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Assessing the Reach of MyPlate using National Health and Nutrition Examination Survey Data
PRACTICE APPLICATIONS USDA Center for Nutrition Policy and Promotion Corner
Assessing the Reach of MyPlate using National Health and Nutrition Examination Survey Data
T
HE DIETARY GUIDELINES FOR Americans (DGA) serve as a basis for developing federal nutrition education materials for the public.1 Since 1980, the US Department of Agriculture (USDA) and US Department of Health and Human Services have jointly issued the guidelines targeting healthy Americans aged 2 years and older to promote health and reduce the risk of major chronic diseases.2 Over the years, the USDA has adapted communication initiatives using iconic representation of the guidelines such as the Basic 4, Food Guide Pyramid, and MyPyramid. In 2011, the current food guide, MyPlate, was unveiled; MyPlate was conceived as an uncomplicated visual cue that prompts consumers to use food groups as a guide to build healthy plates at meal time.3 Thanks to support from registered dietitian nutritionists (RDNs) and nutrition educators across a variety of settings, the popularity and public awareness of MyPlate among consumers as well as health professionals has continuously grown.4 A few surveys in the past have assessed consumers’ familiarity of the MyPlate graphic and the extent of its use by health professionals. For example, a communications survey released in late 2013 reported that a majority of practicing RDNs (w75%) used MyPlate to counsel patients.5 Similarly, the International Food Information Council Foundation’s 2016 Food and Health Survey that showed the
This article was written by Angie Tagtow, MS, RD, LD, US Department of Agriculture Center for Nutrition Policy and Promotion, Alexandria, VA; and Ramkripa Raghavan, MPH, MSc, subject matter expert nutritionist consultant, the Panum Group, Bethesda, MD. http://dx.doi.org/10.1016/j.jand.2016.11.015
ª 2017 by the Academy of Nutrition and Dietetics.
MyPlate icon to participants to assess their familiarity, stated that almost two out of three Americans were able to recognize it.6 These surveys demonstrate that MyPlate is being widely disseminated to Americans. We know that many Americans recognize MyPlate, but does that knowledge translate to behavior change? Our nutritionists at the Center for Nutrition Policy and Promotion (CNPP) assessed the national reach of MyPlate using the National Health and Nutrition Examination Survey (NHANES) data and evaluated whether recognition of MyPlate is correlated with other health-seeking behaviors. Specifically, we used the diet, behavior, and nutrition component of NHANES 2013-2014 in which eligible respondents (n¼6,464) over 16 years of age were asked three questions to ascertain their familiarity with MyPlate: 1) Have you heard of MyPlate? 2) Have you looked up MyPlate on the internet? and 3) Have you tried to follow the plan recommended in MyPlate? The survey also collected demographic, income, diet, and health-related information that was used in this analysis.
STUDY FINDINGS Within about 2 years of the launch of MyPlate, 20.2% (n¼1,054) of the respondents reported that they had heard about MyPlate. Unlike other studies, these participants were not shown a picture of MyPlate; rather, they were asked whether they recognized it by name. Of these, one-third looked it up on the internet (33.2%, n¼351) and slightly over one-third (35.3%, n¼365) tried to follow the plans recommended in MyPlate.
FAMILIARITY WITH MYPLATE VARIES BY DEMOGRAPHICS Similar to previous findings,7 our analysis showed that women are likely to be more receptive to nutrition information when compared with men (25.9% vs 14.2%). This pattern was consistent across all age groups. Women are generally considered the nutritional gatekeepers for families and are often involved in making decisions about a family’s food intake.8 Thus, their familiarity with MyPlate may result in healthy eating patterns for their family. Adolescents (30.6%) were the most likely of all age groups to have reported
100% 90% 80% 70% 60% 50%
No
40%
Yes
30% 20% 10% 0% 16-19
20-29
30-39
40-49 50-59 60-69 Age Range Figure. Extent of MyPlate familiarity across age ranges.
70-79
>80
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
181
PRACTICE APPLICATIONS hearing about MyPlate. The familiarity of MyPlate among adolescents is not surprising considering that MyPlate is often hung in classrooms and lunch rooms and used in schools for nutrition education programs. Because of these targeted outreach efforts, school-aged children were likely to be some of the first exposed to the MyPlate symbol when it was launched. Familiarity with MyPlate is less common among older Americans (Figure). With regard to race/ethnicity, non-Hispanic whites were most familiar with MyPlate when compared with Mexican Americans, non-Hispanic blacks, and Asian Americans. However, a recent study suggested that healthy eating index score, a measure of overall diet quality, was not different between races/ethnicities, especially in the absence of food insecurity.9 Families that reported an annual income greater than USD $75,000 were most likely to have heard of MyPlate.
RELATIONSHIP BETWEEN MYPLATE FAMILIARITY AND DIET QUALITY At least four out of five Americans (81%) that expressed familiarity with MyPlate also reported superior diet quality, and this number was even higher (87.5%) among those that reported trying MyPlate. Familiarity with MyPlate was correlated with a respondent’s overall pattern of using nutrition information when eating outside of the home. Over half of the respondents that had heard of MyPlate also noted seeing nutrition information on menus during their previous visit to fast-food outlets (52.7%); further, they also reported using this information to choose fast foods (54%) (Table). Similar findings were noted with eating patterns in restaurants (Table). Overall, two out of three respondents that reported familiarity with MyPlate mentioned that they would likely use nutrition information if available while ordering at a restaurant and fast-food outlet. In contrast, among those that were not familiar with MyPlate, less than 25% said they would likely use nutrition information while choosing their food at a fast-food outlet. Empowering people with nutrition information to make informed food and beverage choices has been at the 182
Table. Familiarity of MyPlate among those that eat outside the home Familiar with MyPlate
Unfamiliar with MyPlate
<0.001
Saw nutrition information on the fast-food menu Yes
495
52.7%
1,605
39.3%
No
463
46.3%
2,801
59.9%
Saw nutrition information on the restaurant menu
0.015
Yes
361
38.2%
1,266
30.9%
No
598
61.4%
3,017
68.4%
8
0.4%
32
0.7%
Don’t know Used nutrition information to choose fast foods
0.003
Yes
253
54%
590
38.8%
No
242
46%
1,014
61.1%
Used nutrition information to choose restaurant menu
0.04
Yes
183
50.5%
519
39.2%
No
178
17.8%
745
60.7% <0.001
Would use fast-food nutrition information, if available Often/Sometimes
678
70.8%
Rarely
148
Never
139
2,454
24.5%
15.7%
710
16.8%
13.9%
1,267
28.2% <0.001
Would use nutrition information in a restaurant, if available Often/Sometimes
679
70.5%
Rarely
144
Never
144
core of MyPlate messages.10 When MyPlate was launched in 2011, the MyPlate icon and its associated communication messages were intended to bridge the gap between knowledge and behavior.10 Our study findings linking familiarity with MyPlate and self-perceived diet quality, although a correlation—and not causation—provides evidence for bridging the gap. The association between familiarity with MyPlate and using nutrition information on the menu while ordering foods is further attestation to this potential relationship.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
P value
2,407
55.5%
14.1%
728
18.6%
15.4%
1,173
25.8%
CONCLUSION The reach of MyPlate within only a few years of its existence is promising, and studies using more recent data suggest that nearly two-thirds of Americans recognize the MyPlate icon when they see it. It is possible that more respondents in our study could have recognized MyPlate if the icon was visibly shown to the respondents, rather than asked as a question, “Have you heard of MyPlate?” It is also possible that at the time of the survey, MyPlate messaging had not reached sufficient saturation to produce February 2017 Volume 117 Number 2
PRACTICE APPLICATIONS measurable results in a span of few years.10 While these speculations are reasonable, we also recognize that broad segments of the American population such as men, older adults, racial minorities, and people of lower socio-economic status will need more targeted marketing strategies.7 Cognizant of this need, CNPP has been vigorously rolling out several new promotions in the past few years such as the MyPlate, MyWins campaign, which communicates the key messages of the 2015-2020 DGA to consumers, and the MyPlate, MyState initiatives, which bring communities together around healthy eating by supporting local and regional agriculture. In addition, social media outreach efforts have expanded and MyPlate has been translated into other languages.11 As we reflect on the findings of this research and think about avenues for taking MyPlate to new frontiers, we at CNPP are reaching out to you—our community partners and experts in nutrition—to help us spread the MyPlate message and empower Americans to find their healthy eating styles.
for Americans. Nutr Rev. 2011;69(7): 404-412. 3.
Post RC. A new approach to dietary guidelines communications: Make MyPlate, Your Plate. Childhood Obesity. 2011;7(5):349-351.
4.
Haven J, Maniscalco S, Bard S, Ciampo M. MyPlate myths debunked. J Acad Nutr Diet. 2014;114(5):674-675.
5.
14 Top Trends for 2014. New York, NY: Pollock Commuications. 2013. http://www. lpollockpr.com/blog/14-top-diet-trends2014-2/. Accessed January 10, 2017.
6.
Food Decision 2016. Food & Health Survey. International Food Information Council Foundation. http://www.foodinsight.org/ sites/default/files/2016-Food-and-HealthSurvey-Report_FINAL1.pdf. Accessed November 23, 2016.
7.
Wright JD, Wang C-Y. Awareness of Federal Dietary Guidance in persons aged 16 years and older: Results from the National Health and Nutrition Examination Survey 2005-2006. J Am Diet Assoc. 2011;111(2):295-300.
8.
Haack SA, Byker CJ. Recent population adherence to and knowledge of United States federal nutrition guides, 19922013: A systematic review. Nutr Rev. 2014;72(10):613-626.
9.
Allen AJ, Kuczmarski MF, Evans MK, Zonderman AB, Waldstein SR. Race differences in diet quality of urban foodinsecure blacks and whites reveals resiliency in blacks. J Racial Ethn Health Disparities. 2016;3(4):706-712.
10.
Levine E, Abbatangelo-Gray J, Mobley AR, McLaughlin GR, Herzog J. Evaluating MyPlate: An expanded framework using traditional and nontraditional metrics for assessing health communication campaigns. J Nutr Educ Behav. 2012;44(4): S2-S12.
11.
US Department of Agriculture/Center for Nutrition Policy and Promotion. ChooseMyPlate: Other Languages. https://www. choosemyplate.gov/other-languages. Published 2016. Accessed November 18, 2016.
References 1.
Tagtow A, Rahavi E, Bard S, Stoody EE, Casavale K, Mosher A. Coming together to communicate the 2015-2020 Dietary Guidelines for Americans. J Acad Nutr Diet. 2016;116(2):209-212.
2.
Watts ML, Hager MH, Toner CD, Weber JA. The art of translating nutritional science into dietary guidance: History and evolution of the Dietary Guidelines
February 2017 Volume 117 Number 2
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
183
Assessing the Reach of MyPlate using National Health and Nutrition Examination Survey Data
T
HE DIETARY GUIDELINES FOR Americans (DGA) serve as a basis for developing federal nutrition education materials for the public.1 Since 1980, the US Department of Agriculture (USDA) and US Department of Health and Human Services have jointly issued the guidelines targeting healthy Americans aged 2 years and older to promote health and reduce the risk of major chronic diseases.2 Over the years, the USDA has adapted communication initiatives using iconic representation of the guidelines such as the Basic 4, Food Guide Pyramid, and MyPyramid. In 2011, the current food guide, MyPlate, was unveiled; MyPlate was conceived as an uncomplicated visual cue that prompts consumers to use food groups as a guide to build healthy plates at meal time.3 Thanks to support from registered dietitian nutritionists (RDNs) and nutrition educators across a variety of settings, the popularity and public awareness of MyPlate among consumers as well as health professionals has continuously grown.4 A few surveys in the past have assessed consumers’ familiarity of the MyPlate graphic and the extent of its use by health professionals. For example, a communications survey released in late 2013 reported that a majority of practicing RDNs (w75%) used MyPlate to counsel patients.5 Similarly, the International Food Information Council Foundation’s 2016 Food and Health Survey that showed the
This article was written by Angie Tagtow, MS, RD, LD, US Department of Agriculture Center for Nutrition Policy and Promotion, Alexandria, VA; and Ramkripa Raghavan, MPH, MSc, subject matter expert nutritionist consultant, the Panum Group, Bethesda, MD. http://dx.doi.org/10.1016/j.jand.2016.11.015
ª 2017 by the Academy of Nutrition and Dietetics.
MyPlate icon to participants to assess their familiarity, stated that almost two out of three Americans were able to recognize it.6 These surveys demonstrate that MyPlate is being widely disseminated to Americans. We know that many Americans recognize MyPlate, but does that knowledge translate to behavior change? Our nutritionists at the Center for Nutrition Policy and Promotion (CNPP) assessed the national reach of MyPlate using the National Health and Nutrition Examination Survey (NHANES) data and evaluated whether recognition of MyPlate is correlated with other health-seeking behaviors. Specifically, we used the diet, behavior, and nutrition component of NHANES 2013-2014 in which eligible respondents (n¼6,464) over 16 years of age were asked three questions to ascertain their familiarity with MyPlate: 1) Have you heard of MyPlate? 2) Have you looked up MyPlate on the internet? and 3) Have you tried to follow the plan recommended in MyPlate? The survey also collected demographic, income, diet, and health-related information that was used in this analysis.
STUDY FINDINGS Within about 2 years of the launch of MyPlate, 20.2% (n¼1,054) of the respondents reported that they had heard about MyPlate. Unlike other studies, these participants were not shown a picture of MyPlate; rather, they were asked whether they recognized it by name. Of these, one-third looked it up on the internet (33.2%, n¼351) and slightly over one-third (35.3%, n¼365) tried to follow the plans recommended in MyPlate.
FAMILIARITY WITH MYPLATE VARIES BY DEMOGRAPHICS Similar to previous findings,7 our analysis showed that women are likely to be more receptive to nutrition information when compared with men (25.9% vs 14.2%). This pattern was consistent across all age groups. Women are generally considered the nutritional gatekeepers for families and are often involved in making decisions about a family’s food intake.8 Thus, their familiarity with MyPlate may result in healthy eating patterns for their family. Adolescents (30.6%) were the most likely of all age groups to have reported
100% 90% 80% 70% 60% 50%
No
40%
Yes
30% 20% 10% 0% 16-19
20-29
30-39
40-49 50-59 60-69 Age Range Figure. Extent of MyPlate familiarity across age ranges.
70-79
>80
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
181
PRACTICE APPLICATIONS hearing about MyPlate. The familiarity of MyPlate among adolescents is not surprising considering that MyPlate is often hung in classrooms and lunch rooms and used in schools for nutrition education programs. Because of these targeted outreach efforts, school-aged children were likely to be some of the first exposed to the MyPlate symbol when it was launched. Familiarity with MyPlate is less common among older Americans (Figure). With regard to race/ethnicity, non-Hispanic whites were most familiar with MyPlate when compared with Mexican Americans, non-Hispanic blacks, and Asian Americans. However, a recent study suggested that healthy eating index score, a measure of overall diet quality, was not different between races/ethnicities, especially in the absence of food insecurity.9 Families that reported an annual income greater than USD $75,000 were most likely to have heard of MyPlate.
RELATIONSHIP BETWEEN MYPLATE FAMILIARITY AND DIET QUALITY At least four out of five Americans (81%) that expressed familiarity with MyPlate also reported superior diet quality, and this number was even higher (87.5%) among those that reported trying MyPlate. Familiarity with MyPlate was correlated with a respondent’s overall pattern of using nutrition information when eating outside of the home. Over half of the respondents that had heard of MyPlate also noted seeing nutrition information on menus during their previous visit to fast-food outlets (52.7%); further, they also reported using this information to choose fast foods (54%) (Table). Similar findings were noted with eating patterns in restaurants (Table). Overall, two out of three respondents that reported familiarity with MyPlate mentioned that they would likely use nutrition information if available while ordering at a restaurant and fast-food outlet. In contrast, among those that were not familiar with MyPlate, less than 25% said they would likely use nutrition information while choosing their food at a fast-food outlet. Empowering people with nutrition information to make informed food and beverage choices has been at the 182
Table. Familiarity of MyPlate among those that eat outside the home Familiar with MyPlate
Unfamiliar with MyPlate
<0.001
Saw nutrition information on the fast-food menu Yes
495
52.7%
1,605
39.3%
No
463
46.3%
2,801
59.9%
Saw nutrition information on the restaurant menu
0.015
Yes
361
38.2%
1,266
30.9%
No
598
61.4%
3,017
68.4%
8
0.4%
32
0.7%
Don’t know Used nutrition information to choose fast foods
0.003
Yes
253
54%
590
38.8%
No
242
46%
1,014
61.1%
Used nutrition information to choose restaurant menu
0.04
Yes
183
50.5%
519
39.2%
No
178
17.8%
745
60.7% <0.001
Would use fast-food nutrition information, if available Often/Sometimes
678
70.8%
Rarely
148
Never
139
2,454
24.5%
15.7%
710
16.8%
13.9%
1,267
28.2% <0.001
Would use nutrition information in a restaurant, if available Often/Sometimes
679
70.5%
Rarely
144
Never
144
core of MyPlate messages.10 When MyPlate was launched in 2011, the MyPlate icon and its associated communication messages were intended to bridge the gap between knowledge and behavior.10 Our study findings linking familiarity with MyPlate and self-perceived diet quality, although a correlation—and not causation—provides evidence for bridging the gap. The association between familiarity with MyPlate and using nutrition information on the menu while ordering foods is further attestation to this potential relationship.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
P value
2,407
55.5%
14.1%
728
18.6%
15.4%
1,173
25.8%
CONCLUSION The reach of MyPlate within only a few years of its existence is promising, and studies using more recent data suggest that nearly two-thirds of Americans recognize the MyPlate icon when they see it. It is possible that more respondents in our study could have recognized MyPlate if the icon was visibly shown to the respondents, rather than asked as a question, “Have you heard of MyPlate?” It is also possible that at the time of the survey, MyPlate messaging had not reached sufficient saturation to produce February 2017 Volume 117 Number 2
PRACTICE APPLICATIONS measurable results in a span of few years.10 While these speculations are reasonable, we also recognize that broad segments of the American population such as men, older adults, racial minorities, and people of lower socio-economic status will need more targeted marketing strategies.7 Cognizant of this need, CNPP has been vigorously rolling out several new promotions in the past few years such as the MyPlate, MyWins campaign, which communicates the key messages of the 2015-2020 DGA to consumers, and the MyPlate, MyState initiatives, which bring communities together around healthy eating by supporting local and regional agriculture. In addition, social media outreach efforts have expanded and MyPlate has been translated into other languages.11 As we reflect on the findings of this research and think about avenues for taking MyPlate to new frontiers, we at CNPP are reaching out to you—our community partners and experts in nutrition—to help us spread the MyPlate message and empower Americans to find their healthy eating styles.
for Americans. Nutr Rev. 2011;69(7): 404-412. 3.
Post RC. A new approach to dietary guidelines communications: Make MyPlate, Your Plate. Childhood Obesity. 2011;7(5):349-351.
4.
Haven J, Maniscalco S, Bard S, Ciampo M. MyPlate myths debunked. J Acad Nutr Diet. 2014;114(5):674-675.
5.
14 Top Trends for 2014. New York, NY: Pollock Commuications. 2013. http://www. lpollockpr.com/blog/14-top-diet-trends2014-2/. Accessed January 10, 2017.
6.
Food Decision 2016. Food & Health Survey. International Food Information Council Foundation. http://www.foodinsight.org/ sites/default/files/2016-Food-and-HealthSurvey-Report_FINAL1.pdf. Accessed November 23, 2016.
7.
Wright JD, Wang C-Y. Awareness of Federal Dietary Guidance in persons aged 16 years and older: Results from the National Health and Nutrition Examination Survey 2005-2006. J Am Diet Assoc. 2011;111(2):295-300.
8.
Haack SA, Byker CJ. Recent population adherence to and knowledge of United States federal nutrition guides, 19922013: A systematic review. Nutr Rev. 2014;72(10):613-626.
9.
Allen AJ, Kuczmarski MF, Evans MK, Zonderman AB, Waldstein SR. Race differences in diet quality of urban foodinsecure blacks and whites reveals resiliency in blacks. J Racial Ethn Health Disparities. 2016;3(4):706-712.
10.
Levine E, Abbatangelo-Gray J, Mobley AR, McLaughlin GR, Herzog J. Evaluating MyPlate: An expanded framework using traditional and nontraditional metrics for assessing health communication campaigns. J Nutr Educ Behav. 2012;44(4): S2-S12.
11.
US Department of Agriculture/Center for Nutrition Policy and Promotion. ChooseMyPlate: Other Languages. https://www. choosemyplate.gov/other-languages. Published 2016. Accessed November 18, 2016.
References 1.
Tagtow A, Rahavi E, Bard S, Stoody EE, Casavale K, Mosher A. Coming together to communicate the 2015-2020 Dietary Guidelines for Americans. J Acad Nutr Diet. 2016;116(2):209-212.
2.
Watts ML, Hager MH, Toner CD, Weber JA. The art of translating nutritional science into dietary guidance: History and evolution of the Dietary Guidelines
February 2017 Volume 117 Number 2
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
183