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Despite 35 y of dietary guidance, there has been no substantial shift in consumer compliance. Consumers report that they seek information on nutrition and healthy eating, but most are not paying attention to dietary recommendations. For guidance to be effective, it must be realistic. Even with increasingly detailed nutrition information and evidence that diet affects health outcomes, convenience and taste remain the strongest determinants of food choices. It is up to health educators to clear up confusion and give consumers control with nutrition messages that are realistic, positive, easy to understand, and actionable without an expectation that consumers will surrender foods they love.
The release of the first edition of the Dietary Guidelines for Americans (Guidelines) in 1980 laid the cornerstone of current federal nutrition policy in the United States (1). Seven editions and 35 y of dietary guidance later, consumers’ adoption of dietary practices congruent with the Guidelines remains far from ideal (2). Although some progress has been made, most Americans still fall short of current food-based dietary recommendations (3, 4), with diets containing fewer fruits, vegetables, whole grains, milk, and oils than recommended (5). A substantial portion of the population also does not meet recommended intakes of meat and beans (5). On the other hand, intake of solid fats, added sugars, and alcoholic beverages exceed recommendations (5). For the average consumer, only about 7 d of an entire year came close to matching MyPlate recommendations (6). The high rates of overweight and obesity and corresponding weight-related diseases are indicative of the poor quality of Americans’ diets (5).
The stubborn gap between the Guideline’s recommendations and consumer implementation of the recommendations is likely the result of a constellation of cultural forces, societal norms, family influences, personal food preferences, food availability and accessibility, declining food preparation skills, changes in meal patterns, food marketing practices, time pressures, economic realities, government policies, and the fact that making and sustaining change is hard (2, 4, 7, 8). Moreover, limited operationalization of the Guidelines by consumers is undoubtedly related to the general lack of theory-driven, evidence-based programs that deliver clear, actionable nutrition messages that have been tailored to needs, interests, and sensibilities of specific consumer groups.
Closing the gap between ideal and actual is a shared responsibility. Government and nutrition professional organizations have a duty to weigh available scientific evidence and provide guidance, such as the Guidelines (1), and identify benchmarks and indicators of progress toward goals such as Healthy People 2020 (9). Government also has the responsibility to set policies supportive of an accessible, available food supply that supports healthy choices (10). The food industry’s key role is to create foods that meet consumer preferences while simultaneously promoting progress toward healthier eating (11). One example is the work of the Healthy Weight Commitment Foundation, a coalition of 16 food companies. Recent data indicate these companies more than quadrupled their goal of reducing 1.5 trillion kcal in the marketplace by 2015 (12). Nutrition communicators have the responsibility for creating messages and programming that resonate with consumers and build their capacity and desire to implement dietary recommendations. However, more than one-half of those polled in the 2012 International Food Information Council Food and Health Survey said it was easier to prepare their income taxes than to figure out how to eat healthfully (13). Those who were most confused were more likely to have higher BMIs, heart disease, cholesterol issues, or high blood pressure (13).
Despite consumer inertia toward healthier eating, consumers are interested in the relation between health and diet. Nearly one-half of the participants in a national survey reported that they actively seek information about nutrition and healthy eating (14). Consumers want this information because almost all of them rate nutrition and physical activity as personally important (14). Consumer interest in nutrition and health coupled with their confusion suggests shortcomings in current nutrition communications and important opportunities to improve dietary guidance (15). Application of the points presented in Table 1 could improve nutrition messaging, thereby facilitating behavior change.
The Guidelines, e.g., aim to improve Americans’ diets and health, but many Americans find current dietary guidance frustrating (13, 16). Part of that frustration may come from the overwhelming amount of detail provided (1). Although the 2010 Guidelines promoted 3 major themes (i.e., balancing calories to manage weight, foods and food components to increase in the diet, and foods and nutrients to decrease) (1, 17), it took 112 pages to explain them—the time and energy required to understand, absorb, and implement this guidance is beyond what even the most dedicated consumers can be expected to invest. Nutrition and health communicators are passionate about nutrition and want to share it all—but to keep consumers’ attention, simplicity and conciseness must be watchwords (7, 15, 18, 19). MyPlate illustrates an effective way to simplify some of these messages. The 2012 International Food Information Council Food and Health Survey found that Americans understand the messages of the Guidelines, as demonstrated by the MyPlate graphic. Specifically, Americans found the graphic to be effective in communicating the following messages: people should eat a variety of food groups for a balanced diet, people should eat a healthful diet, healthful foods are found in each of the 5 food groups, people should have dairy with their meals, and people should make one-half of their meals fruits and vegetables (13).
Conversely, some of the MyPlate guidance is truly esoteric and decidedly consumer unfriendly—e.g., MyPlate expresses intake of eggs in ounce equivalents, rather than whole eggs, and fruits and vegetables as cup servings, as well as whole fruit, and gives either/or instructions for categorizing beans and peas as a vegetable or as a “protein food” (20). Items to limit, according to the Guidelines, include solid fats, added sugars, and alcohol, but amounts are given in grams, a measurement unfamiliar to many American consumers. Additionally, consumers tend to think in terms of eating foods, not nutrients—but the Guidelines advise eating “nutrient-dense” foods with little further explanation. Food is complex and so is dietary guidance—but to effect change, guidance needs to be clearly stated using plain language and consumer-friendly terms (21, 22).
Some of the writing is unnecessarily convoluted and could easily be translated into more simple, easy-to-understand language, using terms familiar to consumers (Table 2) (22). Meanings consumers attach to frequently used dietary guidance terms, such as energy balance, are not always the same as those intended by nutrition communicators (23). Before unleashing guidance, it is imperative that we are sure the target audience understands—simply asking a few to listen to or read the messages and then explain what they heard or read can improve message clarity and usefulness (24, 25).
A key source of consumer confusion is when new studies are released that contrast with previous advice—such as when early research pointed to the risk of saturated fat and dietary guidance recommended consumers switch from butter to margarine—and then when new data indicated trans fats were a bigger risk, we reversed ourselves (26). Nearly 3 of 4 consumers feel that changes in nutrition guidance (13) and contradictory media reports (16, 27) make it difficult to know what to do. Contradictions lead to confusion, which contributes to a backlash against nutrition advice in general, demonstrated by the common consumer sentiment that “scientists really don’t know what foods are good for you” (16). Whether these contradictions are real or perceived does not matter; what does matter is that dietary guidance needs to clearly explain recommended behaviors and why changes have occurred so that consumers have the opportunity to develop an appreciation for how scientific knowledge evolves and why it is important for their diets to evolve too (19, 28). Helping consumers understand why advice changes can help keep them listening and making changes—and lower frustration and confusion.
For guidance to have the intended effect, it has to be realistic and fit in the everyday lives of consumers (7). For instance, the 2010 sodium guidelines were unrealistically low when it comes to palatability and implementation without advanced nutrition training even with continuing efforts by the food industry to lower sodium (29). In addition, meeting both sodium and potassium (a nutrient of concern) guidelines is incompatible with nutritionally adequate diets (30). Cost is another factor generating consumer resistance to accepting and adhering to dietary guidance designed to help them eat healthfully (4). Nutrient-dense foods, required to meet dietary guidelines, tend to cost more than foods that are less nutrient dense (31, 32). Saturated fat and added sugar as calorie sources yield lower diet costs (31, 33–35). There are lower cost options in all MyPlate food groups, such as dry beans in the protein group and flour in the grain group; however, many of them require greater time and skill inputs to prepare and their dollar cost alone does not reveal their true cost—these high resource input choices are not realistic in many of today’s hectic households (27, 36). Guidance that offers options for controlling cost and high time and skill inputs can play a role in moving American diets closer to the Guideline recommendations.
To resonate with consumers and ultimately improve their behaviors, guidance needs to use communication techniques that speak to the audience (37, 38) in a positive, friendly tone that empowers, encourages, and reassures (39, 40). Some research suggests that using a “fear” approach helps people realize their susceptibility to a poor health outcome or a “guilt” approach will goad people into action (41–45). However, negative messaging tones have a strong tendency to discourage consumers by implying they are doing something wrong and may trigger defensive reactions and diminish motivation (46, 47). Hence, encouraging a new behavior, rather than discouraging an undesirable behavior, likely has a better chance of success. Another type of tone that is perceived as negative by many consumers is one that is authoritarian or paternalistic (48, 49)—words such as “always,” “never,” “should,” and “need to” make people feel like they are being told what to do, whereas verbal softeners such as “try,” “think about,” or “consider” tend to get a better reception (37) and promote a feeling of partnership between the health communicator and consumer.
Consumers find mandated behaviors particularly distasteful (50). Even though the vast majority of consumers are in favor of the government providing nutritional guidelines and information about how to make healthy choices (51), few support policies that would constrain consumer choices, such as a tax on soft drinks or restrictions on portion sizes allowed to be sold (52–56). The freedom to choose extends to children—almost one-half of surveyed adults were against banning advertisements for unhealthy foods aimed at children (51). Coercing food choices causes children and adults to rebel (54, 55, 57–59) and can result in outcomes the opposite of what was intended (57–60). Nearly 9 of 10 US adults report that they would rather rely on their own knowledge, experience, and common sense to balance their food choices and support labeling to help them more easily identify foods high in calories, saturated fat, and sodium (61). It is clear that for American consumers, freedom of choice is paramount (51)—consumers want to make their own decisions. James O. Hill, Ph.D., of the Anschutz Health and Wellness Center, University of Colorado, may have summed it up best, “…Trying to regulate what people eat could backfire, as Americans value their independence and many don’t want to be told what they should eat or not eat” (62).
Dietary recommendation messages frequently are directed at “everyone,” even though communications designed for “everyone” often really apply to “no one.” To enhance the effectiveness of dietary guidance, it is time to target and tailor them to specific consumer groups (7, 40). Targeted and tailored messages are more likely to be read, remembered, rated as attention catching, saved and discussed with others, and perceived as personally relevant (63). They stimulate more active cognitive processing, which enhances message retention and behavior change (64, 65). Advertisers have mastered the technique of targeting and tailoring—that is why there are so many brands of toothpaste, varieties of breakfast cereals, and models of cars. When it comes to nutrition guidance, targeting and tailoring continues to lag. Indeed, traditional “one-size-fits-all” nutrition communications may have contributed to consumer confusion and, perhaps, the lack of motivation for dietary change expressed by many Americans (2, 66).
Widespread access to electronic media makes it possible to cost-effectively harness the power of tailoring dietary guidance to individual’s lifestyles, preferences, and personal circumstances. A key limiting factor is that there is very little published research reporting psychographic data that helps nutrition communicators understand the “goals in life” or “quality-of-life” needs, values, and motivations of consumer segments; i.e., we do not yet fully understand why certain groups make the food and physical activity selections they do—is it because of what they do or do not know, what they believe or find relevant and worthwhile, and/or what their social, physical, or resource (i.e., skills, time, or budget) environment “permits” them to do (67)? A new tool that can jump-start tailoring and targeting efforts by nutrition communicators is the audience and cultural insights from the CDC (68).
Eating behaviors are more than the sum of the nutrients and energy consumed—effective guidance must take a holistic approach and consider all of the reasons we eat beyond health and satiety. Emphasizing eating enjoyment, internal regulation, and moderation of food intake, regular meals, and accomplishing dietary goals by eating mainly for pleasure rather than to achieve dietary recommendations leads to more positive eating behaviors, healthier weights, and better cardiovascular disease biomarkers, such as LDL cholesterol (69–72).
Effective guidance needs to speak to what really matters to consumers (71, 73). Eight consumers in 10 say they do not eat healthier because they do not want to give up the foods they love (14). This stance suggests that guidance has not adequately considered that virtually all research indicates that taste is the most important factor considered when choosing foods—cost, convenience, health, and safety all take a backseat to taste (10, 74–76). The challenge to nutrition guidance and communicators is to help consumers realize that they can “have it all” by giving them strategies for improving their diets and health while continuing to enjoy foods with the qualities that are important to them.
After 35 y of limited improvements, it is time for dietary guidance to move beyond telling consumers “how to behave” to giving realistic advice about “how to change behavior.” Instead of simply saying “eat more fruit,” make it actionable “today” in “every” home—put a bowl of fresh fruit on the table, serve ice-cold canned fruit for dessert, or toss a box of raisins in your lunch for a snack (18, 27). Messages with an explicit, doable recommendation are more effective than those without—even in highly motivated and educated populations (15, 67). Provide tools, such as checklists or miniquizzes, to help consumers pinpoint problems, personalize the message, and increase their awareness. These tools also let them discover for themselves “why” current behaviors could be endangering their health and how simple, quick, low- or no-cost changes could lower the danger level. Consumers who understand why fiber, fat, fruit, vegetable, soy, and beans are beneficial have healthier intakes of these components (75, 77–80). Especially important is guidance that helps consumers overcome personal and environmental barriers to change—perceived barriers are a powerful negative influence on behavior change (41). Additionally, the focus of guidance needs to expand beyond the notion that individuals are solely responsible for change to motivating them to reshape environments and policies that make healthful choices more convenient, attractive, and affordable.
Consumers worry about making changes—maybe they are concerned about the taste of foods they need to eat, giving up TV time to exercise, or possible embarrassment of explaining their new behaviors to friends and family. Guidance that starts where the consumer is encourages gradual change that lets consumers slowly remodel their comfort zone—including eating familiar foods—and shows how small changes within a “nondiet” approach could reduce worry, facilitate change, and add up to big health benefits (18, 81–84). To aid in this process, guidance could leverage existing consumer behaviors that will allow consumers to simply improve behaviors they already do (e.g., adding vegetables to a sandwich or adding fruit to breakfast cereal) rather than completely overhauling their lifestyle (7, 18, 62, 85, 86). Promoting and celebrating incremental improvements help build the self-confidence needed to improve health and, from a research perspective, it is very important to remember that even though the goal of nutrition and health communications is behavior change, it is important to not only measure behavior change, but also changes in those factors that propel change, such as stronger feelings of self-efficacy, more positive beliefs about the likelihood and value of making changes, greater feelings of perceived control over personal behaviors and environment, and more skillful use of self-regulation strategies (8, 43, 81–84).
Consumers are just that—consumers. They decide what they will consume, whether it is information or food. However, they do want nutrition information and value their health (13, 14, 28). It is up to us as nutrition and health communicators to promote consumer health by developing nutrition guidance messages that clear up the confusion and give consumers increased control over health determinants so they can enjoy better health on their terms (87). A cardinal rule of marketing is to give consumers what they want—in the case of dietary guidance that means realistic, consistent, positive, easy-to-understand, actionable, personalized advice that fits within their time, money, and skill constraints, and, above all, respects their abilities to decide for themselves and enjoy the foods they love. The quality of American diets is not what we as nutrition communicators and health promoters would like it to be. Clearly, many factors contribute to the state of the American diet, with one being that guidance and communications, although improving, are not yet as effective at informing and motivating consumers as they could be. The tips in Table 1 have the potential to make nutrition messaging more accessible and actionable. The challenge for nutrition communicators is to keep trying—in phrasing widely ascribed to Thomas Edison, one of the most creative and persistent men of all time, we “have not failed.” We have “just found 10,000 ways that won‘t work… The most certain way to success is to try one more time” (88).
Both authors read and approved the final manuscript.