- Email: [email protected]
Americans' Awareness, Knowledge, and Behaviors Regarding Fats: 2006-2007
RESEARCH Perspectives in Practice
Americans’ Awareness, Knowledge, and Behaviors Regarding Fats: 2006-2007 ROBERT H. ECKEL, MD; PENNY KRIS-ETHERTON, PhD, RD; ALICE H. LICHTENSTEIN, DSc; JUDITH WYLIE-ROSETT, EdD, RD; ALLISON GROOM, MA; KIMBERLY F. STITZEL, MS, RD; SHIRLEY YIN-PIAZZA, MS
ABSTRACT In recent years, epidemiologic and clinical studies, public and regulatory policy activity, and media coverage have focused on issues related to trans fats. To help increase awareness and understanding of trans fats and other fats, the American Heart Association (AHA) launched the “Face the Fats” national consumer education campaign in April 2007. The AHA commissioned a quantitative tracking survey between 2006 and 2007 to measure changes in consumer awareness, knowledge, and behaviors related fats and oils and their perceived impact on heart disease. The survey was conducted by Cogent Research. Data were collected during March 2006 and May 2007. At both time points, the survey included a representative sample of the American population age 18 to 65 years (n⫽1,000). The sampling plan for the survey was designed based on the 2000 and 2003 US Census. The margin of error was R. H. Eckel is professor of medicine, Division of Endocrinology, Metabolism, and Diabetes and Division of Cardiology, and professor of physiology and biophysics, Charles A. Boettcher II Chair in Atherosclerosis, program director, Adult General Clinical Research Center, University of Colorado Denver, and director of the lipid clinic at University Hospital, Aurora, CO. P. Kris-Etherton is distinguished professor of nutrition, Department of Nutritional Sciences, The Pennsylvania State University, University Park. A. H. Lichtenstein is Gershoff Professor of Nutrition Science and Policy, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, and director and senior scientist, Cardiovascular Nutrition Laboratory, Jean Mayer US Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA. J. Wylie-Rosett is a professor of epidemiology and population health, Albert Einstein College of Medicine, Bronx, NY. A. Groom is a marketing research consultant, K. F. Stitzel is director, Nutrition and Obesity, and S. Yin-Piazza is senior project manager, Trans Fat Initiative, all with the American Heart Association, Dallas, TX. Address correspondence to: Allison Groom, MA, Technology and Customer Strategy, American Heart Association, 7272 Greenville Ave, Dallas, TX 75231-4596. E-mail: [email protected] Manuscript accepted: July 18, 2008. Copyright © 2009 by the American Dietetic Association. 0002-8223/09/10902-0009$36.00/0 doi: 10.1016/j.jada.2008.10.048
288
Journal of the AMERICAN DIETETIC ASSOCIATION
⫾3.10 percentage points. Awareness of trans fats increased during the 1-year study period. In 2007, 92% of respondents were aware of trans fats, an increase from 84% in 2006 (P⬍0.05). The 2007 level was similar to the awareness of saturated fats (93%). Perceptions that certain fats and oils heighten the risk of heart disease increased for trans fats (73% in 2007 vs 63% in 2006; P⬍0.05), saturated fats (77% in 2007 vs 73% in 2006; P⬍0.05), and partially hydrogenated oils (56% in 2007 vs 49% in 2006; P⬍0.05). Knowledge about food sources of different fats remained low. On an unaided basis, 21% could name three food sources of trans fats in 2007, up from 17% in 2006 (P⬍0.05). Knowledge of food sources of saturated fat remained unchanged at 30% in 2007. Significantly more respondents in 2007 reported behavioral changes related to trans fat information, such as buying food products because they show “zero trans fat” on labels or packages (37% in 2007 vs. 32% in 2006; P⬍0.05). Between 2006 and 2007, consumer awareness about trans fats increased and attained awareness levels similar to saturated fats. The increased awareness is associated with improved self-reported behaviors in grocery shopping. Nonetheless, overall knowledge, especially regarding food sources of saturated and trans fats, remains relatively low, underscoring the need for heightened consumer education activities. The positive change in consumer awareness about trans fats is likely attributable to the wide range of messages available to them, including the AHA “Face the Fats” national consumer education campaign. J Am Diet Assoc. 2009;109:288-296.
I
n recent years, epidemiologic and clinical studies, public and regulatory policy activity, and media coverage have focused extensively on issues related to reducing trans fat intake in the American diet and potential benefits with respect to health outcomes (1-6). The American Heart Association (AHA) recommends a healthful dietary pattern and lifestyle to combat heart disease, limiting trans fat consumption to less than 1% (or approximately 2 g on a 2,000-calorie diet) and saturated fat consumption to less than 7% of total daily energy (7). The American Dietetic Association and the Dietitians of Canada have adopted a similar recommendation with respect to trans fats (8). In January 2006 the US Food and Drug Administration (FDA) instituted a requirement to list trans fat content as a separate item on the Nutrition Facts label on packaged foods (9). This change in labeling requirements has served as a catalyst to accelerate food product reformu-
© 2009 by the American Dietetic Association
lation. On a voluntary basis, many food manufacturers and restaurants have reformulated their products and modified their operations to reduce trans fats in their offerings. With respect to public policy, approximately 20 states and local jurisdictions currently have proposals to reduce trans fats in restaurants or schools. As of April 2008, 11 cities and counties have adopted regulations to restrict the use of industrially produced trans fats in restaurants (10). In addition, consumer education is needed to increase awareness and help consumers make better choices when grocery shopping, cooking at home, and eating out. To help increase awareness and understanding of trans fats and other fats, the AHA launched the “Face the Fats” national consumer education campaign in April 2007. News coverage of trans fats doubled between 2006 and 2007, from 516 print articles in May 2006 to 1,138 in May 2007 (11). Given this increase in information, the expectation was that Americans’ awareness of specific types of fats would have increased during those 2 years, and that knowledge of the effects of specific fats on heart health and the consumption pattern would be positively correlated with the increased level of information available. Indeed, two other recent studies have found that the awareness and perceived unhealthfulness of trans fats have increased (12,13). The objectives of this survey were to track Americans’ current awareness of fats and oils and their perceived relationships to heart health over a 1-year period, and to explore changes in knowledge and behaviors regarding fats and oils during that period of time. Although the survey covered a wide range of fats and oils, this article focuses on a subset of the data, particularly data related to saturated fats, trans fats, and partially hydrogenated oils. METHODS This survey included two data-collection phases: baseline and 1-year follow up. The baseline phase was conducted March 27 to April 7, 2006, and the follow-up phase was conducted May 10 to 25, 2007, after the April 2007 launch of the “Face the Fats” campaign. The survey was conducted by Cogent Research (Cambridge, MA), a full-service marketing research firm, and funded by the AHA. Both phases were conducted via Internet survey among a representative sample of Americans age 18 to 65 years, with 1,000 respondents completing the survey in each phase. Sampling was handled by Cogent Research and one of its third-party vendors, Survey Sampling International (Shelton, CT), a global provider of sampling solutions for survey research. Survey respondents were members of Survey Sampling International’s multisourced online panels, which consist of approximately 1.2 million panelists. These panelists are enrolled via banner ads and permission-based online recruitment. In the 2007 phase, the survey invitation was e-mailed to approximately 37,000 panelists. A total of 9,836 panelists started the survey, of whom 1,000 respondents completed the survey, 494 dropped out, 1,484 were terminated, and 6,858 were not asked to complete the survey because quotas for their particular demographic profiles were full. The profile of the respondents in each phase was similar in that both samples were based on the latest US
Table 1. Demographic composition of American adults who participated in a survey to gauge consumers’ awareness about fats
Sex Male Female Age (y) 18-24 25-34 35-44 45-54 55-64 Race/Ethnicity White Black or African American American Indian or Alaskan Native Asian or Pacific Islander Other Hispanic/Latino Yes No Annual income ($) ⬍35,000 35,000 to ⬍50,000 50,000 to ⬍75,000 75,000 to ⬍100,000 100,000 to ⬍150,000 ⱖ$150,000 Don’t know Prefer not to answer Education Less than high school Graduated high school Some college/technical/ vocational Graduated college Graduate/professional Region Northeast Midwest South West
2006 Sample (nⴝ1,000) %
2007 Sample (nⴝ1,000) %
49 51
45 55
10 19 24 27 21
15 22 22 25 16
78 12
81 9
2 3 5
2 4 5
13 87
11 89
29 20 21 10 7 3 1 8
31 18 21 10 6 3 1 9
11 27
9 26
33 19 10
33 21 11
18 24 37 20
18 27 34 21
Census figures (2000-2003). The samples in each phase did not consist of the same individuals, although it is possible that some individuals participated in both phases. Cogent Research used US Census data to determine the number of completed surveys needed for each key demographic variable to have a representative sample. Cogent then provided Survey Sampling International with nested quotas on sex, age, education, and ethnicity (eg, target number completes by men age 18 to 24 with less than high school education). See Table 1 for profiles of the 2006 and 2007 samples in terms of sex, age, race, ethnicity, income, education, and geographic region. Of the 1,000 subjects completing the survey, the percentage of invitations sent to respondents corresponded with the percentages of those groups in the general population.
February 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
289
Figure 1. Concern with amount and type of fat among American adults who participated in a survey to gauge consumers’ awareness about fats.
With any data-collection method, even when the outgoing sample is targeted and balanced to the US Census, some populations are more likely than others to respond. Requiring a minimum number of completes by each key demographic variable allows for more precise data weighting. As such, in the 2006 baseline phase, general population data were weighted to the 2000 US Census by age and education. In 2007, general population data were weighted to the 2003 US Census by education. Weighting is used to ensure that the distribution of the sample reflects that of the population on key demographics. Differences in proportions or means that are noted as statistically significant were tested at a 95% confidence level using a t test. The margin of error was ⫾3.10 percentage points. It is unlikely that observed differences are due to sampling given this nested quota design and that the universe for both waves was the same (Survey Sampling International respondents). Cogent Research developed the questions in conjunction with the AHA. Question text and answer categories were written at a junior-high level to ensure maximum comprehension by all respondents. As part of the validation process, a soft launch of 100 completes was conducted. Frequencies and cross-tabulations of the 100 soft launch completes were analyzed to determine whether there were egregious misunderstandings of the questions based on respondents’ answers and compared with industry data of consumer knowledge about trans fats. The soft launch did not require changes to the questions or answer categories. The 99-question survey covered the following topics: concern with the amount and type of fat consumed; awareness of specific fats and oils; awareness of the FDA trans-fat labeling requirement; knowledge of sources of saturated and trans fats; knowledge of the effects of specific fats and oils on heart disease; behaviors related to fats for grocery store purchases and cooking; and behaviors at restaurants. To measure knowledge of the sources of saturated and trans fats, the AHA compiled a list of
290
February 2009 Volume 109 Number 2
commonly consumed foods, most of which were generally regarded as high in saturated fats and/or trans fats. With regard to the term trans fats, survey respondents were told to consider manmade or artificial trans fats for the purpose of this survey. RESULTS Concern The majority of respondents (62%) reported they were concerned with both the amount and types of fat they consume, and this concern was significantly higher in 2007 than in 2006 (Figure 1). In 2007, more than 6 in 10 respondents (62%) were concerned about the amount of fat consumed, an increase from 55% in 2006 (P⬍0.05). Likewise, in 2007 62% of respondents reported concern about the types of fat consumed, up from 52% in 2006 (P⬍0.05). Communications about Fats To gauge whether Americans have seen or heard information about trans fats that might influence their knowledge, consumers were asked directly whether they had heard or seen information about trans fats from a variety of different sources, including television, magazines, newspapers, the Internet, radio, food packages, the Nutrition Facts panel, advertisements, physicians or other health care professionals, family or friends, or cookbooks. Although the majority of respondents had heard something about trans fats in both years, they were more likely to have heard of trans fats in 2007 (74% in 2007 vs 64% in 2006; P⬍0.05). In 2007, significantly more respondents were aware of the FDA requirement to list trans fat on food labels than in 2006 (43% in 2007 vs 37% in 2006; P⬍0.05). In addition, more than half of respondents (54%) in 2007 had heard announcements from restaurants about reducing
Table 2. Unaided and aided awareness of selected fats and oils among American adults who participated in a survey to gauge consumers’ awareness about fats (n⫽1,000)
Vegetable oils 2007 2006 Saturated fats 2007 2006 Trans fats 2007 2006 Animal fats 2007 2006 n-3 fatty acids 2007 2006 Polyunsaturated fats 2007 2006 Monounsaturated fats 2007 2006 Partially hydrogenated oils 2007 2006 Tropical oils 2007 2006
Unaided: Please list out all the types of fats and oils you can think of a %
Aided: ROTATE. Please check all of the types of fats and oils that you have ever heard of b %
52 55
95 95
29 30
93 92
38* 31
92* 84
25 35*
84 84
8 8
81* 74
12 14
73 76
9 9
66 70*
1 2
66 68
7 7
43 45
a Survey respondents were not prompted with a list of fats and oils in the unaided question. b Survey respondents were exposed to a list of fats and oils in the aided question. The list was rotated to avoid order bias. *P⬍0.05.
trans fats in their foods and about half (51%) had heard of regulations to phase out trans fats in restaurants. Awareness of Fats Awareness about trans fats increased among Americans over the 1-year study period. Specifically, unaided awareness of trans fats increased to 38% in 2007 from 31% in 2006 (P⬍0.05; Table 2). When prompted with a list of fats and oils, consumer awareness of trans fats increased significantly to 92% in 2007 from 84% in 2006 (P⬍0.05), and became on par with awareness of saturated fats (93% in 2007). Even though partially hydrogenated oils and trans fats are closely related, consumer awareness of partially hydrogenated oils was less than for trans fats in 2007. Only approximately two thirds of respondents heard of par-
tially hydrogenated oils in 2007, even when shown a list of fats and oils, and that percentage was virtually unchanged from 2006. Knowledge of the Relationship between Dietary Fat Type and Heart Disease Consumers were asked to determine, to the best of their knowledge, what effects specific fats and oils have on the risk of heart disease. In 2007, among respondents already aware of specific fats, more reported that saturated fats, trans fats, and partially hydrogenated oils increase the risk of heart disease (Table 3), with 77% in 2007 responding that saturated fats increase heart disease risk, an increase from 73% in 2006 (P⬍0.05); 73% in 2007 responded that trans fats increase this risk, up from 63% (P⬍0.05), and 56% in 2007 responded that partially hydrogenated oils increase this risk, up from 49% (P⬍0.05). The improvement in knowledge generally held true for the entire population regardless of the awareness level. More respondents in 2007 correctly associated saturated fats with an increased risk of heart disease (72% in 2007 vs 67% in 2006; P⬍0.05). Similarly, more respondents in 2007 correctly associated trans fats with an increased risk of heart disease (68% in 2007 vs 52% in 2006; P⬍0.05). Knowledge of Sources of Saturated and Trans Fats Consumers were asked to list, unaided, sources of saturated and trans fats, and were also asked to identify sources from a list of foods (aided). Unaided and aided awareness of specific sources of saturated fats remained similar in 2006 and 2007. Slightly fewer than one third of respondents could name three food sources of saturated fats in both years. Another one third could not name any sources of saturated fats without seeing a list. Knowledge of sources of saturated fats was significantly higher when consumers were aided with a list of foods. More than two thirds of respondents identified french fries, lard, butter, fatty beef, and doughnuts as foods that typically contain saturated fats (Table 4). However, the fact that french fries and doughnuts are not typically high in saturated fat indicates that a certain level of consumer confusion exists. Unaided and aided awareness of sources of trans fats increased from 2006 to 2007. In 2007, 21% of respondents could identify three food sources of trans fats on an unaided basis, an increase from 17% on 2006 (P⬍0.05). Close to half (46%) could not name any sources of trans fats on their own. When given a list of foods from which to select, significantly more respondents identified french fries (53% in 2007 vs 41% in 2006; P⬍0.05) and doughnuts (51% in 2007 vs 44% in 2006; P⬍0.05) as the top food examples that typically contain trans fats. Interestingly, perhaps again indicating consumer confusion, more also incorrectly identified lard (40% in 2007 vs 35% in 2006; P⬍0.05) as a food that typically contains trans fats. Also, consumers continued to be more aware of foods that typically contain saturated fats than foods that typically contain trans fats.
February 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
291
Table 3. Knowledge of relationship between dietary fats and risk of heart disease among American adults who participated in a survey to gauge consumers’ awareness about fats Response to question: “To the best of your knowledge, what effect, if any, do each of the following have on your risk of heart disease?” (Asked among respondents aware of the fat/oil.) Responses (%) Increases Animal fats (eg, lard, tallow, butter) 2007 (n⫽836) 2006 (n⫽843) Saturated fats 2007 (n⫽934) 2006 (n⫽920) Trans fats 2007 (n⫽919) 2006 (n⫽838) Partially hydrogenated oils 2007 (n⫽664) 2006 (n⫽680) Tropical oils (eg, palm oil, coconut oil) 2007 (n⫽425) 2006 (n⫽447) n-3 fatty acids (eg, fish, fish oil) 2007 (n⫽805) 2006 (n⫽736) Polyunsaturated fats (eg, nuts, salmon) 2007 (n⫽729) 2006 (n⫽758) Monounsaturated fats (eg, olive oil, avocado) 2007 (n⫽658) 2006 (n⫽702) Vegetable oils (eg, canola oil, corn oil) 2007 (n⫽948) 2006 (n⫽946)
Decreases
No effect
Don’t know
81 78
✓a
2 2
3 3
14 17
77* 73
✓
2 3
3 2
18 22*
73* 63
✓
5 7
3 2
18 28*
56* 49
✓
4 6
4 6
36 38
44 45
✓
19 20
8 5
29 30
6 6
74 72
✓
5 4
15 19*
11 9
60 62
✓
8 6
21 23
9 8
63 61
✓
10 7
18 23*
27 27
28 26
✓
16 16
28 31
a ✓⫽correct response. *P⬍0.05.
Behaviors Consumers were prompted with a list of elements and asked which they looked for on a food label. The elements included: total fats, trans fats, saturated fats, partially hydrogenated oils, hydrogenated oils, tropical oils, cholesterol, sodium, statements about heart health benefits (eg, reduces risk of heart disease, good source of fiber), serving size, and total calories. In 2007, at least half reported looking for sodium, total fats, total calories, cholesterol, trans fats, and saturated fats (Table 5). Significantly more reported looking for trans fats in 2007 (53%) compared to 2006 (44%; P⬍0.05). Consumers were also prompted with a list of dietary behaviors related to fats and asked if any of these were their regular behaviors. In 2007, more than half (54%) reported using vegetable oils (eg, canola oil, olive oil) for food preparation instead of animal fats (eg, butter) and approximately half reported using cooking sprays and liquid vegetable oils instead of butter. These behaviors did not change significantly from 2006 (Table 6).
292
February 2009 Volume 109 Number 2
Significantly more consumers reported behavioral changes related to trans fats in 2007 compared to 2006. Specifically, more respondents in 2007 bought food products because they show “zero trans fat” on labels or packages (37% in 2007 vs 32% in 2006; P⬍0.05). More respondents reviewed information on trans fat before making purchasing decisions (29% in 2007 vs 23% in 2006; P⬍0.05). Finally, more indicated using a “zero/low trans fat” version of solid fat products in 2007 compared to 2006 (26% in 2007 vs 21% in 2006; P⬍0.05). Consumers were also asked about their dietary behaviors at restaurants. Although most did not ask for nutrition information or healthful food options when dining at a restaurant, a small but increasing number of consumers (21% in 2007 vs 15% in 2006; P⬍0.05) requested, at least some of the time, ingredient or nutrition information for menu items. In addition, approximately half (51%) indicated that they ordered the “healthier” menu items at least some of the time (Figure 2).
Table 4. Knowledge of food sources of saturated and trans fats among American adults who participated in a survey to gauge consumers’ awareness about fats (n⫽1,000)
French fries Lard Butter Fatty beef Doughnuts Pastries Hard margarine Vegetable shortening Cookies Dairy products Soft tub margarine Whole milk Crackers Chicken None of the above
Year
Response to question: “Which of these foods, if any, typically contain saturated fats? Check all that apply.” (aided)a % who checked food
Response to question: “Which of these foods, if any, typically contain trans fats? Check all that apply.” (aided)b % who checked food
2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006
72 72 71 72 69 69 68 70 68 67 58 59 56 56 55 57 53 55 46 49 45 49 43 47 28 30 26 26 11 10
53* 41 40* 35 35 33 36* 30 51* 44 46 43 41 40 39 38 44 40 22 23 36 40 19 19 29 28 16 14 19 22
✓ ✓ ✓
✓
✓ ✓
✓
✓c
✓ ✓ ✓ ✓ ✓
✓
a Survey respondents were exposed to a list of fats and oils (aided). Checkmarks are given to food products traditionally high in saturated and/or trans fats. It is acknowledged that reformulation and changes in frying oils have taken place to produce “zero trans fat” versions of some of these products in recent years. In addition, even though a checkmark is given to cookies and pastries for saturated fats, it is recognized that the amount of saturated fats in baked items can vary greatly depending on the main ingredients (eg, butter, chocolate chips) used. b In the questionnaire, respondents were asked to consider artificial trans fats for the purpose of this survey. c ✓⫽correct response. *P⬍0.05.
Differences by Demographic Variables Some demographic differences were observed in the sample regarding awareness, knowledge, and behaviors related to trans fats. Significant differences in responses were driven by sex, age, education, and income. Respondents who exhibited higher levels of awareness, knowledge, and/or healthrelated behaviors were more apt to be female, age 45 years or older, report at least some college education, report household incomes of $75,000 or more, and live in the
Northeast or South. The geographical variation may have been influenced by regional regulatory and media activity (Table 7). No pattern of significant differences was found with regard to race or ethnicity. DISCUSSION Substantially more information related to fats became available to the American public between when the base-
February 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
293
Table 5. Heart health nutrition information American consumers look for on a food label based on responses to a survey about fats (n⫽1,000)
Table 6. Specific dietary behaviors related to fats when selecting and preparing food among American adults who participated in a survey to gauge consumers’ awareness about fats (n⫽1,000)
Year
Response to question: “Which of the following specific types of information that relate to heart health do you look for on food or beverage labels or packages? Please check all that apply.” % who checked item
Response to question: “Which of the following, if any, are you doing on a regular basis? Check all that apply.” % who checked Year behavior
2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006
60 57 58 58 56 56 54 52 53* 44 50 47 42 43 41 42 26 26 26 25 14 16 17 19
Sodium Total fats Total calories Cholesterol Trans fats Saturated fats Serving size Statement about heart health benefits Partially hydrogenated oils Hydrogenated oils Tropical oils None of the above *P⬍0.05.
line information was collected, mid 2006, and approximately 1 year later. Consumers indicated that they had heard more about trans fats in 2007 from a variety of sources. We hypothesized that the awareness of fats shifted between 2006 and 2007, and that knowledge of the effects of specific fats on heart health and the overall consumption pattern would be positively correlated with the increased level of information available. The hypothesis seems to hold true for awareness and to a certain extent, knowledge. Awareness of specific fats and oils shifted from 2006 to 2007, and was positively correlated with the increased level of information about trans fats. Further, respondents’ knowledge about the effect of saturated fats and trans fats on the risk of heart disease increased. In many print articles and on the Internet (such as the www.AmericanHeart.org/FaceThe Fats Web site), saturated fats and trans fats are mentioned as the “bad” fats for heart health. This may have contributed to the increased knowledge. The increased awareness has also had some impact on behaviors, although more so in food choices at grocery stores and food preparation at home than in food behavior
294
February 2009 Volume 109 Number 2
Using vegetable oils (eg, canola oil, olive oil) instead of animal fats (eg, butter) Using cooking spray or liquid vegetable oils instead of butter Using more healthful fats instead of trans fats Buying food products because they show “zero trans fat” on labels or packages Using more healthful fats instead of saturated fats Using more liquid vegetable oils instead of solid fats Reviewing information on trans fats specifically before making decisions on purchases Reviewing information on trans fats and saturated fats together before making decisions on purchases Using a “zero/low trans fat” version of products instead of a solid fat version None of the above
2007 54 2006 54 2007 48 2006 50 2007 2006 2007 2006
37 36 37* 32
2007 2006 2007 2006 2007 2006
32 34 31 34 29* 23
2007 27 2006 24 2007 26* 2006 21 2007 24 2006 25
*P⬍0.05.
at restaurants. Americans reported taking more actions to make more healthful food choices, particularly related to trans fats. However, knowledge levels about the major food sources of saturated fats and trans fats remain insufficient. The lack of knowledge about tropical oils is of note, too, especially because tropical oils, high in saturated fats, are being used in some foods as substitutes for trans fats. Consequently, consumers need some key information to improve their food choices. It seems that the media’s extensive coverage of trans fat–related issues as well as consumer education efforts have had a substantial impact on consumer awareness and knowledge of trans fats. It is not yet clear whether consumers are focusing on trans fats and overlooking other fats or switching to trans fat–free products without checking the saturated fat content. Efforts should be made to continue to monitor consumer behaviors in this area and educate consumers about different types of fats.
Figure 2. Frequency of requesting nutrition information or ordering healthful menu items at restaurants among American adults who participated in a survey to gauge consumers’ awareness about fats. Table 7. Differences in specific awareness, knowledge, and behavior by demographic variables among American adults who participated in a survey to gauge consumers’ awareness about fats (n⫽1,000)
Sex Malew Femalex Age (y) 25-34w 35-44x 45-54y 55-65z Education High school or lessw Some collegex College graduatey Income ⬍$35,000w $35,000-49,999x $50,000-74,999y ⬎$75,000z Region Northeastw Midwestx Southy Westz
Concerna %
Unaided awarenessb %
Aided awarenessc %
Increases riskd %
Name three sourcese %
Consume lessf %
55 68w
40 37
89 95w
73 74
25 21
66 75w
54 56 65wx 70wx
43y 37 31 38
95 91 92 90
69 72 73 79w
24 21 26 23
69 60 75x 78wx
58 63 64
32 41w 45w
88 92 96w
63 76w 83w
21 23 27
60 76w 78w
64 58 57 66
36 39 44 43
90 97w 93 94
69 75 74 81w
18 26 26 27w
66 72 74 75
63 57 65x 59
42 40 38 35
94 92 90 94
83xyz 74 72 68
23 25 22 23
74x 64 73x 68
a
“How concerned, if at all, are you with the amount of fat that you consume in foods?” (Top-2 box rating on 5-point scale). “Please list out all the types of fats and oils that you can think of.” “Please check all of the types of fats and oils that you have ever heard of.” d “To the best of your knowledge, what effect, if any, do trans fats have on your risk of heart disease?” e “(If aware of trans fats) Can you name up to three types of foods that typically contain trans fats?” (unaided). f “Please indicate whether you are trying to consume less trans fats.” wxyz Significant differences between different demographic variable values are indicated (P⬍0.05). b c
February 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
295
Specific communications should be developed to target groups with different demographic profiles, specifically based on sex, age, education, and income.
broiled, baked, grilled, or roasted; and asking restaurant servers about the oil used in food preparation and the availability of nutrition information.
CONCLUSION Between 2006 and 2007, consumer awareness about trans fats increased and attained levels similar to saturated fats. The increased awareness is associated with improved self-reported behaviors in grocery shopping. Nonetheless, overall knowledge, especially regarding food sources of saturated and trans fats, remains relatively low, underscoring the need for heightened consumer education activities. The positive change in consumer awareness about trans fats is likely attributable to the wide range of messages available to them, including the AHA “Face the Fats” national consumer education campaign.
The American Heart Association funded the marketing research related to this manuscript. Institutional Review Board approval does not pertain to this survey.
Practical Application for Dietitians and Other Health Professionals The Nutrition Facts panel on food labels can be very informative, and registered dietitians and other health professionals should teach consumers to examine it closely. Regarding trans fats, registered dietitians and other health professionals should stress to consumers to look not only at the Nutrition Facts panel for trans-fat content, but to also check the ingredient list for partially hydrogenated oils, which indicate the existence of trans fats. In addition, it is important to teach consumers to review both saturated fat and trans fat content on the Nutrition Facts panel to avoid substituting one unhealthful fat for another. Consumers also need help identifying foods high in saturated and/or trans fats so they can learn to limit these foods. With the recent food reformulation and the publicity surrounding policies to restrict trans fats in foods served in restaurants, consumers may not appreciate that “trans fat–free” foods are not necessarily healthful. Many fried foods and baked goods are high in saturated fats and calories even if trans fat–free oils and fats are used. Registered dietitians and other health professionals also should stress to consumers that many foods naturally contain saturated fats (regardless of the preparation method) and should provide examples of these foods. Registered dietitians and other health professionals should help consumers identify ways to cook hearthealthy foods at home and choose more heart-healthy options in restaurants. To facilitate behavior change, registered dietitians and other health professionals should provide specific tips such as using liquid vegetable oils instead of animal fats; choosing foods that are steamed,
296
February 2009 Volume 109 Number 2
References 1. Eckel RH, Lichtenstein AH, Borra S, Yin-Piazza SY. Understanding the complexity of trans fatty acid reduction in the American diet. Circulation. 2007;115:2231-2246. 2. Mozaffarian D, Katan MB, Ascherio A, Stampfer MJ, Willett WC. Trans fatty acids and cardiovascular disease. N Engl J Med. 2006; 354:1601-1613. 3. Mensink RP, Zock PL, Kester A, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: A meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003;77:1146-1155. 4. Howard B, Van Horn L, Hsia J, Manson JE, Stefanick ML, Wassertheil-Smoller S, Kuller LH, LaCroix AZ, Langer RD, Lasser NL, Lewis CE, Limacher MC, Margolis KL, Mysiw WJ, Ockene JK, Parker LM, Perri MG, Phillips L, Prentice RL, Robbins J, Rossouw JE, Sarto GE, Schatz IJ, Snetselaar LG, Stevens VJ, Tinker LF, Trevisan M, Vitolins MZ, Anderson GL, Assaf AR, Bassford T, Beresford SA, Black HR, Brunner RL, Brzyski RG, Caan B, Chlebowski RT, Gass M, Granek I, Greenland P, Hays J, Heber D, Heiss G, Hendrix SL, Hubbell FA, Johnson KC, Kotchen JM. Low-fat dietary pattern and risk of cardiovascular disease: The Women’s Health Initiative Randomized Controlled Dietary Modification Trial. JAMA. 2006;295:655-666. 5. Lopez-Garcia E, Schulze MB, Meigs JB, Manson JE, Rifai N, Stampfer MJ, Willett WC, Hu FB. Consumption of trans fatty acids is related to plasma biomarkers of inflammation and endothelial dysfunction. J Nutr. 2005;135:562-566. 6. Salmerón J, Hu FB, Manson JE, Stampfer MJ, Colditz GA, Rimm EB, Willett WC. Dietary fat intake and risk of type 2 diabetes in women. Am J Clin Nutr. 2001;73:1019-1026. 7. Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, Franklin B, Kris-Etherton P, Harris WS, Howard B, Karanja N, Lefevre M, Rudel L, Sacks F, Van Horn L, Winston M, Wylie-Rosett J. Diet and Lifestyle Recommendations Revision 2006: A Scientific Statement From the American Heart Association Nutrition Committee. Circulation. 2006;114:82-96. 8. Position of the American Dietetic Association and Dietitians of Canada: Dietary fatty acids. J Am Diet Assoc. 2007;107:1599-1611. 9. Food and Drug Administration. Federal Register. Food Labeling: Trans Fatty Acids in Nutrition Labeling, Nutrient Content Claims, and Health Claims. National Archives and Records Administration. 2003:41434-41506. 10. American Heart Association. Status of Trans Fat Regulatory Proposals. American Heart Association Web site. http://www.facethefats. com/presenter.jhtml?identifier⫽3051334. Accessed January 15, 2008. 11. Dow Jones Factiva Web site. http://www.factiva.com. Accessed January 11, 2008. 12. International Food Information Council. 2007 Food & Health Survey: Consumer Attitudes toward Food, Nutrition & Health. 2007. International Food Information Council Foundation Web site. http:// www.ific.org/research/foodandhealthsurvey.cfm. Accessed December 21, 2007. 13. United Soybean Board Consumer Attitudes about Nutrition 2008. Soy Foods Association of North America Web site. http://www. soyconnection.com/health_nutrition/pdf/ConsumerAttitudes2008. Accessed December 1, 2008.
Americans’ Awareness, Knowledge, and Behaviors Regarding Fats: 2006-2007 ROBERT H. ECKEL, MD; PENNY KRIS-ETHERTON, PhD, RD; ALICE H. LICHTENSTEIN, DSc; JUDITH WYLIE-ROSETT, EdD, RD; ALLISON GROOM, MA; KIMBERLY F. STITZEL, MS, RD; SHIRLEY YIN-PIAZZA, MS
ABSTRACT In recent years, epidemiologic and clinical studies, public and regulatory policy activity, and media coverage have focused on issues related to trans fats. To help increase awareness and understanding of trans fats and other fats, the American Heart Association (AHA) launched the “Face the Fats” national consumer education campaign in April 2007. The AHA commissioned a quantitative tracking survey between 2006 and 2007 to measure changes in consumer awareness, knowledge, and behaviors related fats and oils and their perceived impact on heart disease. The survey was conducted by Cogent Research. Data were collected during March 2006 and May 2007. At both time points, the survey included a representative sample of the American population age 18 to 65 years (n⫽1,000). The sampling plan for the survey was designed based on the 2000 and 2003 US Census. The margin of error was R. H. Eckel is professor of medicine, Division of Endocrinology, Metabolism, and Diabetes and Division of Cardiology, and professor of physiology and biophysics, Charles A. Boettcher II Chair in Atherosclerosis, program director, Adult General Clinical Research Center, University of Colorado Denver, and director of the lipid clinic at University Hospital, Aurora, CO. P. Kris-Etherton is distinguished professor of nutrition, Department of Nutritional Sciences, The Pennsylvania State University, University Park. A. H. Lichtenstein is Gershoff Professor of Nutrition Science and Policy, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, and director and senior scientist, Cardiovascular Nutrition Laboratory, Jean Mayer US Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA. J. Wylie-Rosett is a professor of epidemiology and population health, Albert Einstein College of Medicine, Bronx, NY. A. Groom is a marketing research consultant, K. F. Stitzel is director, Nutrition and Obesity, and S. Yin-Piazza is senior project manager, Trans Fat Initiative, all with the American Heart Association, Dallas, TX. Address correspondence to: Allison Groom, MA, Technology and Customer Strategy, American Heart Association, 7272 Greenville Ave, Dallas, TX 75231-4596. E-mail: [email protected] Manuscript accepted: July 18, 2008. Copyright © 2009 by the American Dietetic Association. 0002-8223/09/10902-0009$36.00/0 doi: 10.1016/j.jada.2008.10.048
288
Journal of the AMERICAN DIETETIC ASSOCIATION
⫾3.10 percentage points. Awareness of trans fats increased during the 1-year study period. In 2007, 92% of respondents were aware of trans fats, an increase from 84% in 2006 (P⬍0.05). The 2007 level was similar to the awareness of saturated fats (93%). Perceptions that certain fats and oils heighten the risk of heart disease increased for trans fats (73% in 2007 vs 63% in 2006; P⬍0.05), saturated fats (77% in 2007 vs 73% in 2006; P⬍0.05), and partially hydrogenated oils (56% in 2007 vs 49% in 2006; P⬍0.05). Knowledge about food sources of different fats remained low. On an unaided basis, 21% could name three food sources of trans fats in 2007, up from 17% in 2006 (P⬍0.05). Knowledge of food sources of saturated fat remained unchanged at 30% in 2007. Significantly more respondents in 2007 reported behavioral changes related to trans fat information, such as buying food products because they show “zero trans fat” on labels or packages (37% in 2007 vs. 32% in 2006; P⬍0.05). Between 2006 and 2007, consumer awareness about trans fats increased and attained awareness levels similar to saturated fats. The increased awareness is associated with improved self-reported behaviors in grocery shopping. Nonetheless, overall knowledge, especially regarding food sources of saturated and trans fats, remains relatively low, underscoring the need for heightened consumer education activities. The positive change in consumer awareness about trans fats is likely attributable to the wide range of messages available to them, including the AHA “Face the Fats” national consumer education campaign. J Am Diet Assoc. 2009;109:288-296.
I
n recent years, epidemiologic and clinical studies, public and regulatory policy activity, and media coverage have focused extensively on issues related to reducing trans fat intake in the American diet and potential benefits with respect to health outcomes (1-6). The American Heart Association (AHA) recommends a healthful dietary pattern and lifestyle to combat heart disease, limiting trans fat consumption to less than 1% (or approximately 2 g on a 2,000-calorie diet) and saturated fat consumption to less than 7% of total daily energy (7). The American Dietetic Association and the Dietitians of Canada have adopted a similar recommendation with respect to trans fats (8). In January 2006 the US Food and Drug Administration (FDA) instituted a requirement to list trans fat content as a separate item on the Nutrition Facts label on packaged foods (9). This change in labeling requirements has served as a catalyst to accelerate food product reformu-
© 2009 by the American Dietetic Association
lation. On a voluntary basis, many food manufacturers and restaurants have reformulated their products and modified their operations to reduce trans fats in their offerings. With respect to public policy, approximately 20 states and local jurisdictions currently have proposals to reduce trans fats in restaurants or schools. As of April 2008, 11 cities and counties have adopted regulations to restrict the use of industrially produced trans fats in restaurants (10). In addition, consumer education is needed to increase awareness and help consumers make better choices when grocery shopping, cooking at home, and eating out. To help increase awareness and understanding of trans fats and other fats, the AHA launched the “Face the Fats” national consumer education campaign in April 2007. News coverage of trans fats doubled between 2006 and 2007, from 516 print articles in May 2006 to 1,138 in May 2007 (11). Given this increase in information, the expectation was that Americans’ awareness of specific types of fats would have increased during those 2 years, and that knowledge of the effects of specific fats on heart health and the consumption pattern would be positively correlated with the increased level of information available. Indeed, two other recent studies have found that the awareness and perceived unhealthfulness of trans fats have increased (12,13). The objectives of this survey were to track Americans’ current awareness of fats and oils and their perceived relationships to heart health over a 1-year period, and to explore changes in knowledge and behaviors regarding fats and oils during that period of time. Although the survey covered a wide range of fats and oils, this article focuses on a subset of the data, particularly data related to saturated fats, trans fats, and partially hydrogenated oils. METHODS This survey included two data-collection phases: baseline and 1-year follow up. The baseline phase was conducted March 27 to April 7, 2006, and the follow-up phase was conducted May 10 to 25, 2007, after the April 2007 launch of the “Face the Fats” campaign. The survey was conducted by Cogent Research (Cambridge, MA), a full-service marketing research firm, and funded by the AHA. Both phases were conducted via Internet survey among a representative sample of Americans age 18 to 65 years, with 1,000 respondents completing the survey in each phase. Sampling was handled by Cogent Research and one of its third-party vendors, Survey Sampling International (Shelton, CT), a global provider of sampling solutions for survey research. Survey respondents were members of Survey Sampling International’s multisourced online panels, which consist of approximately 1.2 million panelists. These panelists are enrolled via banner ads and permission-based online recruitment. In the 2007 phase, the survey invitation was e-mailed to approximately 37,000 panelists. A total of 9,836 panelists started the survey, of whom 1,000 respondents completed the survey, 494 dropped out, 1,484 were terminated, and 6,858 were not asked to complete the survey because quotas for their particular demographic profiles were full. The profile of the respondents in each phase was similar in that both samples were based on the latest US
Table 1. Demographic composition of American adults who participated in a survey to gauge consumers’ awareness about fats
Sex Male Female Age (y) 18-24 25-34 35-44 45-54 55-64 Race/Ethnicity White Black or African American American Indian or Alaskan Native Asian or Pacific Islander Other Hispanic/Latino Yes No Annual income ($) ⬍35,000 35,000 to ⬍50,000 50,000 to ⬍75,000 75,000 to ⬍100,000 100,000 to ⬍150,000 ⱖ$150,000 Don’t know Prefer not to answer Education Less than high school Graduated high school Some college/technical/ vocational Graduated college Graduate/professional Region Northeast Midwest South West
2006 Sample (nⴝ1,000) %
2007 Sample (nⴝ1,000) %
49 51
45 55
10 19 24 27 21
15 22 22 25 16
78 12
81 9
2 3 5
2 4 5
13 87
11 89
29 20 21 10 7 3 1 8
31 18 21 10 6 3 1 9
11 27
9 26
33 19 10
33 21 11
18 24 37 20
18 27 34 21
Census figures (2000-2003). The samples in each phase did not consist of the same individuals, although it is possible that some individuals participated in both phases. Cogent Research used US Census data to determine the number of completed surveys needed for each key demographic variable to have a representative sample. Cogent then provided Survey Sampling International with nested quotas on sex, age, education, and ethnicity (eg, target number completes by men age 18 to 24 with less than high school education). See Table 1 for profiles of the 2006 and 2007 samples in terms of sex, age, race, ethnicity, income, education, and geographic region. Of the 1,000 subjects completing the survey, the percentage of invitations sent to respondents corresponded with the percentages of those groups in the general population.
February 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
289
Figure 1. Concern with amount and type of fat among American adults who participated in a survey to gauge consumers’ awareness about fats.
With any data-collection method, even when the outgoing sample is targeted and balanced to the US Census, some populations are more likely than others to respond. Requiring a minimum number of completes by each key demographic variable allows for more precise data weighting. As such, in the 2006 baseline phase, general population data were weighted to the 2000 US Census by age and education. In 2007, general population data were weighted to the 2003 US Census by education. Weighting is used to ensure that the distribution of the sample reflects that of the population on key demographics. Differences in proportions or means that are noted as statistically significant were tested at a 95% confidence level using a t test. The margin of error was ⫾3.10 percentage points. It is unlikely that observed differences are due to sampling given this nested quota design and that the universe for both waves was the same (Survey Sampling International respondents). Cogent Research developed the questions in conjunction with the AHA. Question text and answer categories were written at a junior-high level to ensure maximum comprehension by all respondents. As part of the validation process, a soft launch of 100 completes was conducted. Frequencies and cross-tabulations of the 100 soft launch completes were analyzed to determine whether there were egregious misunderstandings of the questions based on respondents’ answers and compared with industry data of consumer knowledge about trans fats. The soft launch did not require changes to the questions or answer categories. The 99-question survey covered the following topics: concern with the amount and type of fat consumed; awareness of specific fats and oils; awareness of the FDA trans-fat labeling requirement; knowledge of sources of saturated and trans fats; knowledge of the effects of specific fats and oils on heart disease; behaviors related to fats for grocery store purchases and cooking; and behaviors at restaurants. To measure knowledge of the sources of saturated and trans fats, the AHA compiled a list of
290
February 2009 Volume 109 Number 2
commonly consumed foods, most of which were generally regarded as high in saturated fats and/or trans fats. With regard to the term trans fats, survey respondents were told to consider manmade or artificial trans fats for the purpose of this survey. RESULTS Concern The majority of respondents (62%) reported they were concerned with both the amount and types of fat they consume, and this concern was significantly higher in 2007 than in 2006 (Figure 1). In 2007, more than 6 in 10 respondents (62%) were concerned about the amount of fat consumed, an increase from 55% in 2006 (P⬍0.05). Likewise, in 2007 62% of respondents reported concern about the types of fat consumed, up from 52% in 2006 (P⬍0.05). Communications about Fats To gauge whether Americans have seen or heard information about trans fats that might influence their knowledge, consumers were asked directly whether they had heard or seen information about trans fats from a variety of different sources, including television, magazines, newspapers, the Internet, radio, food packages, the Nutrition Facts panel, advertisements, physicians or other health care professionals, family or friends, or cookbooks. Although the majority of respondents had heard something about trans fats in both years, they were more likely to have heard of trans fats in 2007 (74% in 2007 vs 64% in 2006; P⬍0.05). In 2007, significantly more respondents were aware of the FDA requirement to list trans fat on food labels than in 2006 (43% in 2007 vs 37% in 2006; P⬍0.05). In addition, more than half of respondents (54%) in 2007 had heard announcements from restaurants about reducing
Table 2. Unaided and aided awareness of selected fats and oils among American adults who participated in a survey to gauge consumers’ awareness about fats (n⫽1,000)
Vegetable oils 2007 2006 Saturated fats 2007 2006 Trans fats 2007 2006 Animal fats 2007 2006 n-3 fatty acids 2007 2006 Polyunsaturated fats 2007 2006 Monounsaturated fats 2007 2006 Partially hydrogenated oils 2007 2006 Tropical oils 2007 2006
Unaided: Please list out all the types of fats and oils you can think of a %
Aided: ROTATE. Please check all of the types of fats and oils that you have ever heard of b %
52 55
95 95
29 30
93 92
38* 31
92* 84
25 35*
84 84
8 8
81* 74
12 14
73 76
9 9
66 70*
1 2
66 68
7 7
43 45
a Survey respondents were not prompted with a list of fats and oils in the unaided question. b Survey respondents were exposed to a list of fats and oils in the aided question. The list was rotated to avoid order bias. *P⬍0.05.
trans fats in their foods and about half (51%) had heard of regulations to phase out trans fats in restaurants. Awareness of Fats Awareness about trans fats increased among Americans over the 1-year study period. Specifically, unaided awareness of trans fats increased to 38% in 2007 from 31% in 2006 (P⬍0.05; Table 2). When prompted with a list of fats and oils, consumer awareness of trans fats increased significantly to 92% in 2007 from 84% in 2006 (P⬍0.05), and became on par with awareness of saturated fats (93% in 2007). Even though partially hydrogenated oils and trans fats are closely related, consumer awareness of partially hydrogenated oils was less than for trans fats in 2007. Only approximately two thirds of respondents heard of par-
tially hydrogenated oils in 2007, even when shown a list of fats and oils, and that percentage was virtually unchanged from 2006. Knowledge of the Relationship between Dietary Fat Type and Heart Disease Consumers were asked to determine, to the best of their knowledge, what effects specific fats and oils have on the risk of heart disease. In 2007, among respondents already aware of specific fats, more reported that saturated fats, trans fats, and partially hydrogenated oils increase the risk of heart disease (Table 3), with 77% in 2007 responding that saturated fats increase heart disease risk, an increase from 73% in 2006 (P⬍0.05); 73% in 2007 responded that trans fats increase this risk, up from 63% (P⬍0.05), and 56% in 2007 responded that partially hydrogenated oils increase this risk, up from 49% (P⬍0.05). The improvement in knowledge generally held true for the entire population regardless of the awareness level. More respondents in 2007 correctly associated saturated fats with an increased risk of heart disease (72% in 2007 vs 67% in 2006; P⬍0.05). Similarly, more respondents in 2007 correctly associated trans fats with an increased risk of heart disease (68% in 2007 vs 52% in 2006; P⬍0.05). Knowledge of Sources of Saturated and Trans Fats Consumers were asked to list, unaided, sources of saturated and trans fats, and were also asked to identify sources from a list of foods (aided). Unaided and aided awareness of specific sources of saturated fats remained similar in 2006 and 2007. Slightly fewer than one third of respondents could name three food sources of saturated fats in both years. Another one third could not name any sources of saturated fats without seeing a list. Knowledge of sources of saturated fats was significantly higher when consumers were aided with a list of foods. More than two thirds of respondents identified french fries, lard, butter, fatty beef, and doughnuts as foods that typically contain saturated fats (Table 4). However, the fact that french fries and doughnuts are not typically high in saturated fat indicates that a certain level of consumer confusion exists. Unaided and aided awareness of sources of trans fats increased from 2006 to 2007. In 2007, 21% of respondents could identify three food sources of trans fats on an unaided basis, an increase from 17% on 2006 (P⬍0.05). Close to half (46%) could not name any sources of trans fats on their own. When given a list of foods from which to select, significantly more respondents identified french fries (53% in 2007 vs 41% in 2006; P⬍0.05) and doughnuts (51% in 2007 vs 44% in 2006; P⬍0.05) as the top food examples that typically contain trans fats. Interestingly, perhaps again indicating consumer confusion, more also incorrectly identified lard (40% in 2007 vs 35% in 2006; P⬍0.05) as a food that typically contains trans fats. Also, consumers continued to be more aware of foods that typically contain saturated fats than foods that typically contain trans fats.
February 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
291
Table 3. Knowledge of relationship between dietary fats and risk of heart disease among American adults who participated in a survey to gauge consumers’ awareness about fats Response to question: “To the best of your knowledge, what effect, if any, do each of the following have on your risk of heart disease?” (Asked among respondents aware of the fat/oil.) Responses (%) Increases Animal fats (eg, lard, tallow, butter) 2007 (n⫽836) 2006 (n⫽843) Saturated fats 2007 (n⫽934) 2006 (n⫽920) Trans fats 2007 (n⫽919) 2006 (n⫽838) Partially hydrogenated oils 2007 (n⫽664) 2006 (n⫽680) Tropical oils (eg, palm oil, coconut oil) 2007 (n⫽425) 2006 (n⫽447) n-3 fatty acids (eg, fish, fish oil) 2007 (n⫽805) 2006 (n⫽736) Polyunsaturated fats (eg, nuts, salmon) 2007 (n⫽729) 2006 (n⫽758) Monounsaturated fats (eg, olive oil, avocado) 2007 (n⫽658) 2006 (n⫽702) Vegetable oils (eg, canola oil, corn oil) 2007 (n⫽948) 2006 (n⫽946)
Decreases
No effect
Don’t know
81 78
✓a
2 2
3 3
14 17
77* 73
✓
2 3
3 2
18 22*
73* 63
✓
5 7
3 2
18 28*
56* 49
✓
4 6
4 6
36 38
44 45
✓
19 20
8 5
29 30
6 6
74 72
✓
5 4
15 19*
11 9
60 62
✓
8 6
21 23
9 8
63 61
✓
10 7
18 23*
27 27
28 26
✓
16 16
28 31
a ✓⫽correct response. *P⬍0.05.
Behaviors Consumers were prompted with a list of elements and asked which they looked for on a food label. The elements included: total fats, trans fats, saturated fats, partially hydrogenated oils, hydrogenated oils, tropical oils, cholesterol, sodium, statements about heart health benefits (eg, reduces risk of heart disease, good source of fiber), serving size, and total calories. In 2007, at least half reported looking for sodium, total fats, total calories, cholesterol, trans fats, and saturated fats (Table 5). Significantly more reported looking for trans fats in 2007 (53%) compared to 2006 (44%; P⬍0.05). Consumers were also prompted with a list of dietary behaviors related to fats and asked if any of these were their regular behaviors. In 2007, more than half (54%) reported using vegetable oils (eg, canola oil, olive oil) for food preparation instead of animal fats (eg, butter) and approximately half reported using cooking sprays and liquid vegetable oils instead of butter. These behaviors did not change significantly from 2006 (Table 6).
292
February 2009 Volume 109 Number 2
Significantly more consumers reported behavioral changes related to trans fats in 2007 compared to 2006. Specifically, more respondents in 2007 bought food products because they show “zero trans fat” on labels or packages (37% in 2007 vs 32% in 2006; P⬍0.05). More respondents reviewed information on trans fat before making purchasing decisions (29% in 2007 vs 23% in 2006; P⬍0.05). Finally, more indicated using a “zero/low trans fat” version of solid fat products in 2007 compared to 2006 (26% in 2007 vs 21% in 2006; P⬍0.05). Consumers were also asked about their dietary behaviors at restaurants. Although most did not ask for nutrition information or healthful food options when dining at a restaurant, a small but increasing number of consumers (21% in 2007 vs 15% in 2006; P⬍0.05) requested, at least some of the time, ingredient or nutrition information for menu items. In addition, approximately half (51%) indicated that they ordered the “healthier” menu items at least some of the time (Figure 2).
Table 4. Knowledge of food sources of saturated and trans fats among American adults who participated in a survey to gauge consumers’ awareness about fats (n⫽1,000)
French fries Lard Butter Fatty beef Doughnuts Pastries Hard margarine Vegetable shortening Cookies Dairy products Soft tub margarine Whole milk Crackers Chicken None of the above
Year
Response to question: “Which of these foods, if any, typically contain saturated fats? Check all that apply.” (aided)a % who checked food
Response to question: “Which of these foods, if any, typically contain trans fats? Check all that apply.” (aided)b % who checked food
2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006
72 72 71 72 69 69 68 70 68 67 58 59 56 56 55 57 53 55 46 49 45 49 43 47 28 30 26 26 11 10
53* 41 40* 35 35 33 36* 30 51* 44 46 43 41 40 39 38 44 40 22 23 36 40 19 19 29 28 16 14 19 22
✓ ✓ ✓
✓
✓ ✓
✓
✓c
✓ ✓ ✓ ✓ ✓
✓
a Survey respondents were exposed to a list of fats and oils (aided). Checkmarks are given to food products traditionally high in saturated and/or trans fats. It is acknowledged that reformulation and changes in frying oils have taken place to produce “zero trans fat” versions of some of these products in recent years. In addition, even though a checkmark is given to cookies and pastries for saturated fats, it is recognized that the amount of saturated fats in baked items can vary greatly depending on the main ingredients (eg, butter, chocolate chips) used. b In the questionnaire, respondents were asked to consider artificial trans fats for the purpose of this survey. c ✓⫽correct response. *P⬍0.05.
Differences by Demographic Variables Some demographic differences were observed in the sample regarding awareness, knowledge, and behaviors related to trans fats. Significant differences in responses were driven by sex, age, education, and income. Respondents who exhibited higher levels of awareness, knowledge, and/or healthrelated behaviors were more apt to be female, age 45 years or older, report at least some college education, report household incomes of $75,000 or more, and live in the
Northeast or South. The geographical variation may have been influenced by regional regulatory and media activity (Table 7). No pattern of significant differences was found with regard to race or ethnicity. DISCUSSION Substantially more information related to fats became available to the American public between when the base-
February 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
293
Table 5. Heart health nutrition information American consumers look for on a food label based on responses to a survey about fats (n⫽1,000)
Table 6. Specific dietary behaviors related to fats when selecting and preparing food among American adults who participated in a survey to gauge consumers’ awareness about fats (n⫽1,000)
Year
Response to question: “Which of the following specific types of information that relate to heart health do you look for on food or beverage labels or packages? Please check all that apply.” % who checked item
Response to question: “Which of the following, if any, are you doing on a regular basis? Check all that apply.” % who checked Year behavior
2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006 2007 2006
60 57 58 58 56 56 54 52 53* 44 50 47 42 43 41 42 26 26 26 25 14 16 17 19
Sodium Total fats Total calories Cholesterol Trans fats Saturated fats Serving size Statement about heart health benefits Partially hydrogenated oils Hydrogenated oils Tropical oils None of the above *P⬍0.05.
line information was collected, mid 2006, and approximately 1 year later. Consumers indicated that they had heard more about trans fats in 2007 from a variety of sources. We hypothesized that the awareness of fats shifted between 2006 and 2007, and that knowledge of the effects of specific fats on heart health and the overall consumption pattern would be positively correlated with the increased level of information available. The hypothesis seems to hold true for awareness and to a certain extent, knowledge. Awareness of specific fats and oils shifted from 2006 to 2007, and was positively correlated with the increased level of information about trans fats. Further, respondents’ knowledge about the effect of saturated fats and trans fats on the risk of heart disease increased. In many print articles and on the Internet (such as the www.AmericanHeart.org/FaceThe Fats Web site), saturated fats and trans fats are mentioned as the “bad” fats for heart health. This may have contributed to the increased knowledge. The increased awareness has also had some impact on behaviors, although more so in food choices at grocery stores and food preparation at home than in food behavior
294
February 2009 Volume 109 Number 2
Using vegetable oils (eg, canola oil, olive oil) instead of animal fats (eg, butter) Using cooking spray or liquid vegetable oils instead of butter Using more healthful fats instead of trans fats Buying food products because they show “zero trans fat” on labels or packages Using more healthful fats instead of saturated fats Using more liquid vegetable oils instead of solid fats Reviewing information on trans fats specifically before making decisions on purchases Reviewing information on trans fats and saturated fats together before making decisions on purchases Using a “zero/low trans fat” version of products instead of a solid fat version None of the above
2007 54 2006 54 2007 48 2006 50 2007 2006 2007 2006
37 36 37* 32
2007 2006 2007 2006 2007 2006
32 34 31 34 29* 23
2007 27 2006 24 2007 26* 2006 21 2007 24 2006 25
*P⬍0.05.
at restaurants. Americans reported taking more actions to make more healthful food choices, particularly related to trans fats. However, knowledge levels about the major food sources of saturated fats and trans fats remain insufficient. The lack of knowledge about tropical oils is of note, too, especially because tropical oils, high in saturated fats, are being used in some foods as substitutes for trans fats. Consequently, consumers need some key information to improve their food choices. It seems that the media’s extensive coverage of trans fat–related issues as well as consumer education efforts have had a substantial impact on consumer awareness and knowledge of trans fats. It is not yet clear whether consumers are focusing on trans fats and overlooking other fats or switching to trans fat–free products without checking the saturated fat content. Efforts should be made to continue to monitor consumer behaviors in this area and educate consumers about different types of fats.
Figure 2. Frequency of requesting nutrition information or ordering healthful menu items at restaurants among American adults who participated in a survey to gauge consumers’ awareness about fats. Table 7. Differences in specific awareness, knowledge, and behavior by demographic variables among American adults who participated in a survey to gauge consumers’ awareness about fats (n⫽1,000)
Sex Malew Femalex Age (y) 25-34w 35-44x 45-54y 55-65z Education High school or lessw Some collegex College graduatey Income ⬍$35,000w $35,000-49,999x $50,000-74,999y ⬎$75,000z Region Northeastw Midwestx Southy Westz
Concerna %
Unaided awarenessb %
Aided awarenessc %
Increases riskd %
Name three sourcese %
Consume lessf %
55 68w
40 37
89 95w
73 74
25 21
66 75w
54 56 65wx 70wx
43y 37 31 38
95 91 92 90
69 72 73 79w
24 21 26 23
69 60 75x 78wx
58 63 64
32 41w 45w
88 92 96w
63 76w 83w
21 23 27
60 76w 78w
64 58 57 66
36 39 44 43
90 97w 93 94
69 75 74 81w
18 26 26 27w
66 72 74 75
63 57 65x 59
42 40 38 35
94 92 90 94
83xyz 74 72 68
23 25 22 23
74x 64 73x 68
a
“How concerned, if at all, are you with the amount of fat that you consume in foods?” (Top-2 box rating on 5-point scale). “Please list out all the types of fats and oils that you can think of.” “Please check all of the types of fats and oils that you have ever heard of.” d “To the best of your knowledge, what effect, if any, do trans fats have on your risk of heart disease?” e “(If aware of trans fats) Can you name up to three types of foods that typically contain trans fats?” (unaided). f “Please indicate whether you are trying to consume less trans fats.” wxyz Significant differences between different demographic variable values are indicated (P⬍0.05). b c
February 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
295
Specific communications should be developed to target groups with different demographic profiles, specifically based on sex, age, education, and income.
broiled, baked, grilled, or roasted; and asking restaurant servers about the oil used in food preparation and the availability of nutrition information.
CONCLUSION Between 2006 and 2007, consumer awareness about trans fats increased and attained levels similar to saturated fats. The increased awareness is associated with improved self-reported behaviors in grocery shopping. Nonetheless, overall knowledge, especially regarding food sources of saturated and trans fats, remains relatively low, underscoring the need for heightened consumer education activities. The positive change in consumer awareness about trans fats is likely attributable to the wide range of messages available to them, including the AHA “Face the Fats” national consumer education campaign.
The American Heart Association funded the marketing research related to this manuscript. Institutional Review Board approval does not pertain to this survey.
Practical Application for Dietitians and Other Health Professionals The Nutrition Facts panel on food labels can be very informative, and registered dietitians and other health professionals should teach consumers to examine it closely. Regarding trans fats, registered dietitians and other health professionals should stress to consumers to look not only at the Nutrition Facts panel for trans-fat content, but to also check the ingredient list for partially hydrogenated oils, which indicate the existence of trans fats. In addition, it is important to teach consumers to review both saturated fat and trans fat content on the Nutrition Facts panel to avoid substituting one unhealthful fat for another. Consumers also need help identifying foods high in saturated and/or trans fats so they can learn to limit these foods. With the recent food reformulation and the publicity surrounding policies to restrict trans fats in foods served in restaurants, consumers may not appreciate that “trans fat–free” foods are not necessarily healthful. Many fried foods and baked goods are high in saturated fats and calories even if trans fat–free oils and fats are used. Registered dietitians and other health professionals also should stress to consumers that many foods naturally contain saturated fats (regardless of the preparation method) and should provide examples of these foods. Registered dietitians and other health professionals should help consumers identify ways to cook hearthealthy foods at home and choose more heart-healthy options in restaurants. To facilitate behavior change, registered dietitians and other health professionals should provide specific tips such as using liquid vegetable oils instead of animal fats; choosing foods that are steamed,
296
February 2009 Volume 109 Number 2
References 1. Eckel RH, Lichtenstein AH, Borra S, Yin-Piazza SY. Understanding the complexity of trans fatty acid reduction in the American diet. Circulation. 2007;115:2231-2246. 2. Mozaffarian D, Katan MB, Ascherio A, Stampfer MJ, Willett WC. Trans fatty acids and cardiovascular disease. N Engl J Med. 2006; 354:1601-1613. 3. Mensink RP, Zock PL, Kester A, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: A meta-analysis of 60 controlled trials. Am J Clin Nutr. 2003;77:1146-1155. 4. Howard B, Van Horn L, Hsia J, Manson JE, Stefanick ML, Wassertheil-Smoller S, Kuller LH, LaCroix AZ, Langer RD, Lasser NL, Lewis CE, Limacher MC, Margolis KL, Mysiw WJ, Ockene JK, Parker LM, Perri MG, Phillips L, Prentice RL, Robbins J, Rossouw JE, Sarto GE, Schatz IJ, Snetselaar LG, Stevens VJ, Tinker LF, Trevisan M, Vitolins MZ, Anderson GL, Assaf AR, Bassford T, Beresford SA, Black HR, Brunner RL, Brzyski RG, Caan B, Chlebowski RT, Gass M, Granek I, Greenland P, Hays J, Heber D, Heiss G, Hendrix SL, Hubbell FA, Johnson KC, Kotchen JM. Low-fat dietary pattern and risk of cardiovascular disease: The Women’s Health Initiative Randomized Controlled Dietary Modification Trial. JAMA. 2006;295:655-666. 5. Lopez-Garcia E, Schulze MB, Meigs JB, Manson JE, Rifai N, Stampfer MJ, Willett WC, Hu FB. Consumption of trans fatty acids is related to plasma biomarkers of inflammation and endothelial dysfunction. J Nutr. 2005;135:562-566. 6. Salmerón J, Hu FB, Manson JE, Stampfer MJ, Colditz GA, Rimm EB, Willett WC. Dietary fat intake and risk of type 2 diabetes in women. Am J Clin Nutr. 2001;73:1019-1026. 7. Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, Franklin B, Kris-Etherton P, Harris WS, Howard B, Karanja N, Lefevre M, Rudel L, Sacks F, Van Horn L, Winston M, Wylie-Rosett J. Diet and Lifestyle Recommendations Revision 2006: A Scientific Statement From the American Heart Association Nutrition Committee. Circulation. 2006;114:82-96. 8. Position of the American Dietetic Association and Dietitians of Canada: Dietary fatty acids. J Am Diet Assoc. 2007;107:1599-1611. 9. Food and Drug Administration. Federal Register. Food Labeling: Trans Fatty Acids in Nutrition Labeling, Nutrient Content Claims, and Health Claims. National Archives and Records Administration. 2003:41434-41506. 10. American Heart Association. Status of Trans Fat Regulatory Proposals. American Heart Association Web site. http://www.facethefats. com/presenter.jhtml?identifier⫽3051334. Accessed January 15, 2008. 11. Dow Jones Factiva Web site. http://www.factiva.com. Accessed January 11, 2008. 12. International Food Information Council. 2007 Food & Health Survey: Consumer Attitudes toward Food, Nutrition & Health. 2007. International Food Information Council Foundation Web site. http:// www.ific.org/research/foodandhealthsurvey.cfm. Accessed December 21, 2007. 13. United Soybean Board Consumer Attitudes about Nutrition 2008. Soy Foods Association of North America Web site. http://www. soyconnection.com/health_nutrition/pdf/ConsumerAttitudes2008. Accessed December 1, 2008.