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 agree
ABSTRACT diet approach promote positive life- that eating healthfully is a better way
It 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 with
eating style. All foods can fit within complaints that nutrition education
this 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 to
ity. 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 of
eating 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 exacerbated
tal diet approach include the Dietary ity. The American Dietetic Association
Guidelines 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, rather
etary 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 or
should 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 of
unhealthful 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 consumption
practices are dynamic and influenced veys suggest that their food habits of energy-dense foods may promote
by 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-dense
economics, 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 health.
media, 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 focused
tiveness of nutrition education in pro- Even though more than half of con- on positive ways to make healthful
moting sensible food choices, food and sumers say they are making dietary food choices over time, rather than
nutrition 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 on
moderation and proportionality in the tical guidance by food and nutrition diet and nutrition from a variety of
context of a healthful lifestyle, rather professionals is needed to promote sources is confusing to the public and
than 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, and
active, 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 adequate
1224 Journal of the AMERICAN DIETETIC ASSOCIATION © 2007 by the American Dietetic Association

2. ADA REPORTS
nutrients within calorie needs. This for Americans, but limited quantities SUCCESSFUL COMMUNICATION
includes the concept that foods are would be acceptable, provided that CAMPAIGNS AND PROGRAMS
not inherently “good” or “bad.” Over nutrient-dense foods comprise the Teaching consumers to make wise
the years, the American Dietetic As- bulk of the day’s choices. This mes- food choices in the context of the total
sociation 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 to
FEDERAL NUTRITION GUIDANCE consumers can use to choose and com- suggest a change to a more healthful
SUPPORTS THE TOTAL DIET APPROACH pare foods. The Nutrition Facts label lifestyle in terms of small steps that
The 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 successes
eral food, nutrition education, and in- agency partners as a consumer infor- in improving fitness or dietary quality
formation 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 coordinated
The DASH (Dietary Approaches to be an effective educational tool that efforts of a number of agencies and
Stop Hypertension) Eating Plan from helps consumers plan their diets. For organizations with similar health
the 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 design
consumers in implementing these product after reading the nutrition la- behavior-oriented food and nutrition
recommendations (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 approach
System is another example of a di- that is sustainable and fits individual
etary pattern that uses a total diet preferences. Nutrition education re-
approach to ensure nutritional ade- Nutrient Intake Recommendations search supports the identification of
quacy and healthful food choices. My- The Dietary Reference Intakes (DRIs) components that are effective across
Pyramid 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 GOOD
MyPyramid found that consumers which had been revised periodically AND BAD FOOD MESSAGES
and 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 in
tastes 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 into
cohol) was introduced to allow con- tional deficiencies.” In addition to the their decision strategies.
sumers to choose small amounts of Recommended Daily Allowances
less-nutrient-dense foods while meet- (RDAs), DRI categories include Esti-
ing nutrient needs within caloric lim- mated Average Requirements The Magic Bullet Approach
its (14). For example, consumers can (EARs), Adequate Intakes (AIs), and Thinking in terms of dichotomous or
balance 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 school
garine, jelly, alcohol) with nutrient- week for most nutrients. For macro- children believe that there are good
dense foods (vegetables, whole grains, nutrients, recommendations are and/or bad foods (21). Although the
nonfat milk) to achieve an overall stated as Acceptable Macronutrient ability to think in more abstract and
healthful dietary pattern (13). How- Distribution Ranges (AMDRs). The complex modes is prevalent among
ever, the discretionary calorie values AMDRs show that there is not just adolescents and adults, consumers of
can be quite low (150 kcal/day), such one acceptable value, but rather a all ages tend to rely on dichotomous
that 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 as
energy 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 perceived
added sugars, or alcohol are not com- consumers understand the impor- control (self-efficacy). However, when
patible 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. ADA REPORTS
situation such as a tempting food (eg, and growth. To avoid this confusion, sumption of savory, high-fat snacks
a cookie), loss of control may occur, the Food and Drug Administration was associated with poor diet quality
depending 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 substantially
regarded as a forbidden food and a Conversely, even foods associated over time both inside and outside the
dieter who yields to a desire for a with a healthful diet such as egg household (34). Nutrition education is
cookie would tend to say, “I ate the whites and soybeans should not be critical because individuals tend to
cookie. I have blown my diet. I might oversimplified as being perfect. Egg eat more calories when served large
as 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 the
there is not much that can be done ciency when used as a primary or sole total diet, if these foods are consumed
once 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 of
duce 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 has
personal favorites in individualized and the health benefits of adding soy been a cornerstone principle in the
eating patterns, and promoting ac- to the diet have not been consistently Dietary Guidelines for Americans, but
ceptance of personal responsibility supported by research (30). For exam- that emphasis has changed from
and choice (“I can refuse to eat it” or “I ple, animal studies in which soy in- overall variety to varying choices
can occasionally enjoy a small por- take was higher than that found in within the food groups. Choosing a
tion”). The option of providing simple, Asian diets found an increase in tu- variety of nutrient-dense foods helps
one-size-fits-all decision rules may be mor growth (31). Thus, foods such as to ensure adequate intakes of more
an expedient approach to education egg white and soy cannot be classified than 50 nutrients that are needed for
and counseling, but it often misleads as completely good or bad, but rather growth, repair, and maintenance of
consumers into thinking that a given their value is determined within the good health. However, an increase in
type 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, the
sive and targeted education involves
tion Science Alliance, a collaboration multitude of choices at a buffet and
context-based judgment. This type of
of seven scientific professional organi- the temptation to taste each food can
educational message is more difficult
zations (5). result in a greater intake of calories
to address in language that is easy to
With over 45,000 food items in the than from a plated or family-style
understand and apply, but it is more
average supermarket (32) and an in- meal. When McCrory and colleagues
likely to help the consumer to make finite array of recipe combinations, (38) analyzed 1999 food consumption
well-reasoned food choices and adopt the futility of attempting to sort all data, increases in energy intakes and
behavior 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) observed
lar disease associated with ingestion as discretionary calories, provides that a variety of foods was associated
of 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 provides
naturally from ruminant animal CONTROVERSIES WITH THE TOTAL DIET excess calories without added health
sources (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 as
tion, and physiological outcomes (25). permitting unlimited inclusion of low- WHY WE EAT WHAT WE DO
In contrast to the atherogenic nature nutrient-density foods and beverages Convenience, Cost, and Confusion
of most synthetic forms of trans fat, or encouraging overconsumption of Although 87% of consumers reported
conjugated linoleic acid has been foods with marginal nutritional being very or somewhat concerned
shown 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 not
mune response, energy distribution, healthful diet quality, heavy con- occurred (2). Shoppers say healthful
1226 July 2007 Volume 107 Number 7

4. ADA REPORTS
foods 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 nutrient
places and the cost is too high. Also, self-improvement, the dieter may re- needs, it is important to stress that
confusion exists over conflicting infor- strict foods or macronutrients consid- the total diet approach is designed for
mation 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 Influences
sumption 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 the
dark green vegetables, orange vegeta- and an exercise pattern that can be lack of time in our rapidly changing
bles, 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 much
contribute 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 a
basic taste sensations—sweet, sour, beyond basic nutrition and new agri- desire to spend less than 15 minutes
bitter, salty, umami (L-amino acid), cultural and biotechnology tech- to prepare a meal (59), there has been
and fatty acids—are affected initially niques. Many new biotechnologies a virtual explosion of convenience
by 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 is
are further developed by experiences abundance of functional foods may being replaced by parents purchasing
related to one’s sex, age, weight, and contribute to increased energy in- take-out foods from a variety of
eating 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 not
born. This preference for sweetness, foods that are good for them (53), such only affect taste preferences, but also
in 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. In
choices in young children (44). Be- nutrition professionals need to stay 2005, the minority population totaled
cause young children (45) and even current through continuing education 98 million, or 33%, of a total of 296
rats (46) can learn to prefer high-en- to meet the needs of an ever-changing million (60). As people from varying
ergy foods, the avoidance of these society. backgrounds become acculturated
foods may be foiled by feelings of de- into US society, their dietary habits
privation because of a well-estab- tend to change from a pattern based
lished desire to eat sweet and high- Physiological Influences on whole grains and vegetables to
calorie 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 be
casions are permissible within the alization, dementia, and/or dimin- considered good or bad by persons
context 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 are
sonal 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 food
high 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 choices
quality (47) and a greater weight loss cheese, meat) often become unpleas- such as brown rice and whole-wheat
in 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 their
weight control (49). One common con- on obesity and feeding behaviors is effects on food choice behaviors. In
sequence 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. ADA REPORTS
economic 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 skills
1999, only 12% held this belief (59). In cer prevention and dietary fiber to or help learners master more complex
individuals 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 as
reflecting limitations in transporta- the one for fluid milk (“Got Milk?”),
tion, cooking facilities, food prepara- which featured celebrities wearing Adapting Behavior-Oriented Theories for
tion skills, grocery store locations, milk mustaches. Remarkably, these Food and Nutrition Communication
and availability of healthful food campaigns slowed or stopped the de- Knowledge-Attitude-Beliefs. One of the
choices (63,64). However, financial is- clining trend of milk consumption
simplest models for food and nutrition
sues 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 based
a 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 new
Environmental 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 scare
tural 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 in
perceptions, attitudes, and beliefs list of foods that are high in iron may be
near hysteria among mothers who
about fat have shifted in the last half a successful trigger to dietary improve-
thought they had fed their children
of this century, much of it because of ment for someone concerned over a re-
tainted foods. Apple sales plummeted
social trends and marketing cam- cent diagnosis of anemia. However,
as a result, even though the research
paigns. 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 states
techniques (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 eating
fried onion rings, lettuce wedge with not convenient or congruent with per-
apples as in the past (73). Although it
Thousand Island dressing, and baked sonal taste preferences.
is essential to acknowledge that truly
potatoes with butter, cheese, and sour
unsafe foods are never good food Health-Belief Model. The Health-Belief
cream. Today, meals might be lower
choices, in this case, positive mes- Model is one of the most widely used
in fat and reflect changing tastes,
sages about the benefits of diets with theories in health education (74). An
such as pasta with chicken, sun-dried
plenty of fruits and vegetables help example is the promotion of foods
tomatoes, and roasted vegetables, ac-
restore balance in diet and health high in folate to reduce the risk of
companied by a salad of mixed field
goals. certain birth defects. This model ex-
greens, dried cranberries, and bal-
samic dressing. plains human behavior and readiness
Social Influences. Social factors sub- COMPLEXITIES OF CHANGING EATING to act via four main constructs: per-
stantially influence eating behaviors. BEHAVIORS ceived susceptibility (“How likely am
For 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 nutrition
study suggested that social facilita- messages are communicated to con- I feel better if I change the fats that
tion of eating is caused by an im- sumers. Nutrition information must I eat?”), and barriers (“How hard will
paired ability to self-monitor (68). In be presented with sufficient context to it be to make these changes in my
a study of why cardiac patients do not provide consumers with a broader un- fat intake?”). A recent addition to the
follow nutritional advice, 86% re- derstanding of the issues and to de- Health-Belief Model is the concept of
ported that social and work situations termine whether it applies to their self-efficacy (“How confident am I that
presented challenges, in addition to unique needs (4). Communications I can succeed in changing the fats
financial barriers to change and diffi- and educational programs must em- that I eat?”). The Health-Belief
culty 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 behavior
Media. 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 “tune
icans. In 2004 approximately $11 bil- when educators use appropriate the- out” repeated messages of gloom
lion 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. 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 well
Figure. 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 basis
important 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 balanced
Social 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 be
ries 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 Dimension
Cognitive (Social Learning) Theory drinking milk), and reinforcement In addition to programs that target
would support an educational inter- (positive or negative feelings that oc- behavioral practices and dietary
vention addressing behavioral capa- cur when milk drinking is practiced). knowledge/skills of individuals and
bility (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. ADA REPORTS
improvements at the broader organi- it is important to stress that a diet Effective Communication Strategies
zational 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 as
and public policy change within orga- phytochemicals and ultra trace ele- ● focus on high-priority personal
nizations 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 of
REDUCING NUTRITION CONFUSION and toxicity levels of these dietary diet and activity choices as part of a
To 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 models
nutrition 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.
eatright.org/cps/rde/xchq/ada/hs.xsl/media_
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: http://www.ific.org/research/
(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. 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: http://www.fmi.org/newsletters/ 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
eatright.org/cps/rde/xchg/ada/hs.xsl/advocacy_ 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.
http://www.ific.org/research/newconvres.cfm. 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: http://www.healthierus.gov/ 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.
http://www.mypyramid.gov. 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: http://www.nhlbi.nih.gov/health/public/ 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 young
10. Food and Drug Administration. How to un- Available at: http://www.cfsan.fda.gov/
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
http://www.cfsan.fda.gov/ 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.
http://www.ific.org/publications/brochures/ 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, http://www.fmi.org/facts_figs/superfact.htm. 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-modified
16. 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. The human obesity
July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1231

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 model
57. 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 Nutr
59. 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 Am
61. 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: http://www.pbhfoundation.org/pulse/
1118-1126. press/releases/pressrelease.php?recordid
63. 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: http://www.cdc.gov/pcd/issues/2006/jul/ 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 on
67. 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 ppapers@eatright.org.
69. 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 group
70. Advertising Age. 50th Annual 100 Leading
National Advertisers. June 27, 2004. Available (Laura Chalela, MPH, RD, Edelman Public Relations, Chicago, IL); Susan
at: http://www.adage.com/images/random/ 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); Linda
71. 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