diet, if these foods are consumedonce a loss of control occurs (24). A source of protein in the diet (27). Sim- as discretionary calories in combina-skilled nutrition counselor might re- ilarly, soybeans have n-3 fatty acids, tion with appropriate quantities ofduce the probability of relapse by in- flavonoids, and phytoestrogens with other recommended foods (36).creasing awareness of nutrition health-promoting properties, but soy Another controversy with the total(knowledge), teaching coping skills also contains phytates that diminish diet approach is the emphasis on va-(alternative behaviors), incorporating absorption of zinc and iron (28,29) riety. Choosing a variety of foods haspersonal favorites in individualized and the health benefits of adding soy been a cornerstone principle in theeating patterns, and promoting ac- to the diet have not been consistently Dietary Guidelines for Americans, butceptance of personal responsibility supported by research (30). For exam- that emphasis has changed fromand choice (“I can refuse to eat it” or “I ple, animal studies in which soy in- overall variety to varying choicescan occasionally enjoy a small por- take was higher than that found in within the food groups. Choosing ation”). The option of providing simple, Asian diets found an increase in tu- variety of nutrient-dense foods helpsone-size-fits-all decision rules may be mor growth (31). Thus, foods such as to ensure adequate intakes of morean expedient approach to education egg white and soy cannot be classified than 50 nutrients that are needed forand counseling, but it often misleads as completely good or bad, but rather growth, repair, and maintenance ofconsumers into thinking that a given their value is determined within the good health. However, an increase intype of food is always a positive or context of the total diet. Furthermore, food availability and variety in food lists of good and bad foods were con- choices may be a cause of overeating,negative addition to the diet. The al- sidered one of the “Ten Red Flags of especially when applied to energy-ternative of offering more comprehen- Junk Science” by the Food and Nutri- dense foods (37). For example, thesive and targeted education involves tion Science Alliance, a collaboration multitude of choices at a buffet andcontext-based judgment. This type of of seven scientific professional organi- the temptation to taste each food caneducational message is more difficult zations (5). result in a greater intake of caloriesto address in language that is easy to With over 45,000 food items in the than from a plated or family-styleunderstand and apply, but it is more average supermarket (32) and an in- meal. When McCrory and colleagueslikely to help the consumer to make finite array of recipe combinations, (38) analyzed 1999 food consumptionwell-reasoned food choices and adopt the futility of attempting to sort all data, increases in energy intakes andbehavior patterns that are sustain- food items into dichotomous catego- body fatness were associated with in-able over time (17). ries becomes evident, leading to con- gestion of a high variety of sweets,All-Good or All-Bad Foods? Problems oc- fusion and frustration. Thus, the total snacks, condiments, entrees, and car-cur when a food or food component is diet approach, with its emphasis on bohydrate foods, coupled with a lim-oversimplified as all good or all bad. long-term eating habits and a contex- ited variety of vegetables. Krebs-The increased risks for cardiovascu- tual approach to food judgments such Smith and colleagues (39) observedlar disease associated with ingestion as discretionary calories, provides that a variety of foods was associatedof trans fat produced during process- more useful information to guide with nutrient adequacy to a point, be-ing of foods might lead to the classifi- long-term food choices. yond which there was no improve-cation of all trans fat as bad. How- ment. When nutrient needs are satis-ever, a type of trans fat that occurs fied, eating additional foods providesnaturally from ruminant animal CONTROVERSIES WITH THE TOTAL DIET excess calories without added healthsources (dairy and meat), conjugated APPROACH benefits.linoleic acid, has far different effects One concern with the total diet ap-on metabolic function, genetic regula- proach is that it may be viewed astion, and physiological outcomes (25). permitting unlimited inclusion of low- WHY WE EAT WHAT WE DOIn contrast to the atherogenic nature nutrient-density foods and beverages Convenience, Cost, and Confusionof most synthetic forms of trans fat, or encouraging overconsumption of Although 87% of consumers reportedconjugated linoleic acid has been foods with marginal nutritional being very or somewhat concernedshown to have beneficial effects on value. In a study using a Dietary about nutrition, widespread improve-cardiovascular disease, diabetes, im- Guidelines index as a measure of ments in dietary changes have notmune response, energy distribution, healthful diet quality, heavy con- occurred (2). Shoppers say healthful1226 July 2007 Volume 107 Number 7
  4. 4. ADA REPORTSfoods are not readily accessible at control diets is a preoccupation with the great influence of pathophysiolo-fast-food restaurants or take-out food and eating (50). In the context of gies on food choices and nutrientplaces and the cost is too high. Also, self-improvement, the dieter may re- needs, it is important to stress thatconfusion exists over conflicting infor- strict foods or macronutrients consid- the total diet approach is designed formation about the healthfulness of the ered to be “fattening.” Rather than the general, healthy population,wide range of foods that are available focus on total restriction of particular rather than individuals with chronic(40). Americans have made a number foods, which can lead to feelings of diseases.of positive dietary changes in the past deprivation (and subsequent recidi-20 years (41), such as increased con- vism), individuals are encouraged to Lifestyle Influencessumption of fruits, vegetables, and avoid excessive weight gain by under-grains. However, many still fail to in- taking lifestyle changes that repre- Time. One of the most significant in-clude adequate servings of fruits, sent a balanced and healthful diet fluences affecting food choices is thedark green vegetables, orange vegeta- and an exercise pattern that can be lack of time in our rapidly changingbles, mature beans and other le- maintained throughout life (7,51). lifestyle. In the 2000 American Die-gumes, and low-fat dairy products. At tetic Association Trends Survey, 38%the same time, added sugars and fats indicated that, “It takes too muchcontribute substantial calories to the Abundance of Foods with Healthful time to keep track of my diet” (57).American diet. Properties This is even higher than the 1995 The demand for nutritious foods has American Dietetic Association Trends stimulated the food and agriculture Survey, in which 21% cited time re-Taste and Food Preferences industries to develop a variety of straints as an obstacle to change (58).Taste is generally the most important products, including functional foods With 60% of American women try-factor influencing food choice. The six that provide potential health benefits ing to juggle work with families and abasic taste sensations—sweet, sour, beyond basic nutrition and new agri- desire to spend less than 15 minutesbitter, salty, umami (L-amino acid), cultural and biotechnology tech- to prepare a meal (59), there has beenand fatty acids—are affected initially niques. Many new biotechnologies a virtual explosion of convenienceby genetics, but these can be modified have enhanced the quality, safety, foods, take-out, value-added (precut,by physiological and metabolic vari- nutritional value, and variety of foods prewashed), and ready-made foods.ables such as feelings of contentment available to the consumer (52). Con- The traditional role of mothers pre-and satiety (42). Taste preferences cern has been raised that increasing paring healthful foods from scratch isare further developed by experiences abundance of functional foods may being replaced by parents purchasingrelated to one’s sex, age, weight, and contribute to increased energy in- take-out foods from a variety ofeating behaviors (43). For example, takes if individuals tend to think it is vendors.taste preference for sweetness is in- acceptable to eat larger quantities of Culture. Cultural food practices notborn. This preference for sweetness, foods that are good for them (53), such only affect taste preferences, but alsoin conjunction with familiarity, is the as reduced-fat cookies. As consumer shopping habits, manners, communi-most significant determinant of food choices continue to expand, food and cation, and personal interactions. Inchoices in young children (44). Be- nutrition professionals need to stay 2005, the minority population totaledcause young children (45) and even current through continuing education 98 million, or 33%, of a total of 296rats (46) can learn to prefer high-en- to meet the needs of an ever-changing million (60). As people from varyingergy foods, the avoidance of these society. backgrounds become acculturatedfoods may be foiled by feelings of de- into US society, their dietary habitsprivation because of a well-estab- tend to change from a pattern basedlished desire to eat sweet and high- Physiological Influences on whole grains and vegetables tocalorie foods. Consequently, small Digestive decline, poor dental health, foods that are higher in fats and sug-portions of these foods on special oc- swallowing difficulties, bone deminer- ars (43). Sensitivity to what might becasions are permissible within the alization, dementia, and/or dimin- considered good or bad by personscontext of the total diet approach. ished basal metabolism affect food from varying cultures is critical for choices of many individuals, espe- food and nutrition professionals, who cially older adults. Disease states and have the complex job of tailoring ad-Nutrition and Weight Control treatments, such as dialysis for vice to each individual within a cul-Nutrition is a major predictor of food chronic renal failure (54) and chemo- tural context. For example, to im-choices even though it is less of a per- therapy for cancer (55), also change prove the diet of Latinos who aresonal concern for most consumers food habits. For example, patients prone to diabetes and may overem-than taste, convenience, or cost. A with renal failure tend to dislike phasize some traditional foods, a foodhigh level of nutrition knowledge is sweet foods, vegetables, and red and nutrition professional could pro-positively associated with overall diet meats, whereas protein foods (eggs, vide guidance on alternate choicesquality (47) and a greater weight loss cheese, meat) often become unpleas- such as brown rice and whole-wheatin dieting women (48). ant for patients undergoing treat- tortillas and encourage portion con- Food choices are significantly influ- ment for cancer. More recently, the trol (61).enced by misdirected concerns over profound significance of one’s genes Economics. Food prices vary in theirweight control (49). One common con- on obesity and feeding behaviors is effects on food choice behaviors. Insequence of many popular weight- being investigated (56). Because of 1993, 53% of Americans thought that July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1227
  5. 5. ADA REPORTSeconomic factors were the most im- When Kellogg’s high-fiber cereals promoting healthful behaviors, com-portant issue facing this country; by first added health claims about can- munications designed to build skills1999, only 12% held this belief (59). In cer prevention and dietary fiber to or help learners master more complexindividuals with lower incomes, con- their package label, sales escalated concepts usually benefit from the in-venience is rated as a more important 47% within the first 6 months (71). clusion of principles from health-be-influence on food choices as compared Trade association programs have pro- havior theories and models (Figure).with those with higher incomes (62), moted generic advertising, such asreflecting limitations in transporta- the one for fluid milk (“Got Milk?”),tion, cooking facilities, food prepara- which featured celebrities wearing Adapting Behavior-Oriented Theories fortion skills, grocery store locations, milk mustaches. Remarkably, these Food and Nutrition Communicationand availability of healthful food campaigns slowed or stopped the de- Knowledge-Attitude-Beliefs. One of thechoices (63,64). However, financial is- clining trend of milk consumption simplest models for food and nutritionsues were associated with limited and 47 lb of milk were purchased for communication is the Knowledge-Atti-compliance with dietary guidelines in each advertising dollar spent (72). tude-Beliefs approach, which is baseda recent study of low-income women Thus, consumers can change their(65). perceptions of foods and food choices on the often-mistaken assumption that when given repeated and positive nu- the person who is exposed to new infor- trition messages. mation will attend to it, gain newEnvironmental Factors knowledge, change attitude, and im- Product Safety. Concerns about prod-Attitudes and Beliefs. Attitudes and be- prove dietary patterns (20). This ap- uct safety can affect food choices pro-liefs about foods tend to reflect cul- proach can be effective if the individual foundly. For example, the 1988 scaretural values, but they change more is already motivated and the new infor- of Alar (Chemtura Corporation,quickly with time (66). For example, mation is easy to follow. For example, a Middlebury, CT) in apples resulted inperceptions, attitudes, and beliefs list of foods that are high in iron may be near hysteria among mothers whoabout fat have shifted in the last half a successful trigger to dietary improve- thought they had fed their childrenof this century, much of it because of ment for someone concerned over a re- tainted foods. Apple sales plummetedsocial trends and marketing cam- cent diagnosis of anemia. However, as a result, even though the researchpaigns. Also, the typical “meat and without such a “teachable moment,” in- behind the scare was controversial.potatoes” plates have been replaced creased knowledge, such as a memo- When Alar (a plant growth regulator)by varying cuisines and preparation rized list of high-iron foods, often fails was removed from use in some statestechniques (67). An illustration is a to result in changed behavior. This is and the perceived risk of cancer min-1950s restaurant meal of beef steak, true especially if following the advice is imized, consumers returned to eatingfried onion rings, lettuce wedge with not convenient or congruent with per- apples as in the past (73). Although itThousand Island dressing, and baked sonal taste preferences. is essential to acknowledge that trulypotatoes with butter, cheese, and sour unsafe foods are never good food Health-Belief Model. The Health-Beliefcream. Today, meals might be lower choices, in this case, positive mes- Model is one of the most widely usedin fat and reflect changing tastes, sages about the benefits of diets with theories in health education (74). Ansuch as pasta with chicken, sun-dried plenty of fruits and vegetables help example is the promotion of foodstomatoes, and roasted vegetables, ac- restore balance in diet and health high in folate to reduce the risk ofcompanied by a salad of mixed field goals. certain birth defects. This model ex-greens, dried cranberries, and bal-samic dressing. plains human behavior and readinessSocial Influences. Social factors sub- COMPLEXITIES OF CHANGING EATING to act via four main constructs: per-stantially influence eating behaviors. BEHAVIORS ceived susceptibility (“How likely amFor example, the presence of a friend I to get heart disease and how soon?”), The impact of nutrition information(but not a stranger) while eating in- severity (“How bad would it be to on promoting healthful lifestyles de-creases energy intake by 18%. This have heart disease?”), benefits (“Will pends on how effectively nutritionstudy suggested that social facilita- messages are communicated to con- I feel better if I change the fats thattion of eating is caused by an im- sumers. Nutrition information must I eat?”), and barriers (“How hard willpaired ability to self-monitor (68). In be presented with sufficient context to it be to make these changes in mya study of why cardiac patients do not provide consumers with a broader un- fat intake?”). A recent addition to thefollow nutritional advice, 86% re- derstanding of the issues and to de- Health-Belief Model is the concept ofported that social and work situations termine whether it applies to their self-efficacy (“How confident am I thatpresented challenges, in addition to unique needs (4). Communications I can succeed in changing the fatsfinancial barriers to change and diffi- and educational programs must em- that I eat?”). The Health-Beliefculty with restraint when facing large phasize the importance of considering Model is useful when the target au-amounts of food (69). a food or meal in terms of its contri- dience perceives a problem behaviorMedia. The media is a powerful force butions to the total diet. This type of or condition in terms of health mo-influencing the food choices of Amer- communication can be more effective tivation. Yet many consumers “tuneicans. In 2004 approximately $11 bil- when educators use appropriate the- out” repeated messages of gloomlion was spent for food, beverage, and ories and models of factors related to and doom for habits that seem com-restaurant advertising in magazines, human behavior (18). Although pro- mon and without immediate nega-newspapers, television, and radio (70). viding information can be effective in tive consequences.1228 July 2007 Volume 107 Number 7
  6. 6. ADA REPORTS terms of their progress through a se- ries of behavioral stages (stages of change). It also includes related di- I realize that eating whole fruit is a good way to help me increase my intake mensions such as processes of change, of fruits and vegetables each day. I also realize that I have been getting self-efficacy, and decisional balance most of my fruit in the form of juice. I will start buying more whole fruit and (pros/cons) and allows educators to less juice the next time I go to the supermarket. tailor educational messages to learn- Stages and processes of change ers’ needs and readiness for behav- Transtheoretical Model ioral change. Social Marketing. Social marketing is a 1 behaviorally focused process that adapts commercial marketing tech- If the vending machines at my office have fruit, I will be more likely to niques to programs designed to influ- select it as a snack. ence the behavior of target audiences Reciprocal determinism to improve their well-being. Social Social Cognitive Theory marketers work to create and main- tain exchanges of target audience re- 1 sources, such as money or time, for perceived benefits such as feeling bet- I know that I can eat more fruit and less juice by learning which fruits are in ter or having more independence. season and putting those fruits on my weekly shopping list. Just as educators may use a range of Self-efficacy theoretical concepts to design effec- Social Learning Theory, Transtheoretical, and Health-Belief Models tive interventions, marketing cam- paigns also may be more effective 1 when important determinants of be- havior are identified and used in a Whole fruits have fiber that helps me feel full. If I drink juice instead of media campaign (77). eating whole fruit, I would get less fiber and have a harder time managing The Fruits and Veggies: More Mat- my calorie intake. That could lead to gaining excess weight which would ters campaign and its predecessor, make me feel less attractive. However, I may not be able to eat whole fruit the 5-A-Day for Better Health cam- as often as I want to because it is easier to find fruit juice when I need paign, are examples that adapt mar- something that’s fast and easy from a vending machine or a convenience keting theory to food and nutrition store. communication (78). Designers of Perceived benefits, threats, and barriers these campaigns studied the prefer- Health-Belief Model ences and habits of various audience segments; developed messages that would be perceived as relevant, com- 1 prehensible, and actionable; and then distributed these to consumers in set- Calorie per calorie, whole fruit has more dietary fiber than fruit juice. tings such as supermarkets, restau- Health information rants, and the Internet (79). The ef- Knowledge-Attitude-Behavior fectiveness of these campaigns in increasing Americans’ consumption of fruits and vegetables is wellFigure. Example of how behavioral models can be used to provide positive nutrition messages known.for increasing consumption of fruit (eg, eating whole fruit more often than juice). Each level adds Regardless of the theoretical basisimportant concepts to factors addressed by models on the levels below it. of communications, messages must be consistent with an emphasis on a to- tal dietary pattern that is balancedSocial Cognitive Theory/Transtheoretical The- reciprocal determinism (availability and moderate, and guard against in-ory. When problem behaviors are of milk-based foods in vending ma- advertent use of oversimplified mes-closely tied to social or economic mo- chines and restaurants), expectations sages such as good/bad foods. Other-tivations, more comprehensive theo- (beliefs about osteoporosis as a conse- wise, communicators may not beries and models may be effective tools quence of avoiding milk-based foods), effective in achieving their educa-for planning nutrition interventions self-efficacy (confidence in one’s abil- tional goals (80).(75). For instance, if an educator ity to use more milk-based foods), ob-needs to promote milk-based foods as servational learning or modeling (see-sources of dietary calcium, Social ing peers and other role models The Socio-Ecological DimensionCognitive (Social Learning) Theory drinking milk), and reinforcement In addition to programs that targetwould support an educational inter- (positive or negative feelings that oc- behavioral practices and dietaryvention addressing behavioral capa- cur when milk drinking is practiced). knowledge/skills of individuals andbility (knowledge and skills needed to The Transtheoretical Model/Stage families, it is often appropriate to pro-select and prepare milk-based foods), of Change (76) describes learners in mote behavioral changes and dietary July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1229
  7. 7. ADA REPORTSimprovements at the broader organi- it is important to stress that a diet Effective Communication Strategieszational or societal levels. A socio-eco- based on a wide variety of foods re- To be communicated effectively, edu-logical model has been developed to mains the preferred overall source cational messages and counseling in-guide programs that facilitate choices of nutrients (83). Numerous bioac- terventions should:of targeted systems, environment, tive compounds in foods such asand public policy change within orga- phytochemicals and ultra trace ele- ● focus on high-priority personalnizations at the community and state ments have been identified that and/or public health needs;levels (81). have potential health benefits. Yet ● provide a proactive, positive, and the precise role, dietary require- practical approach; ments, influence on other nutrients, ● promote an enjoyable pattern ofREDUCING NUTRITION CONFUSION and toxicity levels of these dietary diet and activity choices as part of aTo reduce confusion from the high components are still unclear. Fur- long-term overall healthful life-volume and apparent inconsistencies thermore, foods may contain addi- style;of nutrition advice, the following tional nutritional substances that ● use successful educational strate-should be considered when designing have not yet been discovered. Thus, gies based on theories and modelsnutrition education for the public: appropriate food choices, rather that promote behavioral change; than supplements, should be the and● Promote variety, proportionality, foundation for achieving nutri- ● evaluate and share information on moderation, and gradual improve- tional adequacy (7). effectiveness of food and nutrition ment. Variety refers to an eating ● Stress that physical activity com- programs. pattern that includes foods from all plements the total diet approach MyPyramid food groups and sub- because it permits individuals to As leaders in nutrition communica- groups. Proportionality, or balance, help manage weight and lowers the tion, food and nutrition professionals means eating more of some foods risk of premature diseases. The need to continue strengthening skills, (fruits, vegetables, whole grains, minimum amount recommended updating competencies, and docu- fat-free or low-fat milk products), for health benefits by MyPyramid menting outcomes. Suggested tech- and less of others (foods high in sat- and the Dietary Guidelines for niques to achieve these goals are: urated or trans fats, added sugars, Americans is 30 minutes, prefera- cholesterol, salt, and alcohol). Mod- bly each day. To avoid weight gain, ● build coalitions with industry, gov- eration may be accomplished 60 minutes per day may be neces- ernment, academia, and organiza- through advice to consumers to sary, and this may increase up to 90 tions; limit overall portion size and to minutes to maintain weight loss. ● use a full range of available and choose foods that will limit intake of appropriate communication tech- saturated or trans fats, added sug- nologies and take advantage of op- ars, cholesterol, salt, and alcohol. ROLE OF FOOD AND NUTRITION portunities to communicate with To make gradual improvement, in- PROFESSIONALS professional colleagues and the dividuals can take small steps to Food and nutrition professionals have public, such as giving presentations improve their diet and lifestyle a responsibility to communicate unbi- and writing publications to influ- each day (16). ased food and nutrition information ence social norms and public policy;● Emphasize food patterns, rather that is culturally sensitive, scientifi- ● act as role models of active partici- than individual nutrients or indi- cally accurate, medically appropriate, pation in local and professional as- vidual foods, as key considerations and feasible for the target audience. sociations; in evaluating and planning one’s Some health and nutrition experts ● maintain state-of-the-art knowl- food choices. Be aware of the social, and many “pseudo-experts” promote edge through continuing education; cultural, economic, and emotional specific foods or types of food to choose and meanings that may be attached to or avoid in order to improve health. A ● take a professional and unbiased some foods and allow for flexibility more responsible and effective ap- approach to promoting healthful whenever possible. Understand proach is to help consumers under- eating and physical activity that social and cultural aspects of stand and apply the principles of patterns. food consumption are essential for healthful diet and lifestyle choices. planning educational programs to Unless there are extenuating circum- help correct nutritional problems of stances (eg, individuals with severe individuals and population groups cognitive or physical limitations such References (82). as dementia or renal failure), the to- 1. American Dietetic Association. Nutrition● Acknowledge the importance of ob- tal diet approach is preferred because and You: Trends 2002 Final Report of Find- taining nutrients from foods, rather it is more consistent with research on ings. October 2002. Available at: http://www. than relying on nutrients from sup- effective communication and inclu- 1578_ENU_HTML.htm. Accessed June 10, plements or fortified foods. Al- sive of cultural/personal differences. 2006. though nutrient modifications are To achieve this goal, the Board of the 2. International Food Information Council. recommended when food intake is American Dietetic Association ap- Food & Health Survey: Consumer Attitudes toward Food, Nutrition & Health. 2006. inadequate to meet specific needs proved the objective to focus nutrition Available at: (eg, iron, folic acid, vitamins B-12 messages on total diet, not individual foodandhealthsurvey.cfm#EXECUTIVE% and D for some population groups), foods (84). 20SUMMARY. Accessed August 28, 2006.1230 July 2007 Volume 107 Number 7
  8. 8. ADA REPORTS 3. Food Marketing Institute. SuperMarket Re- cians, registered in health promotion and within calories needs. J Am Diet Assoc. search. Volume 6, Number 2, Summer 2004. disease prevention. J Am Diet Assoc. 2007;107:860-869. Available at: 2006;106:1875-1884. 37. Coulston AM. Limitations on the adage “eat uploads/SupermarketResearch/SMRSummer 19. American Dietetic Association. Former posi- a variety of foods”? Am J Clin Nutr. 1999; 04.pdf Accessed June 21, 2006. tion of the American Dietetic Association: 69:350-351. 4. American Dietetic Association. Position of Nutrition education for the public. J Am 38. McCrory MA, Fuss PJ, McCallum JE, Yao the American Dietetic Association: Food and Diet Assoc. 1996;96:1183-1187. M, Vinken AG, Hays NP, Roberts SB. Di- nutrition misinformation. J Am Diet Assoc. 20. Contento I, Balch GI, Bronner YL, Lytle LA, etary variety within food groups: Associa- 2006;106:601-607. Available at: http://www. Maloney SK, Olson CM, Swadener SS. The- tion with energy intakes and body fatness in oretical frameworks or models for nutrition men and women. Am J Clin Nutr. 1999;69: adar0202_ENU_HTML.htm. Accessed June education. J Nutr Educ. 1995;27:287-290. 440-447. 21, 2006. 21. Lytle LA, Eldridge AL, Kotz K, Piper ??, 39. Krebs-Smith SM, Smiciklas H, Guthrie HA, 5. International Food Information Council. Williams S, Kalina B. Children’s interpreta- Krebs-Smith J. The effects of variety in food How consumers feel about food and nutrition tion of nutrition messages. J Nutr Educ. choices on dietary quality. J Am Diet Assoc. messages. February 2002. Available at: 1997;29:128-136. 1987;87:897-903. 22. O’Dea JA. Children and adolescents identify 40. EPM Communications. Consumers’ health Accessed June 21, 2006. food concerns, forbidden foods, and food-re- and nutrition concerns don’t always trans- 6. American Dietetic Association. Position of lated beliefs. J Am Diet Assoc. 1999;99:970- late into action. Res Alert. 2004;22:1. the American Dietetic Association: Fortifica- 973. 41. Kantor LS. A comparison of the US food tion and nutritional supplements. J Am Diet 23. Marlatt GA. Relapse prevention: Theoretical supply with the Food Guide Pyramid recom- Assoc. 2005;105:1300-1311. rationale and overview of the model. In: mendations. In: Frazao E, ed. America’s Eat- 7. US Department of Health and Human Ser- Marlatt CA, Gordon JR, eds. Relapse Pre- ing Habits: Changes and Consequences. vices, US Department of Agriculture. Dietary vention. New York, NY: Guilford Press; Washington, DC: US Department of Agricul- Guidelines for Americans 2005. 6th edition. 1985:3-70. ture; 1999;71-95. Agriculture Information Available at: 24. Zywiak WH, Connors GJ, Maisto SA, West- Bulletin No. 750. dietaryguidelines. Accessed June 21, 2006. erberg VS. Relapse research and the Rea- 42. Abumrad NA. CD36 may determine our de- 8. US Department of Agriculture. MyPyramid sons for Drinking Questionnaire: A factor sire for dietary fats. J Clin Invest. 2005;115: Food Guidance System. 2005. Available at: analysis of Marlatt’s relapse taxonomy. Ad- 2965-2967. Accessed June diction. 1996;91(suppl):S121-S130. 43. Drenowski A. Taste preferences and food in- 21, 2006. 25. Belury M. Not all trans-fatty acids are alike: take. Ann Rev Nutr. 1997;17:237-253. 9. US Department of Health and Human Ser- What consumers may lose when we oversim- 44. Birch LL, Fisher JO. Food intake regulation vices. DASH Eating Plan. 2006. Available plify nutrition facts. J Am Diet Assoc. 2002; in children. Annals NY Acad Sci. 1997;819: at: 102:1606-1607. 194-220. heart/hbp/dash/new_dash.pdf. Accessed Au- 26. Federal Register. 21CFR. 101.9 (c) (2) (i) 45. Birch LL, McPhee L, Steinberg L, Sulllivan gust 28, 2006. Trans Fatty Acids in Nutritional Labeling. S. Conditioned flavor preferences in young10. Food and Drug Administration. How to un- Available at: children. Physiol Behav. 1990;47:501-505. derstand and use the nutrition facts label acrobat/fr03711a.pdf. Accessed February 8, 46. Sclafani A. How food preferences are . . .Updated November 2004. Available at: 2007. learned: Laboratory animal models. Proc dms/foodlab.html. 27. Freeland-Graves J, Hendrickson PJ, Eban- Nutr Soc. 1995;54:419-427. Accessed June 21, 2006. git ML, Snowden JY. Salivary zinc as an 47. Variyam JN, Blaylock J, Smallwood D, Ba-11. International Food Information Council, Food index of zinc status in women fed a low-zinc siotis PP. USDA’s Healthy Eating Index and Marketing Institute, US Department of Agri- diet. Am J Clin Nutr. 1981;34:312-321. Nutrition Information. Washington, DC: US culture. Your personal plan to health: Steps to 28. Liener IE. Possible adverse effects of soy- Department of Agriculture; 1998. Technical a healthier you [brochure]. 2006. Available at: bean anticarcinogens. J Nutr. 1995; Bulletin No. 1866. 125(suppl 3):744S-750S. upload/MyPyramidBrochure.pdf. Accessed 29. Freeland-Graves J. Mineral adequacy of 48. Klohe DM, Freeland-Graves JH, Anderson August 28, 2006. vegetarian diets. Am J Clin Nutr. 1988; ER, McDowell T, Clarke KK, Hanss-Nuss H,12. King S, Gibney M. Dietary advice to reduce 48(suppl 3):859-862. Puri D, Milani TJ. Nutrition knowledge is fat intake is more successful when it does 30. Sacks FM, Lichtenstein A, Van Horn L, Har- associated with greater weight loss in obese not restrict habitual eating patterns. J Am ris W, Kris-Etherton P, Winston M. Soy pro- and overweight low-income mothers. J Am Diet Assoc. 1999;99:685-689. tein, isoflavones, and cardiovascular health: Diet Assoc. 2006;106:65-75.13. Welsh S, Davis C, Shaw A. Development of A summary of a statement for professionals 49. Volek JS, Vanheest JL, Forsythe CE. Diet the Food Guide Pyramid. Nutr Today. 1992; from the American Heart Association Nutri- and exercise for weight loss: A review of the 27:12-23. tion Committee. Arterioscler Thromb Vasc current issues. Sports Med. 2005;35:1-9.14. Dietary Guidelines Advisory Committee. Re- Biol. 2006;26:1689-1692. 50. Polivy J. Psychological consequences of food port of the Dietary Guidelines Advisory Com- 31. Trock BJ, Hilakivi-Clarke L, Clarke R. restriction. J Am Diet Assoc. 1996;96:589- mittee on the Dietary Guidelines for Ameri- Meta-analysis of soy intake and breast can- 592. cans, 2005. Beltsville, MD: US Department cer risk. J Natl Cancer Inst. 2006;98:459- 51. National Task Force on the Prevention and of Agriculture, Agricultural Research Ser- 471. Treatment of Obesity. Weight cycling. vice; 2004. 32. Food Marketing Institute. Supermarket JAMA. 1994;272:1196-1202.15. Crane NT, Hubbard VS, Lewis CJ. Ameri- facts: Industry overview 2005. Available at: 52. American Dietetic Association. Position of can diets and year 2000 goals. In: Frazao E, the American Dietetic Association: Agricul- ed. America’s Eating Habits: Changes & Accessed August 28, 2006. tural and food biotechnology. J Am Diet As- Consequences. Washington, DC: US Depart- 33. Neuhouser ML, Patterson RE, Kristal AR, soc. 2006;106:285-293. ment of Agriculture; 1999:111-133. Agricul- Rock CL, Neumark-Sztainer D, Thornquist 53. Sigman-Grant M. Can you have your low-fat ture Information Bulletin No. 750. MD, Cheskin LJ. Do consumers of savory cake and eat it too? The role of fat-modified16. Committee on Dietary Reference Intakes. snacks have poor quality diets? J Am Diet products. J Am Diet Assoc. 1997;97(suppl Dietary Reference Intakes for Calcium, Phos- Assoc. 2000:100:576-579. 7):S76-S81. phorus, Magnesium, Vitamin D, and Fluo- 34. Nielsen SJ, Popkin BM. Patterns and trends 54. Dobell E, Chan M, Williams P, Allman M. ride. Washington, DC: National Academies in food portion sizes, 1977-1998. JAMA. Food preferences and food habits of patients Press; 1997. 2003;289:450-453. with chronic renal failure undergoing dialy-17. Sahyoun NR, Pratt CA, Anderson A. Evalu- 35. Rolls BJ, Liane SR, Meengs JS. Larger por- sis. J Am Diet Assoc. 1993;93:1129-1135. ation of nutrition education interventions tion sizes lead to a sustained increase in 55. Bernstein IL. Symposium on nutritional as- for older adults: A proposed framework. energy intake over 2 days. J Am Diet Assoc. pects of recovery from severe illness and sur- J Am Diet Assoc. 2004;104:58-69. 2006;106:543-549. gery. Proc Nutr Soc. 1994;53:131-137.18. American Dietetic Association. Position of 36. American Dietetic Association. Practice pa- 56. Perusse L, Rankinen T, Zuberi A, Chagnon the American Dietetic Association: The roles per of the American Dietetic Association: Y, Weisnagel SJ, Argyropoulos G, Walts B, of registered dietitians and dietetic techni- Nutrient density: Meeting nutrient goals Snyder EE, Bouchard C. 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  9. 9. ADA REPORTS gene map: The 2005 update. Obesity Res. 188. Agriculture Information Bulletin No. Zotz K. System, environmental, and policy 2006;14:529-644. 750. changes: Using the social-ecological model57. American Dietetic Association. Nutrition 73. Friedman SM, Villamil K, Suriano RA, Egolf as a framework for evaluating nutrition and You: Trends 2000. Chicago, IL: Ameri- BP. Alar and apples: Newspapers, risk and education and social marketing programs can Dietetic Association; 2000. media responsibility. Public Underst Sci. with low-income audiences. J Nutr Educ Be-58. American Dietetic Association. 1995 Nutri- 1996;5:1-20. hav. 2001;33(suppl 1):S4-S15. tion Trends Survey. Executive Summary. 74. Janz NK, Champion VL, Strecher VJ. The 82. Devine CM, Sobal J, Bisogni CA Connors M. Chicago, IL: American Dietetic Association; health belief model. In: Glanz K, Lewis FM, Food choices in three ethnic groups; interac- 1995. Rimer BK, eds. Health Behavior and Health tions of ideals, identities and roles. J Nutr59. Food Marketing Institute. Trends in the Education: Theory, Research and Practice. Educ. 1999;31:86-93. United States. Consumer Attitudes & the Su- 3rd ed. San Francisco, CA: Jossey-Bass Pub- 83. Committee on Dietary Reference Intakes. permarket, 1999. Washington, DC: Food lishers; 2002:49-66. Dietary Reference Intakes for Vitamin C, Vi- Marketing Institute; 1999. 75. Brug J, Glanz K, Kok G. The relationship tamin E, Selenium, and Carotenoids. Wash-60. US Census Bureau. Nation’s population one- between self-efficacy, attitudes, intake com- ington, DC: National Academies Press; third minority. US Census Bureau News. pared to others, consumption, and stages of 2000. May 2006. Available at: http://www.census. change related to fruit and vegetables. Am J 84. Derelian D. President’s Page: Nutrition ed- gov/Press-Release/www/releases/archives/ Health Promot. 1997;12:25-30. ucation philosophies—Why we do the things population/006808.html. Accessed August 76. Greene GW, Rossi SR, Rossi JS, Velicer WF, we do. J Am Diet Assoc. 1996;96:191. 24, 2006. Fava JL, Prochaska JO. Dietary applica- tions of the Stages of Change Model. J Am61. Rosal MC, Olendzki B, Reed GW, Gumien- Diet Assoc. 1999;99:673-678. iak O, Scavron J, Ockene I. Diabetes self- 77. Balch GI, Loughrey K, Weinberg L, Lurie D, management among low-income Spanish- Eisner E. Probing consumer benefits and speaking patients: A pilot study. Ann Behav barriers for the national 5 A Day campaign: Med. 2005;29:225-235. Focus group findings. J Nutr Educ. 1997;29:62. Glanz K, Basil M, Maibach E, Goldberg J, 178-183. Snyder D. Why Americans eat what they do: 78. Produce for Better Health Foundation. Fruit Taste, nutrition, cost, convenience, and and Veggies—More Matters, the Next Gen- weight control concerns as influences on food eration “5 a Day” [press release]. Available consumption. J Am Diet Assoc. 1998;98: at: 1118-1126. press/releases/pressrelease.php?recordid63. Inagami S, Cohen DA, Finch BK, Asch AM. 182. Accessed April 19, 2007. You are where you shop. Grocery store loca- 79. Lefebvre RC, Donner L, Johnson C, Lough- tions, weight and neighborhoods. Am J Prev rey K, Balch GI, Sutton SM. Use of database Med. 2006;31:10-17. marketing and consumer-based health com-64. Baker EA, Schootman M, Barnidge E, Kelly munication in message design: An example C. The role of race and poverty in access to from the Office of Cancer Communications’ foods that enable individuals to adhere to “5 A Day for Better Health” program. In: dietary guidelines. Prev Chronic Dis [serial Maibach E, Parrott R, eds. Designing Health online]. Centers for Disease Control and Messages: Approaches from Communication Prevention Web site. July 2006. Available Theory and Public Health Practice. Thou- at: sand Oaks, CA: Sage Publications; 1995: 05_0217.htm. Accessed August 29, 2006. 217-246.65. George GC, Milani TJ, Hanss-Nuss H, Free- 80. van den Heede MA, Pelican S. Reflections on land-Graves JH. Compliance with dietary marketing as an inappropriate model for nu- guideline and relationship to psychosocial trition education. J Nutr Educ. 1995;27:141- factors in low-income women in late postpar- 150. tum. J Am Diet Assoc. 2005;105:916-926. 81. Gregson J, Foerster SB, Orr R, Jones L,66. Nestle M, Wing R, Birch L, DiSogra L, Benedict J, Clarke B, Hersey J, Lewis J, Drewnowski A, Middleton S, Sigman-Grant M, Sobal J, Winston M, Economos C. Behav- ioral and social influences on food choice. Nutr Rev. 1998;56:S50-S74. ADA position adopted by the House of Delegates Leadership Team on67. Dyson LK. American cuisine in the 20th September 13, 2001, and on June 30, 2005. This position is in effect until Century. Food Rev. 2000;23:2-7.68. Hetherington MM, Anderson AS, Norton December 31, 2011. The ADA authorizes republication of the position state- GNM, Newson L. Situational effects on meal ment/support paper, in its entirety, provided full and proper credit is given. intake: A comparison of eating alone and Requests to use portions of the position must be directed to ADA headquar- eating with others. Physiol Behav. 2006;88: 498-505. ters at 800/877-1600, ext. 4835, or Lappalainen R, Koikkalainen M, Julkunen Authors: Susan Nitzke, PhD, RD (University of Wisconsin-Madison, Mad- J, Saarinen T, Mykkanen H. Association of ison, WI) and Jeanne Freeland-Graves, PhD, RD (The University of Texas at sociodemographic factors with barriers re- ported by patients receiving nutrition coun- Austin, Austin, TX). seling as part of cardiac rehabilitation. J Am Reviewers: Mary Anne Burkman, MPH, RD (Dairy Council of California, Diet Assoc. 1998;98:1026-1029. Oakland, CA); Nutrition Education for the Public dietetics practice group70. Advertising Age. 50th Annual 100 Leading National Advertisers. June 27, 2004. Available (Laura Chalela, MPH, RD, Edelman Public Relations, Chicago, IL); Susan at: Finn, PhD, RD, FADA (Finn/Parks Associates, Columbus, OH); Jean M. lna2005.pdf. Accessed August 23, 2006. Kerver, PhD, RD (Michigan State University, East Lansing, MI); Linda71. Levy A, Stokes R. Effects of a health promo- tion advertising campaign on sales of ready- Knol, PhD, RD (University of Alabama, Tuscaloosa, AL); Mary Kay Meyer, to-eat cereals. Public Health Rep. 1987;102: PhD, RD (Alabama State Department of Education, Montgomery, AL); Su- 398-403.72. Blisard N. Advertising and what we eat. In: san M. Sanders, RN, MPH, RD (The Coca-Cola Company, Atlanta, GA). Frazao E, ed. America’s Eating Habits: Association Positions Committee Workgroup: Dianne Polly, JD, RD (chair); Changes & Consequences. Washington, DC: Patricia Schaaf, MS, RD; Barbara Olendzki, MPH, RD (content advisor). US Department of Agriculture; 1999;181-1232 July 2007 Volume 107 Number 7