NUTRITION COMMUNICATIONS ENVIRONMENT
Now is the most interesting and challenging time seen in many years with regard to communicating about food and nutrition issues. The obesity epidemic, issues around what constitutes the “perfect diet,” and constantly emerging science on health benefits of foods and food components have reached epic proportions, which impact efforts to communicate with patients and other consumers about healthful eating. Additionally, the political climate and ongoing factors post 9/11 have impacted how consumers “view” food and nutrition. Consumers today hold dichotomous attitudes about food and health. They recognize the pleasures of food as well as its power to influence their health. 1 Since 9/11, there has been an increased demand for indulgent foods and more interest in the comforts of home, much of it centering on food. At the same time, there is a growing concern about self-care and personal health. As more shoppers are indulging their cravings this year, more of them also admit that what they eat can have a major effect on how healthy they feel. 1
Given the obesity epidemic and concerns about caloric intake, it may be more important than ever for consumers to understand how to obtain optimal nutrient intake in the most nutrient dense package possible. Upcoming issues and discussions surrounding the revisions to the Dietary Guidelines for Americans and reevaluation of the Food Guide Pyramid and its ability to deliver against new recommendations for certain nutrients will be a primary focus. Fortification as a means of meeting goals for certain nutrients, as well as for delivering information about nutrient dense alternatives for consumers, has become paramount in light of these various issues.
The incredible quantity of information on food, nutrition, and health (physical activity, disease risk reduction, etc.), and its ultimate impact on consumer behavior, also present challenges. On one hand, consumers desire and ingest increasing amounts of information. However, they are numbed by the volume and conflicting nature of messages in the media about what is perceived to be the “right” eating pattern. Consumer confusion, in addition to the steady rise in the incidence of obesity, presents something of a conundrum to nutrition communicators—including practitioners in clinical care environments.
In the past, communicating health benefits of food—whether that benefit was cholesterol lowering or providing a significant source of a particular nutrient—was enough to garner attention from consumers. Today it is important for health professionals to educate patients and consumers in terms of “eating plans” or approaches that synchronize with what consumers are willing to do which is important for patients who are advised to adjust dietary habits for therapeutic reasons. More than ever, food and nutrition professionals need to deliver clear, lifestyle-specific information that is immediately useful. Benefit layering may be one answer to facilitating the communications process. Current research is uncovering more and more reasons for consumers to consume foods with certain health benefits that go beyond basic nutrition—and thankfully, this list of “functional foods” is growing at a rapid clip—offering more and more options. But, communicating those benefits in appropriate and credible ways, with solid science and the right portion size is central to the equation. The key is showing consumers how to enjoy their “handful of nuts” (for instance) every day as part of a healthful diet, instead of enlisting the admonishments that were central to the era of fat avoidance.
Technology is becoming increasingly integral to the nutrient delivery equation. While consumer behavior is critical to creating healthful lifestyle habits, the foods that deliver those beneficial nutrients must also accommodate consumer preferences. Improved fortification and emerging ingredients, such as resistant starches, probiotics, plant stanols and sterols, and soy protein, aid in this process.
As food and nutrition professionals, dietitians must work within the existing “frame of mind” or environment in which consumers live to help them navigate successfully through the various issues and products available, and understand how to incorporate healthful, functional foods into their diets—whether for therapeutic purposes, or for longer-term goals of reducing risk of chronic diseases. Consumers want instant access, and they want it individualized.
BETTER LIVING THROUGH FOOD
Four in 10 shoppers state they suffer from tiredness or a lack of energy, one third from overweight/obesity or arthritis, just under one quarter from high cholesterol or hypertension, and 20% from gastrointestinal problems or depression. 2 It is not surprising that the demand for foods that help reduce the risk of, or even treat, a condition is at an all-time high. 2 Shoppers continue to purchase foods that help “prevent,” manage, or treat a condition. 1 A majority (86%) agrees that “eating healthfully is a better way to manage illness than medications.” 3 With two thirds of shoppers admitting that their diets could be healthier, it's not surprising that consumers remain interested in eating fortified foods and beverages, or functional foods. 1 Health care practitioners are in a prime position to help consumers navigate through the myriad of foods in the grocery aisle that may play a role in their long-term or more immediate health concerns. Knowing consumers' attitudes about such foods is important for nutrition experts so that they will be best positioned to meet consumers “where they are.”
Consumer research has been helpful in clarifying what people think about food and nutrition information. It also helps professionals in understanding how to effectively communicate about these issues, so that the information makes sense, and is not presented in “science speak,” which often renders information useless for consumers. The International Food Information Council (IFIC) has been tracking consumer attitudes about foods with health benefits that go beyond basic nutrition, or functional foods, through both qualitative and quantitative research over the past 6 years. Interesting findings from their most recent (2002) telephone surveys with randomly selected US consumers reveal how people interpret the information they hear about emerging foods and nutrients that offer health-promoting or disease risk-reducing benefits. 4
The IFIC survey confirmed that the majority of Americans (85%) have an interest in learning more about functional foods. They also believe that they control their destiny when it comes to maintaining or improving their own health (71%). A plurality of consumers (94%) agree that certain foods have health benefits that go beyond basic nutrition and may reduce the risk of disease or other health concerns. 4
Despite their interest in foods with health promoting benefits, most consumers do not recognize terms such as functional foods or nutraceuticals, which are commonly used to describe these foods among health and food industry professionals. Therefore, use of such terms with consumers and patients is not effective when trying to counsel on ways to optimize health. Terms used by professionals may not be important for consumers who simply want to eat food. The IFIC surveys indicate consumers seem to lean toward purchasing more of the food products they already eat, or may be attracted to specific foods based on marketing of particular health benefits on package labels.
The IFIC survey revealed that many consumers generally associated foods that are naturally high in vitamins and minerals with specific health benefits (see Table 1). This is consistent with supermarket consumer research that indicates people report purchasing food for specific health benefits. 5
The IFIC survey participants also associated the foods in Table 1 with America's top health concerns—cardiovascular disease factors, including heart disease/attack, high blood pressure, stroke, and high cholesterol. Cancer and heart health are the major diseases associated with foods by consumers. They link fruits and vegetables with reduced risk of cancer (44%) and fish/fish oil, garlic, and fiber with reduced risk of heart health (53%). 4 Other common links include carrots for vision, oranges and vitamin C for colds/flu, and calcium for osteoporosis. Other consumer studies indicate obesity is the major concern in the American consumer's consciousness, 6 seemingly displacing heart health and cancer as the most prominent concerns. It may be useful for future consumer research to examine how these health concerns are related in the consumer's mind.
Several surveys indicate that most consumers are trying to include certain foods for a functional health benefit. 4–6 It is important to note that what this implies about overall eating patterns is limited. According to the American Dietetic Association (ADA) Trends 2002 Survey, 6 while 85% of Americans say that diet and nutrition are important to them personally, only 38% say that they have made significant changes to achieve a healthful diet. Although this may seem incongruent, it does show an increase in effort by consumers to improve their health through diet. The 2000 ADA survey showed that only 28% of consumers reporting making changes to achieve an optimal diet. Additionally, it emphasizes the role for not only nutrition education, but also behavior modification interventions.
Awareness about specific food/health pairs varies. This may be dependent on a variety of factors, including how long the association has been made, media attention to the food/health association, and relevance to the consumer. For instance, the connection between calcium and osteoporosis is high (79%). Fewer Americans are aware of the association between antioxidants and cancer (54%), and fewer still know about the heart health benefits of soy protein (35%). 4 This lower awareness of the health benefits for antioxidants and soy protein may be due to the fact that they have more recently surfaced on the nutrition scene.
Interestingly, in the case of soy protein-heart disease, increased research and media attention has not raised the level of awareness of this topic. The IFIC survey indicated that, of those who had heard of the connection, there was a drop in belief in the efficacy of the soy protein-heart disease link (59% versus 65% in 2000). However, the opposite seems to be true for calcium-osteoporosis, where 9 in 10 consumers (of the 79% who were aware of the association) believe in the efficacy of the relationship. 4
The difference may not lie in the overall amount of attention given to these issues by health professionals, researchers, and media, as both are frequently discussed. There were no significant differences in belief in efficacy based on awareness. However, there were significant differences between these groups based on “level of awareness.” Specifically, those who had heard “a lot” about calcium-osteoporosis (64%) versus soy protein-heart disease (23%) were more likely to believe the association was effective. 4 Therefore, the difference may lie in how extensive and well coordinated the communication efforts are by multiple parties. Additionally, the amount of time the link has been part of the health discussion in the United States is influential. Health benefits of soy have only begun to enter the scene in recent years. Compounding that, Americans are not sure about where to find soy in foods that are familiar to them. Additionally, some express the perception that soy products are not palatable. 4
Therein lies the fundamental purpose of the dietetic practitioner for providing context for consumers concerning these issues. It is vital for nutrition professionals to provide information around emerging nutrition and health information and, at the same time, give practical tips to help consumers find these products in the supermarket and prepare them at home.
COMMUNICATING ABOUT FOODS WITH HEALTH BENEFITS TO PATIENTS AND CONSUMERS
Consumers obtain information on new nutrition research from a variety of sources, including health professionals. However, most frequently, consumers learn about the latest nutrition study from the television and magazines. 4,6 A good understanding of the role the media plays in conveying health, food, and dietary supplement information will improve the ability of food and nutrition professionals to reach consumers with understandable messages.
Placing emerging science into context is key to success. When any scientific study is concluded, it is unlikely that its findings will be the final word on a subject. Rather, scientific conclusions and the methods used to reach them are deliberately and methodically scrutinized for their accuracy, validity, reliability, and applicability. Conversely, news stories are judged by their instant appeal—the impact of a headline or the allure of a sound bite. Scientists and clinical care practitioners might view the practicality of a specific study's conclusion much differently than those who report the information to the public via the media. And the functional foods concept adds a complicating twist to the communications mix. Use of folklore and “motherly advice” on the health benefits of foods, such as chicken soup for colds, milk for strong bones, and an “apple-a-day,” predate scientific research by many years. This incongruity between science and media coverage not only perpetuates misinformation, but also fails to provide the wider context that gives isolated scientific conclusions their meaning.
IFIC seeks to bridge the gaps between how science is practiced and how science is communicated to opinion leaders and health influencers, such as registered dietitians and other health practitioners (those who have influence with consumers related to health). Providing the bridge between scientific research and communications with the public is particularly relevant since consumers are consulting a widening variety of sources for health and nutrition advice—sources which can sometimes be confusing and contradictory. Consumers and patients do not typically read (or know) the scientific vernacular. Therefore, food and nutrition professionals must determine how to translate that into meaningful real life applications. A patient's medical and social history are important in assessing individual needs and communicating in consumer-friendly language that is relevant to the individual (eg, providing specific food product suggestions).
In order to understand the reality of what consumers are hearing in the media about food and nutrition, the IFIC Foundation commissions a biannual in-depth qualitative and quantitative analysis of food news to determine the popular media issues that reach consumers, called Food for Thought. The Food for Thought studies consistently show the functional foods concept as one of the top issues communicated to consumers via the media. 7 In Food for Thought IV (2001), more than 3 out of 5 (63%) messages related to food benefits referenced some type of functional food or food component. Many of these references in the media focused on a wide range of specific foods such as soybeans, garlic, and fortified foods. Alternatively, news accounts offered broad dietary recommendations, like eating more dietary fiber, which address functionality in general terms. Discussions rarely went past whole foods to identify specific components in foods that had the beneficial effect. However, the Food for Thought studies conducted in 1999 and 2001 did show an increase in coverage related to benefits of previously obscure ingredients, like lutein, isoflavones, anthocyanidins, lycopene, and omega-3 fatty acids. This specificity in identifying the “functional component” in a food can serve to clarify the consumer's nutrition sense and help them understand connections among foods that may have similar physiological effects. On the down side, this type of discussion can also lead to more confusion if not linked properly to an actual food. The reality is people eat food, like blueberries or tuna fish, not nutrients, like anthocyanidins or omega-3 fatty acids.
Food for Thought IV found that science experts, researchers, and nutrition practitioners were the number one source of food and nutrition information for the media. This indicates that reporters and editors are consulting experts in order to put new findings into the context of scientific literature on a subject. The media's reliance on scientific experts also underscores the role that each nutrition professional can play in helping to interpret science for the public—whether through one-on-one education, teaching opportunities, or through the media.
In communicating with patients about food and health, some types of messages are more effective than others. Consumer research completed for the IFIC reveals key factors that should be considered when communicating the health benefits of foods.
- Knowledge of the health concern affects the level of information needed in a message. Osteoporosis is well understood to be related to bone health, therefore effective messages can focus on maintaining bone health.
- Seriousness of the concern is crucial, as individuals are more likely to be interested in food components that affect a health condition that is seen as very serious or threatening, such as cancer or heart disease.
- Knowledge of the food component is key. As previously discussed, low awareness of the antioxidants-cancer connection translates to a lower belief in efficacy. Also, lack of knowledge of food that provide the component is named as a barrier to consumption.
- Multiple benefits of the food component can increase interest. For example, about two thirds (67%) of consumers named “fruits and vegetables” as a functional food, which is one category that is touted for numerous health benefits.
- Association of a food component with dietary supplements. In focus groups, IFIC found that consumers could not name one food source of vitamin E. If association of the component with supplements is high, education about food sources (cross-promotion) is needed.
- Availability of food component. Both high availability (as with calcium) and low availability (as perceived with soy) can be barriers to consumption. Messages that quantify the component in various sources and educate about health benefits where needed will be more effective in affecting consumption behaviors.
CLAIMS ON FOOD—ONE WAY TO HELP CONSUMERS NAVIGATE
Increasingly, label claims are appearing on foods touting the health benefits of their inherent or added characteristics. Various types of claims exist. They include health claims, nutrient content claims, and structure/function claims. There are legal distinctions among the various claims; each legal status requires a different level of data, clinical proof, and level of scientific confidence. What do these claims mean? What science serves as their basis? How do patients use label claims with regard to food choices?
The presence of claims on food labels does not necessarily translate into patient understanding of specific diet-health relationships. Education provided by food and nutrition professionals can augment, and in fact is essential for application of, information obtained from food labels by patients.
As noted above, the most important factors in communicating a food-health association relates to the patient's concern for and knowledge of the health issue in question, awareness of the food or food component, and knowledge of its relationship to the health condition. Health claims are most effective when patients have a high level of concern about a health condition and high knowledge about food factors that can mitigate it (eg, “Contains 400 μg of folic acid, which may reduce the risk of certain birth defects”). More complex or technical terminology should only be used in messages related to health concerns for which knowledge is high. 4
A content claim describes the level of a nutrient or dietary substance in the product, using terms such as “good source,” “high,” or “free.” Simple content claims (eg, contains “X”) are somewhat appealing only when the link between the component and the health concern has been well established, for example between calcium and osteoporosis. Patients are likely to want additional details such as the amount contained in a product (either in units or percentages). Combining content claims with health claims may educate patients more effectively about the food component and its relationship to the health concern. 4
Messages that imply “maintenance” are unappealing to both those with and without the health concern. Those with the concern do not want to “maintain,” but rather want to improve and those without the health concern feel that they know how to “maintain.” 4
Specificity of the message adds to effectiveness (eg, “may reduce the risk of (type of) cancer” is more effective than “may reduce the risk of some cancer”). Specificity brings the discussion to a personal level, is more believable, and seems more attainable (given it does not imply a solution for all cancers). 4
Strong scientific criteria and evidence are paramount in beginning a conversation about food and its role in health. Also, being able to communicate and put into context the emerging science is of extreme value to patients. Overall, messages regarding the health benefits of food are most effective when specific, credible, and geared toward improving rather than maintaining health. Developing an understanding of the patient's perspective about a specific food or food component, its potential benefits, and the health concern it addresses are extremely important for effective communication. By doing so, effective messages can be crafted within the context of overall dietary intake and lifestyle that will both inform and motivate patients to better health behaviors.
NEW CLAIM ON THE BLOCK: QUALIFIED HEALTH CLAIMS
Recently, the Food and Drug Administration (FDA) announced the Consumer Health Information for Better Nutrition initiative to provide more and better health information about foods and dietary supplements, in order to help American consumers reduce risk of diseases and improve health by making sound dietary decisions. In other words, this initiative will make information available on food labels as it is emerging—providing the “weight of the scientific evidence” supports the claim, and FDA approves the claim (see Table 2). 8
The Consumer Health Information for Better Nutrition initiative is designed to foster two complementary goals concerning the labeling of food and dietary supplements: (1) to encourage makers of conventional foods and dietary supplements to make accurate, science-based claims about the health benefits of their products, and (2) to help eliminate bogus labeling claims by taking on those dietary supplement marketers who make false or misleading claims.
The idea of putting credible, science-based information in the hands of consumers will foster understanding of the real nutritional value of foods which can help empower consumers to make smart, healthful choices about the foods that they buy and consume. The consumer health information initiative comprises 3 related actions as follows:
- Issuing guidance on qualified health claims for conventional foods and dietary supplements. Any such claims must be preapproved by FDA and meet the “weight of the scientific evidence” standard, including support by a credible body of scientific evidence.
- Strengthening enforcement of dietary supplement rules. FDA is emphasizing its commitment to carrying out the intent of Congress in the Dietary Supplement Health and Education Act of 1994 by outlining its enforcement strategy against false or misleading claims about dietary supplements.
- Establishing an FDA Task Force on Consumer Health Information for Better Nutrition. This task force, charged with developing a framework to help consumers obtain accurate, up-to-date, and science-based information about conventional food and dietary supplements, issued its report on July 10, 2003. The report includes the development of additional scientific guidance on how the “weight of the evidence” standard will be applied, consumer testing of communication methods, and the development of regulations that will give these principles the force and the effect of law.
Through this initiative, FDA is attempting to improve opportunities for consumers to get scientifically accurate information about the health consequences of the foods they consume. FDA currently permits such qualified claims for dietary supplements under certain circumstances, but not for conventional foods. To meet the criteria for making a new, qualified claim on a conventional food, the manufacturer would need to provide a credible body of scientific data supporting the claim. The company would need to demonstrate, based on a fair review by scientific experts of the totality of information available, that the “weight of scientific evidence” supports the proposed claim. All qualified health claims will require review by FDA before they may be used on the food label.
Since FDA announced the task force report for this initiative in July 2003, the first qualified health claim for conventional foods—tree nuts and peanuts—was approved. The claim states: “Scientific evidence suggests but does not prove that eating 1.5 ounces per day of most nuts as part of a diet low in saturated fat and cholesterol may reduce the risk of heart disease.” What does this mean for the clinical practitioner? It means that more helpful tools—via claims on food packages—will be available to assist in educating consumers about which foods may provide health benefits. Like a treasure hunt through the grocery store—you can task your patients with identifying foods with FDA-approved health claims on their label in the grocery store. Health professionals will also be indispensible in ensuring that consumers are not misled and obtain expected health benefits through comprehensive lifestyle changes.