Lifestyle Medicine

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Role of Communication in Changing Nutrition Behaviors to Promote Healthy Lifestyles Jeanne Goldberg, PhD, RD and Lindsay Peterson, MS, MEd

Contents Introduction................................................................................................................................................................................ 185 People......................................................................................................................................................................................... 186 Individual Level.................................................................................................................................................................... 186 Fundamental Importance of Taste.................................................................................................................................... 187 Cost, Convenience, and Self-Efficacy.............................................................................................................................. 188 Health Literacy: Special Case of Nutrition Communication............................................................................................ 188 People Eat Diets, Not Foods or Nutrients........................................................................................................................ 189 Everyone Is an Expert...................................................................................................................................................... 189 Social Networks.................................................................................................................................................................... 189 Personal Network and Social Support.............................................................................................................................. 189 Opinion Leaders............................................................................................................................................................... 190 Population/Community......................................................................................................................................................... 190 Places......................................................................................................................................................................................... 190 Shift in Communications Landscape.................................................................................................................................... 190 Other Challenges to Communication of Nutrition Messages for Behavior Change..............................................................191 Media Advocacy: Using Media to Get Behind Your Cause/Sway Public Opinion and Policymakers..................................191 Role of Nutrition Communication in Changing Behavior: Community-Level Interventions................................................... 192 Sisters Together: Move More, Eat Better.............................................................................................................................. 192 People-Based Campaign Components............................................................................................................................. 192 Place-Based Campaign Components............................................................................................................................... 193 Shape Up Somerville: Eat Smart, Play Hard........................................................................................................................ 193 People-Based Campaign Components............................................................................................................................. 193 Place-Based Campaign Components............................................................................................................................... 193 General Nutrition Communication Recommendations......................................................................................................... 194 Acknowledgments...................................................................................................................................................................... 194 References.................................................................................................................................................................................. 194

Introduction An old saw says that “food is not food until it is eaten.” To paraphrase, “a behavior is not a behavior until it is adopted.” That is, science-based evidence, no matter how solid, is of little value until it is adopted by those to whom it applies. The Dietary Guidelines for Americans, first issued in 1980 by the U.S. Department of Agriculture (USDA) and the U.S. Department of Health, Education, and Welfare (USDHEW), later renamed Health and Human Services (HHS), articulate science-based recommendations for healthy diets that provide adequate amounts of all essential nutrients and at the same time minimize the risk of chronic diseases associated with dietary factors. The problem is that the gap between

the recommendations, which have been modified relatively little since they were first released, and their adoption by the American public remains wide. The advisory committee that wrote the 2010 report observed that “now, as in the past, a disconnect exists between dietary recommendations and what Americans actually consume. On average, Americans of all ages consume too few vegetables, fruits, high-fiber whole grains, low fat milk and milk products, and seafood and they eat too much added sugars, solid fats, refined grains, and sodium. SoFAS (added sugars and solid fats) contribute approximately 35% of calories to the American diet” [1]. The power of nutrition to shape public health is indisputable. In a 2009 World Health Organization report describing

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the ten leading risk factors for death in high-income countries, seven of the factors—high blood pressure, overweight and obesity, physical inactivity, high blood glucose levels, high cholesterol levels, low fruit and vegetable intake, and alcohol use—are related to diet and physical activity [2]. The same report estimated that in 2004 these risk factors contributed to an estimated 4.1 million deaths in high-income countries, and that modifying food intake and increasing physical activity (along with reducing tobacco use) could increase global life expectancy by 5 years. There is no logical starting point to the discussion of why Americans have not made greater shifts toward the recommendations of the Dietary Guidelines, and there is no single approach to modifying eating behaviors at the population level. What people eat depends on individual factors, on interpersonal interactions through multiple networks, and on the environments in which eating behaviors occur. Simply telling people what to do or what not to do, no matter how well the advice is grounded in scientific evidence, is unlikely to lead to wholesale adoption of the Dietary Guidelines. More successful nutrition communications will likely evolve through identification of barriers to change and solutions to address those barriers, at both the individual and the environmental levels. Public health communication has been defined as the production and exchange of information to inform, influence, or motivate individual, institutional, and public audiences. That definition can be applied to communication about nutritionrelated health issues [3]. Importantly, it is not limited to the interaction between nutrition communicators and individual consumers of information, but also incorporates structural and social factors. Indeed, successful nutrition communications must be delivered in the context of multilevel interventions that promote and support behavior change. As such, this chapter addresses the role of nutrition communication in interventions incorporating individual, social, and environmental components. The design of effective nutrition communications must include specification of the target audience(s) and behavioral objectives, a message strategy and execution plan, and a selection of dissemination channels and settings. It must also include ongoing formative research, campaign monitoring, and outcome evaluation that makes it possible not only to measure effectiveness but also to make course corrections. An IOM report on health communication strategies for diverse populations aptly describes the fluid nature of this work: “A campaign is not defined by a specific and static mix of messages, audiences, and channels. Rather, it is defined as a program that makes decisions about these operational details, decisions that will vary over time” [4]. What we know about the potential of public health media campaigns comes mainly from efforts to influence population behavior by targeting individual-level antecedents to the behavior of concern, factors such as knowledge, perceptions, and self-efficacy [3]. However, addressing individual factors alone may not be sufficient to drive health behavior change;

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indeed, the limited available evidence from national nutrition campaigns confirms that behavioral shifts require far more than messages promoting personal behavior change. For example, the 5-A-Day Campaign, launched jointly by the National Cancer Institute and the Produce for Better Health Foundation in 1991, was designed to increase public awareness of the importance of eating at least five servings of fruits and vegetables every day. Results from 5-A-Day program surveys 6 years after it was launched showed that the majority of the population still did not know the fruit and vegetable recommendation, and, more importantly, that there were no significant changes in fruit and vegetable consumption [5]. In the 20 years since the campaign was introduced there have been numerous communications efforts, extensive programming at the community level, and environmental and policy changes. Yet the most recent data available indicate that more than half of the U.S. population fails to consume recommended intakes. Approximately 33% of adults meet the recommendation for fruit consumption and 26% get the recommended servings of vegetables [6]. To add to the challenge, the 5-A-Day program was renamed “Fruits and Veggies: More Matters” to reflect the change in the 2005 Dietary Guidelines from five servings a day to five to nine servings a day. What effect, if any, this campaign branding shift had on consumer recognition of the fruit and vegetable message or on consumer reaction to a higher goal is unclear. There are many possible explanations for the limited shifts in fruit and vegetable consumption; further research is needed to identify the relative importance of taste, cost, convenience, accessibility, and of course, the role of communication in persuading Americans to eat more fruits and vegetables. Over the past two decades, public health researchers have broadened their approach to understanding and influencing population health, including issues around eating behavior. Maibach, Abroms, and Marosits propose a framework which posits that population health is influenced by the attributes of, and interplay between people and place-based factors [3]. In their framework, people are analyzed through three levels: the individual field, the social network field, and the community or population field. Places are understood in terms of both local and distal influences (see Figure 14.1). Maibach et al. use this framework to discuss avenues for health communication within each field of influence. We will attempt to adapt this model to address challenges specific to nutrition communication, and particularly to address the gap between dietary recommendations and the public’s behavior.

People Individual Level In the ecological framework proposed by Story et al., individual factors such as cognitions, skills and behaviors, lifestyle, biology, and demographics are at the core of the model [7]. All are critical to understanding whether communication can have its intended effect, some because they are impossible

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Role of Communication in Changing Nutrition Behaviors to Promote Healthy Lifestyles

Health of the population

Health behaviors of the people in the population

Local-level (e.g., home, school, neighborhood, local stores, workplace, city)

Distal-level (e.g., state, region, nation, world)

Social cohesion

Availability of products and services

Availability of products and services

Collective efficacy

Physical structures

Physical structures

Social structures: - laws and policies - enforcement

Social structures: - laws and policies - enforcement

Cultural and media messages

Cultural and media messages

Individuals

Social networks

Population or community

Cognitions: - knowledge - beliefs - self-efficacy

Size and connectedness of personal network

Social norms

Affect Skills Motivation Intentions

Social support and modeling by: - family - peers - mentors

Biological Opinion leaders predispositions Demographics Smallest

Culture

Social capital Income disparities Racism

Attributes of people Level of aggregation

Largest

Smallest

The attributes of place Level of aggregation

Largest

Figure 14.1 Maibach et al.’s People and Places framework for public health communication. (From Maibach, E.W. et al., BMC Public Health, 7, 88, 2007. With permission.)

to change, others because they can be modified. Whether a proposed intervention focuses solely on nutrition or includes nutrition among other components, formative research to identify both barriers to the recommended behavior and solutions to enable that behavior are critical. We will place greater focus on the barriers that evidence suggests can be modified. These include taste, cost, convenience, and selfefficacy, and health literacy or lack of it, with respect to the specific behavior being targeted. Fundamental Importance of Taste At the individual level, the disconnect between dietary recommendations and dietary intake is explained in large part by consumers consistently ranking taste as the major factor driving their food choices [8,9], with concern about health ranking third or fourth, behind cost and convenience. Unfortunately, for the majority of individuals, foods that taste good tend to be high in fat, sugar, and salt. In a food environment described in the extreme as “toxic” [10], these highly palatable foods are widely available at relatively reasonable prices, posing a challenge on the individual level as well as at the local and distal levels within the environment. In short, at the individual level, people make choices about whether to prepare and consume energy-dense foods, but policies affecting the cost and availability of these items serve as powerful place-based influences on behavior. It follows, then, that attitudes toward taste must be addressed in any nutrition communication activities if we are to nudge the population toward more healthful diets. Some


tastes, like sweetness, are innately preferred, while others, like bitterness, are innately rejected. Exposure to different flavors can modify these preferences [11]. Clearly, consumers’ preferences for certain types of food are linked to market availability; for example, most Americans prefer refined grains over whole grains [12]. This preference has only emerged in the past 200 years, as commercial milling made refined grains more widely available [13]. Increasing recognition of the benefits of whole grains has led to the public health recommendation to “Make half your grains whole.” However, that seemingly simple message requires modification of taste preferences and consumer understanding of the difference between whole and refined grains. In some cases, to get consumers to cook, buy, and eat more whole grains may require reformulation of products, a challenge to industry at the distal level. Such change is possible, but, whether the recommendation focuses on alterations of fat, sugar, salt, or whole grain intake, population shifts require action at multiple levels. While we lack comprehensive studies to fully explain changes in consumption, examples such as the slow increase in low-fat and fat-free milk consumption and decrease in whole milk consumption in the United States over time are probably explained both by messages that promote lower fat milk and by changes in taste preferences as more palatable products appeared in the marketplace [14]. Unfortunately, taste preferences often conflict with nutrition advice. To compound the problem, most nutrition advice is based on evidence related to long-term outcomes, such as

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reduced risk of heart disease and certain cancers. The dietary advice related to risk reduction, as well as to weight loss and maintenance, competes with the short-term gratification of indulging in energy-dense foods. There are no immediate, perceptible benefits to adopting nutrition recommendations and generally no immediate consequences to ignoring them either. The challenges, therefore, are to address the tension between the palatability of many unhealthful foods and the advice to cut back on them, and also to get people to increase their intake of foods they often find unpalatable. Which approach or combination of approaches will be most effective depends on understanding the target audience. Cost, Convenience, and Self-Efficacy Cost, convenience, and self-efficacy interact to affect food choice and food consumption. The relative importance of each of these factors varies from one individual to another and can change over time. They are related to family economics, time (or perceived time) available to purchase and prepare food, and skills and confidence to make costeffective purchase decisions and to efficiently prepare appetizing food. At times of high unemployment and rising food prices, for example, it is reasonable to expect increased attention to low-cost shopping than during better economic times. Identifying whether cost, convenience, or self-efficacy is the strongest driver of food choice requires formative research. For example, formative research for the Sisters Together campaign, described more fully later in this chapter, identified self-efficacy, specifically the lack of kitchen skills, as a major barrier to preparing healthier meals. In turn, the intervention incorporated the promotion of a cable television cooking show hosted by a member of the Sisters Together Advisory Board, which supported the development of these needed skills. Health Literacy: Special Case of Nutrition Communication A key consideration in the development of any form of nutrition communication is the health literacy of the intended audience, or the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions [15]. In a national survey, 36% of adults exhibited basic health literacy, and only 12% demonstrated proficient health literacy [16]. Low health literacy has been called a silent killer, linked with higher mortality rates, poor utilization of preventive health care services, improper use of medications, and delayed or inadequate care for chronic diseases such as diabetes and heart disease [17,18]. Increased awareness of these adverse effects has made efforts to improve health literacy a high priority; the Healthy People 2020 objectives, for example, strongly advocate for improved health literacy among Americans [19]. Early efforts to improve health literacy focused on simplifying the language of health communication materials, but current approaches also address social, cultural, and © 2013 by Taylor & Francis Group, LLC

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environmental factors, all of which influence health literacy. Addressing health literacy in this multifaceted manner is difficult, especially given the diversity of the American public. The development of clear and usable nutrition communication presents a special health literacy challenge for a number of reasons. Most nutrition information does not lend itself to succinct, actionable messages, and scientifically sound information often competes with advertising and other messages that are concise and persuasive, but not necessarily accurate or balanced. Moreover, understanding of the role of nutrition in health promotion and chronic disease prevention continues to evolve, and so too must guidance to consumers about how to integrate that knowledge into their daily food practices. The role of fat in the diet illustrates the problem. Since the first edition of the Dietary Guidelines was released in 1980, there have been recommendations regarding fat intake. In the first two editions, the guidance was to “avoid too much fat, saturated fat, and cholesterol.” In the next two editions, the guidance was modified to convey a positive tone: “Choose a diet low in fat, saturated fat, and cholesterol.” Then, in 2005, it was modified to emphasize the need to limit saturated fat, to include “moderate amounts” of unsaturated fat, and to limit cholesterol to less than 300 mg/day. In the 2010 Guidelines, Americans are advised to “Consume less than 10% of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids” and to “Consume less than 300 mg of cholesterol” [1]. Evidence from periodic studies of consumer comprehension of these guidelines suggests that there is a wide gap between recommendations and consumer understanding of what they mean and, more importantly, how to translate them into actionable behaviors [20,21]. To be sure, the Guidelines were intended for use by health professionals whose challenge is to translate them into language that consumers—even those with limited health literacy—can understand and act on. Unfortunately, popular materials designed to translate the Guidelines into actionable steps tend to use the same scientific language found in the Guidelines themselves. There is no simple solution to this problem. Information about dietary fats (and many other nutrition topics) is complex. It is not always possible to simplify complex information to a point where it remains accurate, actionable, and comprehensible to the target population. As a first step, it is probably logical to consider a basic question: what does the individual or group need to know in order to implement the dietary guidance? Given that not all information on a particular topic is equally important, it is the role of the health professional to determine which information is needed most urgently and to prioritize those messages accordingly. For example, it is probably more important to help people to understand how to substitute unsaturated for saturated fats than to focus on dietary cholesterol. It is also a good idea to take advantage of existing resources, but to evaluate such materials with members of the target population to ensure they are both accurate and clear. If no available materials are suitable for the target population, it may be possible to modify relevant sources to make them more


audience-appropriate. Many useful resources are now accessible on the Internet. For example, an article on the complex topic of salt-reduction strategies can be found at the Harvard School of Public Health’s website “The Nutrition Source” (http://hsph.harvard.edu/nutritionsource/salt/). The article, which was developed to help individuals implement the recommendations of the National Academy of Sciences Report [22], is divided into reasonable “bites,” which could easily be adapted to a series of instructional sessions. While some of the language may be above the literacy level of many audiences, and some critics might debate details of the recommendations, this comprehensive, modifiable mini curriculum provides specific steps necessary for the consumer to reduce sodium intakes. This translation of dietary guidance into actionable steps can serve as a model for development of materials on other nutrition-related topics. People Eat Diets, Not Foods or Nutrients Further complicating matters is that messages to promote dietary behaviors often address a singular focus. The environment is saturated with nutrition messages related to specific health conditions. People are told to consume a diet to reduce cardiovascular risk, or to promote bone health, or to prevent cancer, or of course, to lose weight. Other messages focus on one particular nutrient. Individuals are advised to eat for more vitamin C, vitamin D, or iron or to avoid trans fats or carbohydrates. These pointed messages, which appear on everything from printed public health materials to frontof-package food labels, neglect the fact that most individuals do not eat to reduce risk of one disease or another, but instead consume a group of foods commonly referred to as their “diet.” With this in mind, nutrition communicators should as a general rule place information about individual foods or nutrients within the context of the total diet. The 2010 Dietary Guidelines Advisory Committee recently took steps in this regard, advocating for a “total diet approach to achieving dietary goals” and providing an evidence-based review of healthful eating patterns, such as the Dietary Approaches to Stop Hypertension (DASH) and Mediterranean patterns [1]. Everyone Is an Expert The challenge of influencing eating behavior begins at the most fundamental level: everyone eats. Consciously or unconsciously, people draw on their vast reservoir of experiences with food each time they decide to buy, prepare, and consume food. Further, in their role as caregivers, many individuals draw on those experiences to make decisions about the foods that they serve to their families. When new information conflicts with what they “know” about food (that is, their preferences) they engage in the process of deciding whether that information should be used to modify their choices. For example, a common concern expressed by participants in Sisters Together focus groups was that substitution of healthier choices would not be acceptable to family members. Therefore, the campaign needed to address women’s reluctance to modify certain food practices based on family preferences [23]. © 2013 by Taylor & Francis Group, LLC

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Despite years of attempts to regulate who can say what about nutrition, it remains generally true that almost anyone can set themselves up as an expert and dispense nutrition advice even to broad audiences. The problem has grown as more and more individuals turn to the Internet for nutrition information. As a result, it is more difficult than ever for consumers to identify sound, unbiased nutrition information. A challenge related to this proliferation of unchecked nutrition advice is that, when it comes to health messages, we accept or reject nutrition information depending on our experiences, beliefs, and biases. In the current nutrition communication landscape, we can easily find sources that confirm what we want to believe. For example, one might find any number of communications that extol the health benefits of dark chocolate, red wine, or fast food diets. Stumbling upon a source that affirms a favorite food as healthful may, in turn, prompt a consumer to ignore the less attractive, but accurate, advice communicated by more reputable sources [24]. That said, while TV, magazines, and the Internet represent the most frequently used sources of nutrition information, consumers rank registered dietitians, doctors, and nurses as the most credible sources [25,26]. Clearly, one-on-one interactions with patients are an important opportunity for health professionals to cut through the noise and establish themselves as providers of sound, actionable nutrition guidance.

Social Networks Social networks, “the web of social relationships that surround individuals” [27], provide another avenue for meaningful nutrition communication. The relationship between social networks and health gained attention in the 1970s when researchers demonstrated that less connected individuals had a higher risk of all-cause mortality than wellconnected individuals [28–30]. Since then, social networks have been studied for their effect on health issues as varied as smoking cessation, sexual behaviors, and obesity. Maibach and colleagues highlight the importance of the size and connectedness of one’s personal network; the social support and modeling provided by family members, peers, and mentors within that network; and the role of opinion leaders as key influences on health behaviors [3]. Personal Network and Social Support While well-connected individuals are generally healthier than less connected individuals, extending the size of individuals’ social networks seems beyond the scope of most nutrition communication efforts. However, health providers should be sensitive to the fact that an individual’s level of social support and day-to-day influences can have a significant impact on whether or not they adopt or maintain healthy eating behaviors. More important for the nutrition communicator is understanding how to engage with the social networks that individuals occupy in order to promote healthful behaviors. Evidence shows that having a friend who becomes obese can significantly increase one’s own risk of obesity, yet this research also suggests that these same social influences

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could be used to slow the spread of obesity [31]. Formative research with the target audience is a key step in integrating social support and modeling into a nutrition communications strategy, particularly by identifying the people who have the most influence (positive or negative) on eating habits within a social network. For example, if formative research shows that members of the target audience are most influenced by their mothers, messaging can be designed to invoke a mother’s voice. Alternatively, if research shows that spouses most frequently undermine healthy eating habits, messaging can specifically target spouses. Opinion Leaders Opinion leaders, sometimes called champions, are individuals who influence the opinions, attitudes, beliefs, motivations, and behaviors of others. They can act as gatekeepers for interventions, help change social norms, and accelerate behavior change. In public health, they have been used to gain support for and implement community health programs in at least four different ways. They provide access for and legitimize external change agents, serve as the communication link between communities and external agencies that implement programs, act as role models for behavior change within a community, convey health messages, and serve as the “capital” that institutionalizes program goals after an outside agency has left a community. In the diffusion of innovation model, it is the opinion leaders who tend to monitor the climate of opinion and use their influence when the advantages of a new idea is apparent or when it is clear that norms will change [32]. Community opinion leaders often include clergy, teachers, legislators, and physicians. However, it is important to assess the primary influencers within each target audience through formative research.

Population/Community The attributes of groups, communities, and populations that influence health behaviors are perhaps less well understood than are other factors in the people and places framework [3]. However, a large body of work is beginning to clarify how racial and socioeconomic disparities negatively influence health. Furthermore, a growing number of interventions based on community-based participatory models incorporate community organization and coalition building to create sustainable change. Within this context, it is critical to understand factors such as social norms, culture, social cohesion, collective efficacy, social capital, and income disparities. Both interventions described in some detail in this chapter, Sisters Together: Move More, Eat Better and Shape Up Somerville, addressed these factors in the planning and execution stages.

Places Place-based factors outlined by Maibach and colleagues include the availability of products and services, the physical structure of the environment, the social structures within the © 2013 by Taylor & Francis Group, LLC

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environment, and media and cultural messages to which the target population is exposed. At the local level, these include home, school, neighborhood, local stores, workplaces, and the city. At the distal level they include state, regional, national, and even international factors. Health practitioners working at the local level must familiarize themselves with the community in which they work, identifying supportive individuals and groups as well as gaps in available resources. For example, if the goal is to increase fruit and vegetable consumption, then it is essential to understand the availability of food markets and seasonal farmer’s markets that provide high-quality fruits and vegetables at fair market prices, as well as to help organize advocacy efforts to bring such resources to underserved neighborhoods. If the goal is to insure that public schools are following the mandated wellness policies with respect to nutrition and physical activity, it is important to know what these policies are, to identify where progress is being made and where it has lagged, and to actively participate in efforts to ensure progress. In the Sisters Together campaign, beauty salons were identified as an important component of the social structure of the community, so those businesses were engaged as partners to promote healthy eating by providing materials developed by the campaign. While attention to such place-based resources can enhance the effectiveness of nutrition communications, the challenges of engaging such resources are considerable.

Shift in Communications Landscape As Abroms and Maibach aptly note, “A communication revolution has blurred traditional distinctions between mass and interpersonal communication, and changed in many ways how we must think about using the media to promote the public’s health” [33]. The rise of the Internet has radically altered the way that information flows through our society. In an earlier era, communication occurred largely on a one-onone or one-to-few basis and flowed in a somewhat linear fashion through one of two pathways. In the “treatment model” pathway, information flowed from research to medical practitioners and then to consumers as patients. In the wellness domain, it flowed through media and health professionals to consumers. The arrival of next-generation technologies has enabled dramatic shifts in that process, providing individuals and organizations with dynamic and powerful new communication tools to spread their influence to thousands, if not millions, of people, independent of traditional media channels and their associated gatekeepers. Not only is the interested consumer receiving the latest research findings at the same time as the practitioner, but the consumer can also take on the role of “citizen journalist,” actively engaging in the dialogue about nutrition and health issues. In short, there is a lack of clarity about who exactly are the experts, increasing the level of consumer confusion. The proliferation of mass media channels has also led to a decline in the size of the audience captured by any individual channel. As a result, each channel now tends to focus narrowly on the interests of a specific audience,


decreasing the likelihood that a particular message will reach the intended audience with sufficient clarity and repetition to influence behavior. This shift in the nutrition communication landscape has led to a shift in Americans’ sources for food and nutrition information. Two-thirds of Americans look to Internet articles, cooking shows/hosts, TV or radio news programs, magazine articles, newspapers, talk shows, public service announcements or ad campaigns on TV or radio, and blogs or social networking sites like Twitter and Facebook [8]. That Americans are increasingly connected with these media sources is both an opportunity and a challenge for communicating about nutrition. While communications campaigns can target specific populations from multiple angles, it has grown much more difficult to cut through the noise. On the other hand, it is extremely important to keep in mind that, while there has been a burgeoning of electronic resources to communicate all kinds of information, there is still a significant percentage of the population that still do not use such resources. In developing nutrition communications activities, it is critical to assess the types of channels the target population uses and the reasons why those channels are preferred, and then to tailor the intervention accordingly.

Other Challenges to Communication of Nutrition Messages for Behavior Change While it is uncertain exactly how many nutrition-related messages the average American is exposed to each day, the number is undoubtedly extremely large, and growing given the proliferation of opportunities made available through Internet-based communications. These messages include information on food labels, in advertising, in print and electronic media of all types, and even on billboards at sporting events. The goal of much of the information that is provided is to persuade the individual to behave in way that is desired by the provider of that information. The behavior that is being advocated will depend on the agenda of those that are providing it. In the case of the media, a chronic problem is that, more often than not, nutrition research is portrayed as revolutionary, with findings inappropriately described as breakthroughs that are ready to translate to actionable behaviors. For example, a 1995 epidemiologic study suggesting a potential inverse relationship between lycopene and prostate cancer led to widespread recommendations from mainstream media and food and supplement manufacturers to increase lycopene intakes [34]. By 2007, however, the media exposed the limitations of research on lycopene’s protective effects: a headline in the New York Times, for example, read, “Lycopene as Cancer Blocker? Review Says Evidence Is Scant.” That same year, new reports posited another nutritional panacea for prostate cancer prevention: an article in Science Daily asked, “Worried about prostate cancer? Tomato-broccoli combo shown to be effective.” It went on to report that rats who had been implanted with prostate cancer cells and fed a combination of 10% of their diet as © 2013 by Taylor & Francis Group, LLC

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tomato powder and another 10% as broccoli powder had less growth of prostate tumors than rats fed one or the other, lycopene powder, or a drug given to men with enlarged prostates. Translating that advice to humans (an extrapolation, given that the effect was seen in rats who consumed 20% of their diet from two vegetables), a 55-year-old man concerned about prostate health should consume 1.4 cups of raw broccoli and 1 cup of tomato sauce or a half cup of tomato paste every day! Because new findings are so often framed as absolute truth rather within the context of a specific issue, it is understandable that consumers say they are confused when conflicting results appear. Another problem that is particularly important in nutrition communication is the tendency among health professionals and the media to focus on dietary objectives that are not being met, rather than acknowledging progress that is being achieved. Such negative messaging can be discouraging. Further, even as the public falls short of meeting certain dietary guidelines, we continue to raise the bar, delivering guidance that many Americans may view as infeasible or impractical. To an individual who eats two servings of fruits and vegetables a day, for example, raising the guideline from five servings to nine may seem so lofty as to be counterproductive. Communicating achievable goals and celebrating incremental successes can enhance the success of nutrition communications.

Media Advocacy: Using Media to Get Behind Your Cause/Sway Public Opinion and Policymakers In some cases the strategic use of media can help promote policy changes that support desired health behaviors. Advocacy is the process of using evidence to influence government-level policymakers and working with partners to elevate issues to decision-makers’ agendas. (For readers interested in how to influence health policy, Essentials of Public Health Communication offers an excellent discussion.) If it is not possible to communicate with policymakers directly, an alternative is grassroots advocacy by a group of citizens interested in the same issue. In this situation, the key is to form an effective coalition that becomes informed about the problem and possible solutions to it, and then draws a focus to it through local events or work with the local media to frame the discussion according to the objectives of the group. Mothers Against Drunk Driving (MADD), for example, brings together individuals with a common concern and works to influence policy pertaining to that issue. At the local level, community members might use a media advocacy strategy to bring a supermarket to an underserved area. The effective use of media can raise the volume of their message to a level where it is heard by policymakers who have the power to influence environmental change. There are a number of resources available to help with the design of media advocacy campaigns, such as that published by the American Public Health Association (http:// www.apha.org/advocacy).

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Role of Nutrition Communication in Changing Behavior: Community-Level Interventions Mass media campaigns have been defined as “any planned effort that disseminates messages to produce awareness or behavior change among an intended population through channels that reach a broad audience” [33]. That definition can be readily applied to the design of nutrition communication efforts at the community level. The following two case studies illustrate the process. The first, Sisters Together: Move More, Eat Better, is a communications campaign that was accompanied by community-building efforts. The second, Shape Up Somerville: Eat Smart, Play Hard, was designed according to the principles of community-based participatory research (CBPR), and nutrition communications played a major role in many aspects of the intervention.

Sisters Together: Move More, Eat Better Sisters Together: Move More, Eat Better was designed to prevent obesity through promotion of improved nutrition and increased physical activity in African American women between 18 and 35 years old in three inner city communities in Boston, MA. The overall framework for the campaign was drawn from the ecological model, as proposed by McLeroy et al. in 1988 [35]. People-Based Campaign Components Defining and understanding a target population was the first step in developing Sisters Together. The contract from National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) for the development, implementation, and evaluation of the intervention mandated that the campaign focus on obesity prevention in a minority group, but did not further specify the target population. The population was defined through a series of steps. A literature review that documented higher prevalence of obesity in African American women than in the general population was confirmed by data from the behavioral risk factor surveillance study [36] in Massachusetts, which also showed that increased risk was associated with low income and living in an urban area. A search of peer-reviewed publications and popular literature, including magazines and newspapers, explored obesity treatment interventions and weight loss practices, target audience understanding of the link between disease and obesity, perceptions of body weight and image, and other cultural factors that would affect acceptance of campaign messages. In addition to helping identify a target population, this formative research uncovered insights that later informed the design of the campaign, and particularly to ensure that it addressed population-specific attributes. The focus of the campaign was narrowed following a series of key informant interviews with nutritionists and other community health workers, who identified 18- to 35-yearold black women as an underserved population. To further understand culture, gender, social class issues, attitudes, and © 2013 by Taylor & Francis Group, LLC

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preferences, the campaign planning group was expanded to include experts in media, education, and nutrition who lived and/or worked in the communities and were familiar with the culture of the target population. This was a crucial step in creating a foundation for community building and community linkages. Throughout the project, design of all new materials and activities were based on formative evaluation that addressed three fundamental questions: Do the materials address the themes, key information, and skills that are needed? Does the design reflect the culture and preferences of the target population? Is the language and style appropriate and understandable? The campaign logo for Sisters Together (see Figure 14.2), for example, communicates the culturally relevant concept of sisterhood expressed repeatedly in lay literature. The shapes of the women reflect the acceptance of a heavier weight as ideal, hair styles and variations typical of the target population, and the sense of movement being promoted by the campaign. While the logo could be reproduced successfully in black and white, the green, red, and black used in the original design were recommended by campaign planning group members familiar with the community. The various features of the logo were tested in focus groups and, when that was not feasible, in intercept interviews to ensure that decisions were acceptable to the target population. Beyond such campaign branding efforts, the messages and materials in Sisters Together were tailored to social and cultural characteristics of the target population. For example, formative research showed that one widely popular dish was macaroni and cheese, high in calories and saturated fat. The challenge was to create a version that would be significantly lower in calories and acceptable to the target population. The first step was to identify recipes that met the criteria. The second step was to show the recipes to women in the target

Figure 14.2 The logo for the Sisters Together: Move More, Eat Better campaign was developed from extensive formative research with the target population.


population to identify which ones might be acceptable, and to reject those that were not; with this population, it emerged that few of the women would prepare a recipe with cottage cheese, so the numerous calorie-reduced versions with this ingredient were removed from consideration. Once possible recipes were selected, the third step was a taste test, again with members of the target population, to determine the recipe that would be accepted most widely. This process was repeated for each of the 12 recipes used in a calendar, one of the materials designed for the communication campaign. In an evaluation of the calendar, many women reported that they liked and used the recipes, demonstrating the value of the formative research [37]. The campaign also included cooking demonstrations, which were held at as many community events as possible, with the goal of addressing key concerns for women in the community: cost, convenience, and self-efficacy with respect to preparation of food that tastes good and follows healthful criteria. Recipes used relatively less expensive ingredients and could be prepared quickly. Demonstrations emphasized basic kitchen skills, such as knife skills, frequently found to be a barrier to food preparation. Place-Based Campaign Components Sisters Together also incorporated place-based components, at both the local and distal levels. For example, the campaign’s launch was publicized through local broadcast and print media, and promotion through these channels continued for the duration of the campaign. A coalition of community partners was also established to support and extend the campaign message. Attendance at partner events allowed not only the Sisters team but also its partners to cross promote their programs and events. In addition, events were used to compile a mailing list for a monthly newsletter. Each newsletter had a monthly theme, with a review of recent events held by partners, a description/promotion of partner organizations, and a detailed calendar of events for the next month. At the distal level, Sisters Together remains a national initiative of the NIDDK Weight-Control Information Network, and has been and continues to be adapted to meet the needs of communities throughout the United States. The campaign workbook and other materials are available at http:// win.niddk.nih.gov/publications/SisPrmGuide2.pdf. Ongoing reevaluation of the messages and materials is essential to identify adaptations that appear necessary and to ensure suitability for target populations.

Shape Up Somerville: Eat Smart, Play Hard Shape Up Somerville: Eat Smart, Play Hard (SUS) was an intervention designed according to CBPR, a collaborative approach that combines systematic inquiry, participation, and action to address urban health problems. This approach aligns closely with the People and Places framework [3]. SUS was designed to bring the energy equation into balance by increasing physical activity options and availability of healthful foods for early elementary school children, © 2013 by Taylor & Francis Group, LLC

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within the before-, during-, and after-school environments, as well as the home and community. The goal was to prevent the expected weight gain in elementary school children through small changes in their diets and physical activity [38]. Nutrition communications, which grew out of formative research with the members of the target community, played a key role in virtually every aspect of the project. People-Based Campaign Components Similar to Sisters Together, the branding of SUS was developed based on formative research specific to the target population. The name for the campaign, “Shape Up Somerville: Eat Smart, Play Hard,” came out of focus groups with children. (Coincidentally, “Eat Smart, Play Hard” was also adopted as the name of a national USDA campaign, so there was a logical synergy that strengthened the messaging.) A logo, designed to reflect physical activity and healthy eating behavior in both boys and girls, was derived from ideas suggested by the children in focus groups representative of the target population. Alternative designs, including different graphics and colors, were tested in formative research with the children. The final logo was a red and orange line drawing of a boy jumping rope and a girl eating a banana, with words in a font chosen and approved specifically for the project. This logo was used on all project communications, including written communications to families, promotional materials such as water bottles and T-shirts, window stickers that promoted Shape Up Approved restaurants in the community, and reflective tags for “Walk to School” day. This consistent branding was critical to increasing campaign recognition. SUS also engaged families through newsletters that were developed based on information obtained in parent focus groups. In response to feedback from parents and caregivers, coupons for produce were solicited from a local vendor and included in the newsletters. Knowing that the newsletters contained coupons raised the likelihood that parents and caregivers would open and read them. In addition, newsletters provided information that would be of value to the target population, including recipes for foods that were being promoted, publicity about locations and times of farmers markets and local events, ideas for activities with their children, important food safety information, and research findings of particular relevance to the population. Place-Based Campaign Components Given SUS’s focus on children, its place-based components logically included several school-based elements. For example, school lunches and a la carte offerings were adapted to include less energy-dense food and beverage options, with an emphasis on fruits and vegetables, whole grains, and low-fat dairy. Schools also adopted new wellness policies and were provided new play equipment to allow more active recess activities. Another program component specifically aimed to increase children’s acceptance of dried beans, a nutrientdense commodity food. Recipes were developed and tested to ensure that children would like them, and beans were promoted through a unique audio program broadcast through

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the school public address system. In order to heighten interest in the program, students in the schools participated in the design and delivery of each of the 11 messages. Focus groups with children in the community informed message development, and content analysis of food advertisements to children was conducted to identify characteristics and persuasive techniques that might be used effectively [39]. Beyond the school setting, SUS also addressed issues of access to healthful foods through a program that certified restaurants as “SUS-approved” if they met specific healthy eating standards. To support physical activity in the context of an urban built environment, a “walking school bus” program was initiated, and a mandate was developed to paint crosswalks with more durable paint to make them safer for crossing. A column in the local newspaper, The Somerville Journal, featured regular articles to raise the visibility of the intervention and the many activities that were being conducted. For example, the Journal ran a series of articles titled “Where’s Mayor Joe?” focusing the mayor’s visits to restaurants that had adopted SUS healthy eating standards. The articles positioned Mayor Joseph Curtatone, an opinion leader in the community social network, as an individual who could promote the normative behavior being recommended in the environment. The success of this program component depended largely on the shared interests among SUS researchers and community stakeholders: SUS benefitted from the promotion of approved restaurants, the mayor gained favorable publicity, restaurants obtained a no-cost marketing opportunity, and the newspaper enhanced public relations through its promotion of community programs. At the conclusion of the intervention, the SUS logo was signed over to the city, which has continued many aspects of the intervention. At the distal level, the success of SUS led to the development of the Balance Project, which has adapted and implemented the SUS model for other U.S. communities. National publicity, including a front-page feature of SUS in the Wall Street Journal, further extended the campaign’s influence on nationwide policies surrounding child nutrition and physical activity.

Lifestyle Medicine

specific strategies can help your message resonate with the target audience and drive the desired behavior change.

Acknowledgments The authors would like to acknowledge the editorial contributions by Daniel Hatfield, MS, to the preparation of this manuscript.

References

General Nutrition Communication Recommendations Nutrition communication, by itself, cannot be expected to influence eating behavior. Its greatest promise is as a component of a comprehensive intervention that begins with a definition and understanding of the target population, based on thorough formative research, and a clearly specified, measurable set of outcome objectives. Nutrition advice must be framed in the context of total diet and be consistent with the Dietary Guidelines for Americans. The information is complex for most consumers and is generally more effective when divided into digestible bits and actionable steps. Nutrition messages and materials should be accurate, actionable, and relevant to the target population. Whether you are designing a nutrition communication intervention for a small group with very specific needs, or for a large, generalized group, a well-planned approach using © 2013 by Taylor & Francis Group, LLC

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