Barriers and Facilitators for Consumer Adherence to the Dietary Guidelines for Americans: The HEALTH Study

Barriers and Facilitators for Consumer Adherence to the Dietary Guidelines for Americans: The HEALTH Study

RESEARCH Qualitative Research Barriers and Facilitators for Consumer Adherence to the Dietary Guidelines for Americans: The HEALTH Study Theresa A. ...

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RESEARCH

Qualitative Research

Barriers and Facilitators for Consumer Adherence to the Dietary Guidelines for Americans: The HEALTH Study Theresa A. Nicklas, DrPH; Lisa Jahns, PhD, RD; Margaret L. Bogle, PhD, RD; Deirdra N. Chester, PhD, RD; Maria Giovanni, PhD; David M. Klurfeld, PhD; Kevin Laugero, PhD; Yan Liu, MS; Sandra Lopez; Katherine L. Tucker, PhD ARTICLE INFORMATION

ABSTRACT

Article history:

The majority of the US population does not meet recommendations for consumption of milk, whole grains, fruit, and vegetables. The goal of our study was to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans for four nutrient-rich food groups in fifth-grade children and unrelated adult caregivers across six sites in a multistate study. A total of 281 unrelated adult caregivers (32% African American, 33% European American, and 35% Hispanic American) and 321 children (33% African American, 33% European American, and 34% Hispanic American) participated in 97 Nominal Group Technique sessions. Nominal Group Technique is a qualitative method of data collection that enables a group to generate and prioritize a large number of issues within a structure that gives everyone an equal voice. The core barriers specific to unrelated adult caregivers were lack of meal preparation skills or recipes (whole grains, fruit, vegetables); difficulty in changing eating habits (whole grains, fruit, vegetables), cost (milk, whole grains, fruit, vegetables), lack of knowledge of recommendation/portion/health benefits (milk, vegetables), and taste (milk, whole grains, vegetables). Specific to children, the core barriers were competing foods (ie, soda, junk foods, sugary foods [whole grains, milk, fruit, vegetables]), health concerns (ie, milk allergy/upset stomach [milk]), taste/flavor/smell (milk, whole grains, fruit, vegetables), forget to eat them (vegetables, fruit), and hard to consume or figure out the recommended amount (milk, fruit). For both unrelated adult caregivers and children, reported facilitators closely coincided with the barriers, highlighting modifiable conditions that could help individuals to meet the Dietary Guidelines for Americans.

Accepted 2 May 2013 Available online 17 July 2013

Keywords: Barriers Facilitators Dietary guidelines Children Caregivers Copyright ª 2013 by the Academy of Nutrition and Dietetics. 2212-2672/$36.00 http://dx.doi.org/10.1016/j.jand.2013.05.004

J Acad Nutr Diet. 2013;113:1317-1331.

D

URING THE PAST 3 DECADES, THE PERCENTAGE OF adults who are obese has doubled; the percentage of children who are overweight has doubled; and the percentage of adolescents who are overweight has tripled. Two thirds of US adults are overweight or obese. An estimated one third of US children and adolescents are overweight, whereas 17% are obese.1 Children who are obese tend to become obese adults.2-4 Obesity contributes to the major causes of death in the United States, including atherosclerotic cardiovascular disease, type 2 diabetes, and some forms of cancer.5-7 Obesity affects quality of life, increases medical costs, and increases job absenteeism in adults;8-13 direct and indirect costs associated with obesity in adults is estimated at $209 billion or 20.6% of US health care expenditures.13 Obesity in both children and adults is most prevalent among ethnic minority groups.14-17 The Dietary Guidelines for Americans (DGA) provide science-based advice to promote health and reduce risk for major chronic diseases through diet and physical activity.18,19 The 2010 DGA19 replaced the earlier 2005 DGA18 and the ª 2013 by the Academy of Nutrition and Dietetics.

recommendations for the individual food groups were the same in addition to promoting a nutrient-dense diet. Energy imbalance resulting in overweight or obesity primarily results from poor diet and physical inactivity. Many Americans consume more energy than they need without meeting recommended intakes for specific nutrients.18 On average, adults and children fail to meet recommended intakes for calcium, potassium, fiber, magnesium, and vitamin D.18,19 Americans also consume inadequate amounts of four nutrient-dense food groups—fruit, vegetables, whole grains, and reducedfat dairy products.18,19 Eighty percent to 99% of Americans have usual intakes below the recommended servings of these four food groups.20 Although each food group may have different relationships with disease outcomes, the adequate consumption of all food groups contributes to overall health. Evidence suggests that few individuals comply with the DGA,18,19 and certain populations (eg, low income groups, some racial/ethnic groups, and children) may find the DGA recommendations especially difficult to follow.21 To create solutions for promoting DGA JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH adherence, there is a need to identify what barriers prevent adherence to the DGA and what types of things make it possible for people to follow the DGA. The DGA Advisory Committee recognized that there were major gaps in understanding issues related to the implementation of and adherence to the DGA.18 One overarching research recommendation was identified by the DGA Advisory Committee: More studies are needed to determine the barriers for adhering to the DGA, particularly among special populations.18 The goal of our study was to identify barriers and facilitators reported by unrelated adult caregivers and children to following government dietary recommendations for the four nutrient-dense food groups (ie, fruit, vegetables, milk [specifically reduced-fat/nonfat] and grains [specifically whole grains]). These four nutrient-dense food groups were identified by both the 2005 and 2010 DGA19 as food groups to encourage in the American diet. “Milk group” was used in the 2005 DGA; this was changed to “Dairy group” in the 2010 DGA.

MATERIALS AND METHODS Participants Participants were part of the Healthy Eating and Lifestyle for Total Health (HEALTH) study. HEALTH was a multisite collaboration of five Agricultural Research Service (ARS) Human Nutrition Research Centers (HNRC) and the ARS Delta Obesity Prevention Research Unit. The five ARS-HNRCs were: Western HNRC, Children’s Nutrition Research Center, HNRC on Aging, Beltsville HNRC, and Grand Forks HNRC. The study was conducted from March 2010 to July 2012. The goal of HEALTH was to identify barriers and facilitators to following DGA in a national sample of fifth-grade children and unrelated adult caregivers of fifth-grade children.

Sample/Recruitment At each study site, fifth-grade children and unrelated adult caregivers of fifth-grade children were eligible to participate, based on self-identification of three major racial/ethnic groups: African American, Hispanic American, or European American. Caregivers were defined as “the person responsible for food preparation most days of the week.” A purposive and articulate sample was recruited through fifth-grade teachers who identified children and unrelated adult caregivers deemed knowledgeable and able to substantively address the issues as key informants. Teachers were asked to identify the articulate samples in that they were individuals the teachers believed would be able to speak in clear and effective language and would be willing to interact during the sessions and serve as key informants. As members of the same household may experience similar barriers, adult participants were unrelated caregivers of fifth-grade children (ie, not living in the same household). Participants were recruited from a local public school district at each site. Some of the recruitment strategies included sending a recruitment packet home with the children; presenting information about the project to fifth-grade children and at Parent-Teacher Organization meetings; and active involvement of parent liaisons, teachers, and school administrators in the recruitment efforts. All study materials were available in, and study sessions were conducted in, Spanish and English. Written informed consent was received from the unrelated adult caregivers and verbal and written assent of the child was obtained before 1318

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participation. The institutional review board at each site approved the study.

Nominal Group Technique (NGT) Methodology The NGT method22 combines aspects of qualitative (free generation of responses by individuals) and quantitative (structured multistep systematic ranking of responses) data collection. The stages involved in conducting the NGT method have been published in addition to a number of advantages of using the NGT method over other group processes.23 The highly structured NGT process minimizes the information loss that can sometimes occur with focus groups, particularly when there are real or perceived power differentials among group members. Because the NGT is effective in promoting even rates of participation, and equally weights input from all group members, the responses generated are assumed to provide valid and interpretable ordinal data that reflect implicit prioritized views held by a representative group.24 This technique is therefore an ideal method to identify and prioritize salient barriers and facilitators to DGA adherence expressed by children and unrelated adult caregivers.

Question and Preamble Development Before the group sessions, one-on-one cognitive interviews were conducted at each site with subjects from both age groups and each ethnicity to ensure the understanding of the questions to be used in the groups. During cognitive interviews, participants reviewed questions for clarity, comprehension, and appropriateness. The preamble, which provided participants in NGT sessions with a cognitive referent for considering DGA barriers (or facilitators), was also previewed in the cognitive interviews. The preamble was an introductory slide show that started each NGT session and provided both verbal and visual descriptions of the specific DGA recommendation addressed in that meeting. This study was conducted when the 2005 DGA were being promoted and MyPyramid was the consumer education tool designed for teaching the public on the 2005 DGA; thus, the MyPyramid recommendations were used in the design of the preambles. At each site conducting NGTs, the questions and the preambles were translated into Spanish by Spanish-speaking researchers who had extensive experience with the targeted population.

NGT Sessions Separate child and unrelated adult caregiver group sessions were conducted with subjects participating in either the barriers or the facilitators groups for one of the four nutrientdense food groups (total of 97 sessions). Each session was conducted by two trained facilitators, and involved six to 10 participants. All facilitators followed the same detailed written script. All unrelated adult caregivers completed a detailed demographic questionnaire and sex and ethnicity were obtained from the children before the NGT sessions. After the preamble was presented, participants were given a worksheet and asked to record silently, as concisely as possible, their responses to the question: “What sorts of things make it hard (barriers) or easy (facilitators) for people to follow MyPyramid recommendations for eating fruit, vegetables, milk products (specifically reduced-fat/nonfat), and grains (specifically whole grains)?” Each group focused October 2013 Volume 113 Number 10

RESEARCH on one DGA (fruit, vegetables, milk, or grains). In this step, participants were asked to consider barriers (or facilitators) for generic “people” to remove the onus of a personal disclosure. Next, a round-robin response nomination process was employed to have participants, one at a time, read aloud a single idea from their worksheets. As each response was read, it was recorded verbatim on a Post-it note (3M) and posted in plain view of the participants. Response nominations continued until all responses were exhausted. This process helped ensure that all participants had similar opportunities to contribute their ideas and to produce a high volume of varied responses. A brief clarification process followed. In most cases, 24 to 36 responses were generated. Next, participants chose and recorded five responses they personally considered most salient with respect to a selection criterion (eg, most helpful and least helpful) on index cards without identification, which were passed to the facilitators to sum. The two facilitators summed the rankings for each response and shared the rankings on the post it note for the group to observe. From the rankings a list of top responses were recorded on a new Post-it note. Finally, participants individually ranked this list of top responses from 0 to 10 according to how important/influential each was to them personally. All participants were asked at the beginning of the session if they had heard of MyPyramid. Standardized scripts, protocols, procedures, and worksheets were used to ensure standardized implementation. The same NGT expert trained all group facilitators.

Data Analysis The analysis of data from the NGT and reporting of results was carried out using a combination of both qualitative and quantitative methods. The qualitative component was specifically used to generate ideas from the whole group using accepted methods.24-26 These ideas were then used in the quantitative analyses. The quantitative analysis of data resulted from the scoring and ranking methods used to identify group priorities. Following the system described by Delbecq and colleagues,26 scoring occurred in two stages. The first stage involved rating the importance of entire list of responses, from five (most important) to one (least important), and sum the assigned rating for each rated item (all items did not receive a rating). In the second stage, from among the ranking of the items on the previous list, a new list with the top-10 items (or fewer) was derived. From the new list, now considered most important to the group, a new ranking took place by writing in any number between 0 and 10 for each item, a lower number indicating an item not believed to be a big problem, whereas a higher number represents an item believed to be a big problem. The rankings are based on the average.

RESULTS Participants’ Demographic Characteristics A total of 140 unrelated adult caregivers (31% African American, 35% European American, and 34% Hispanic American; mean age 418.9 years) and 168 fifth-grade children (33% African American, 32% European American, and 35% Hispanic American) participated in 97 NGT sessions specific to the four nutrient-dense food groups (48 NGT for barriers and 49 NGT for facilitators) (Table 1). The unrelated adult caregivers and fifth-grade children participated in either the barriers or October 2013 Volume 113 Number 10

facilitators NGT sessions in one of the four nutrient-dense food groups. Sixty-seven percent of unrelated adult caregivers were married, 43% had a college degree, 63% were employed, approximately 55% had four or fewer people living in the home, and 56% had two or fewer children younger than age 18 years living in the household.

Milk Consumption (Specifically Reduced-Fat/Nonfat) The core barriers (Table 2) reported by the unrelated adult caregivers to meeting the milk recommendation included cost, schedules, poor eating habits, lack of knowledge on the current recommendation for dairy and the quantity of each portion, the recommended daily amounts for dairy consumption were too high, does not like the taste of reduced-fat or nonfat milk, and the notion that milk products are fattening. The core barriers reported by children to meeting the milk recommendation included side effects such as upset stomach; milk allergy; bad taste, flavor, and smell; hard to consume the recommended amount; do not think about wanting yogurt or remembering to have cheese at home; and competing foods (such as drinking soda instead of milk, junk food, and candy). The core facilitators (Table 3) reported by the unrelated adult caregivers to meeting the milk recommendation included availability, affordability, and accessibility; more information about the benefits and intake recommendations and about products that are low in fat; parents should be the example; and the need for recipes and prepackaging. The core facilitators reported by the children to meeting the milk recommendation included consuming specific foods (eg, smoothies, cereal with milk, ice cream, chocolate milk, milk shakes, and cookies with milk); knowledge about the benefits of milk and intake amounts (such as eat dairy products twice a day); consuming milk at every meal, specifically breakfast and lunch; and encouraging adults (eg, doctors and parents) to talk with children about milk.

Grain Consumption (Specifically Whole Grains) The core barriers (Table 4) reported by the unrelated adult caregivers to meeting the grain (specifically whole grains) recommendation included taste, appearance, and cost; difficulty in changing eating habits; having children who are picky eaters; temptation of other foods; preparation and planning time; reducing the intake of carbohydrates and energy; and lack of recipes. The core barriers reported by the children to meeting the grain (specifically whole grains) recommendation included competing foods (such as sugar cookies, junk foods, chips, sugar-sweetened drinks, pickles, and salty foods); taste; hard to eat or remember to eat one half of total grains as whole grains; and some kids do not like to eat healthy foods. The core facilitators (Table 5) reported by the unrelated adult caregivers to meeting the grain (specifically whole grains) recommendation included more whole-grain choices (prepackaged portions) available and prepared in the foods they buy, taste, recipes or ways to improve flavor, coupons, using different types in meals and distribute intake throughout the day, read the Nutrition Facts labels, and education and marketing efforts toward children about whole grains and grains. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH Table 1. Demographic characteristics of children and unrelated adult caregivers in a study to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans Total

Characteristic n

Barriers

%

Sample

Facilitators

n

%

Sample

30

40.0

45

60.0

n

%

53

57.0

40

43.0

Children (n[168) Sex

75

Male

83

49.4

Female

85

50.6

Racial ethnicity

93

75

93

African American

56

33.3

26

34.7

30

32.3

European American

54

32.1

25

33.3

29

31.2

Hispanic American

58

34.5

24

32.0

34

36.6

13

9.3

8

11.9

5

6.9

127

90.7

59

88.1

68

93.2

Unrelated adult caregivers (n¼140) Sex

67

Male Female Racial ethnicity

73

73

73

African American

43

30.7

21

31.3

22

30.1

European American

49

35.0

20

29.9

29

39.7

Hispanic American

48

34.3

26

38.8

22

30.1

Marital status

66

73

Married

93

66.9

43

65.2

50

68.5

Divorced

21

15.1

10

15.2

11

15.1

Never married

17

12.2

7

10.6

10

13.7

8

5.8

6

9.1

2

2.7

Yes

86

62.8

41

62.1

45

63.4

No

51

37.2

25

37.9

26

36.6

Other Employment

66

Education

71

66

73

High school or less

48

34.5

22

33.3

26

35.6

Some college/technical school

32

23.0

18

27.3

14

19.2

College and more

59

42.5

26

39.4

33

45.2

2

2.8

No. people living in home 2

66 7

5.0

72 5

7.5

3

27

19.4

14

20.9

13

18.1

4

42

30.2

22

32.8

20

27.8

5

31

22.3

14

20.9

17

23.6

12

17.9

20

27.8

56.2

38

57.6

39

54.9

6þ No. children under age 18 y who live with you 2

66 77

72

3

33

24.1

15

22.7

18

25.4

4

17

12.4

5

7.6

12

16.9

10

7.3

8

12.1

2

2.8



meanSDa Age (y)

40.68.9

meanSD 67

40.310.4

meanSD 73

40.97.2

a

SD¼standard deviation.

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October 2013 Volume 113 Number 10

RESEARCH Table 2. Ranked votes for reported barriers to meeting milk (specifically reduced-fat/nonfat) recommendations by unrelated adult caregivers and children in a study to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans

Response by caregiver

Average responsea

Response by children

Average responsea 10.0

Cost

9.2

Allergic to milk products

Schedules

8.8

Don’t remember to have cheese at home

8.8

Set a pattern for mealtime

8.6

Eating junk food

6.8

Poor eating habits

7.8

Eating sweets half of the time

6.8

Lifestyle

7.4

Drinking soda instead of milk

6.6

Way we learned to cook

7.2

If you eat something else before, you might feel full

6.5

The daily amount needed is a bit much

6.8

Eating too much candy

6.2

Some people are just picky eaters

6.8

May have upset stomach from >1 c milk

5.8

Habit

6.8

It’s hard to get the right amount

5.8

Easy to eat something else

6.6

Some people don’t like reduced fat types

5.8

The notion that milk products are fattening

6.2

They think that some types of cheese are very disgusting

5.8

Lack of knowledge about the quantity of food needed from the milk group every day

5.8

Before they have a chance to get anything from the milk group they get sweets

5.8

Self-discipline

5.6

Eating too much sugar

5.6

Lack of creativity to prepare dishes with dairy products

5.3

Maybe they think that chocolate milk is better than regular milk

5.2

Knowing the quantity of each portion; that is, if it is correct or not

5.3

Cheese has a funny smell

5.0

Excess quantity of portions

5.3

Milk has no flavor

4.7

Doesn’t like reduced-fat/nonfat milk

4.8

Don’t think about wanting any yogurt

4.6

A lot of diets conflict with milk products

4.6

They probably like whole milk better than reduced-fat

4.5

Rather have other drinks

4.6

They like it but don’t like to eat it or drink it 3 times a day

4.4

Shortage

4.4

Most yogurts don’t taste good

4.3

a

Average of the voters’ responses across 6 study sites.

The core facilitators reported by the children to meeting the grain (specifically whole grains) recommendation included consuming specific foods or grains they liked (such as pizza, pancakes, popcorn, sandwiches, breads, and cereals), consuming foods at specific meals (such as bread at lunch, 2 oz grains at each meal, cereal for breakfast, and grains at lunch every day), and buying and consuming specific amounts (such as 6 oz grains every day, 1 cup breakfast flakes, 2 oz whole wheat from a sandwich).

Fruit Consumption The core barriers (Table 6) reported by the unrelated adult caregivers to meeting the fruit recommendation included spoilage, lack of availability and accessibility, hard to buy October 2013 Volume 113 Number 10

because of seasonality and prohibitive cost, hard to eat fruits that are not sweet, hard to have a variety of fruits, prefer sweets, fast food is easier, preparation time, was not brought up eating fruit, and too much junk food. The core barriers reported by the children to meeting the fruit recommendation included competing foods (such as junk foods and sugary foods), taste, too many pesticides on fruit, busy doing something else or kids schedules are just too tight, not available, likes eating out, school lunch does not give children a lot of fruit, forget to eat them because too busy on the computer or at the television, and hard to figure out portion/ounces. The core facilitators (Table 7) reported by the unrelated adult caregivers to meeting the fruit recommendation included availability and accessibility, variety of fruit available, JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH Table 3. Ranked votes for reported facilitators to meeting milk (specifically reduced-fat/nonfat) recommendations by unrelated adult caregivers and children in a study to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans

Response by caregivers

Average responsea

Inform the intake recommendation

10.0

Response by children

Average responsea

It will help you make strong bones

9.5

Prepackaging

9.2

Encourage kids’ parents to talk to them about milk

9.4

Educate the children, teach them to drink milk as a habit

9.2

Eat dairy products twice a day

9.0

Keeping single-serving snacks in easy reach

9.0

Eating healthy foods

8.8

More information about products that are low in fat

9.0

Eat cookies with milk

8.7

Use prepackaged servings in school lunches, like Go-Gurtb and string cheese

8.8

Drinking milk and milk-based products will also make you healthy

8.5

The parents should be the example

8.8

Eat cereal

8.3

For my health

8.8

Some kids drink chocolate milk

8.0

Inform about the benefits of diary products

8.5

Have a milkshake

7.8

Recipes

8.5

Learn more about milk and see what it does to your body

7.8

Different forms to use the dairy products; consume shakes or licuados

8.3

Eating fruit every day

7.8

These products are available to us at all restaurants

8.2

Doctors can talk about what milk helps you with

7.7

Incorporate the items into prepared meals

8.0

Drink milkshakes

7.5

Easy and affordable access to all these varieties

8.0

Pass MyPyramid program on television

7.4

Plan the purchases to have them available

7.8

Eat ice cream

7.4

Make measurements of the portions to know if we cover the recommendation

7.8

Have a cup of milk at every meal

7.3

Give them something they really enjoy

7.8

It doesn’t take long to make it

7.3

Easy recipes that include dairy products

7.6

Drink smoothies

7.3

My children remind me of my daily servings of milk

7.4

On a hot day go to ice cream shop for a smoothie

7.2

Serve milk with meals

7.3

Drink milk for breakfast and lunch

7.1

a

Average of the voters’ responses across 6 study sites. General Mills.

b

affordability, fruit substitutes for junk food and fewer snacks, more ways to consume fruit (eg, fruit shakes, smoothies, and blended beverages) or make it a point to add to each meal (eg, salads, sandwiches, and cereal), taste-testing before buying, wanting to be a good example to children, and fruit-related activities (eg, specific fruit days and family discussions on the importance of eating fruit for health). The core facilitators reported by the children to meeting the fruit recommendation included availability, taste, making a schedule to eat fruit, consuming specific foods at specific times and places (eg, fruit smoothies, protein drinks with fresh fruit, combined fruits, fruit in juice or milkshakes, lots of orange and apple juice, cooking fruit-related foods, and 1322

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consuming in the morning and at night), and eating fruit with something else you like.

Vegetable Consumption The core barriers (Table 8) reported by the unrelated adult caregivers to meeting the vegetable recommendation included not used to eating vegetables, bad dietary habits and traditions, not knowing vegetables are healthful, bad taste and no preference for vegetables, does not buy them, convenience, costs too much, fast food, does not give proper nutrition, scared to try new vegetables, and lack of preparation skills and recipes. October 2013 Volume 113 Number 10

RESEARCH Table 4. Ranked votes for reported barriers to meeting grain (specifically whole grains) recommendations by unrelated adult caregivers and children in a study to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans Average responsea

Response by children

Average responsea

Hard to be habit-forming

9.0

Don’t like the taste of whole grains

10.0

Reducing the intake of carbs and calories

8.4

It’s hard to eat half of the grains as whole grains

9.0

It is difficult to observe the recommendation for refined grains (want to eat more than recommended)

7.6

Might forget what the recommendation is

8.0

Having children that are picky eaters

7.6

Eating too much junk food

7.9

Not tasty enough

7.4

Some kids do not like to eat healthy foods

7.8

Temptation of other foods

6.8

Sometimes its hard to forget about junk food

7.5

A belief that they are more expensive

6.8

Eating too many sugar cookies

7.0

Time and planning

6.6

Don’t like whole wheat

6.5

It is difficult to change food habits, especially in older adults

6.2

Some grains are plain and have no taste

6.3

Sometimes you are unaware of how to cook them

6.2

It might be hard to remember what types of grains to cook/eat

6.2

The price of whole grains is higher than the price of refined grains

6.0

Sometimes it’s hard to eat pizza with healthy stuff on it

6.0

Taste

6.0

Can’t eat half a burger

5.6

Not knowing recipes to cook whole grains

5.6

There might be a lot to choose from

5.5

Choosing other options off the pyramid

5.6

Eat too much sugar on pizza

5.3

Preparation

5.4

Too much salty foods

5.2

Response by caregivers

b

People don’t want to change

5.2

Kool-Aid and pickles makes it hard

5.1

Doesn’t like the flavor (of whole-grain foods)

5.0

It’s hard for kids to eat 6 oz grains

4.8

Appearance

5.0

They want to eat chips all day

4.7

I really don’t have time

4.8

Might prefer foods from the other groups

4.7

We don’t include them in our grocery list

4.6

When they get a snack that is unhealthy it makes them want to eat more and more

4.3

a

Average of the voters’ responses across 6 study sites. Kraft Foods, Inc.

b

The core barriers reported by the children to meeting the vegetable recommendation included competing foods (eg, fruits, candy, junk food, and sweets), bad taste and smell, addiction to salty and sweet snacks, forget to eat them, and lack of trying vegetables. The core facilitators (Table 9) reported by the unrelated adult caregivers to meeting the vegetable recommendation included buying, preparing, and consuming preferred vegetables (eg, ready-to-steam vegetables, adding/hiding vegetables in sauces, multiple forms on hand [frozen, canned, fresh], and raw precut vegetables for snacks, guacamole, salads, soups, salsa); mother should be the example; taste; cost; knowledge about portion sizes of vegetables; health concerns; and talk to the family about the benefits of eating vegetables. October 2013 Volume 113 Number 10

The core facilitators reported by the children to meeting the vegetable recommendation included benefits of eating vegetables (eg, makes your body healthy, plenty of vitamin C, helps you lose weight, gives kids energy, provides good eyesight, makes your body healthy, makes you grow healthier) and specific foods and preparation (eg, salad, fresh vegetables, vegetable soup, hide/add/serve vegetable in or with favorite foods or meal, add spices, and try different cooking methods).

DISCUSSION The majority of the population does not meet dietary guidelines20,27 with the consequence that many Americans do not meet recommendations for identified shortfall JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH Table 5. Ranked votes for reported facilitators to meeting grain (specifically whole grain) recommendations by unrelated adult caregivers and children in a study to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans Average responsea

Response by children

Average responsea

Distribute the grains during the day, not all together

9.2

Aim to eat 6 oz grains every day

8.9

Teach the kids to eat the whole grains

9.2

Have grains at lunch every day

8.0

Clearly worded and visible packaging and nutrition labels with up-to-date information

9.0

They can eat cereal

7.7

Use different types in the meals, mixed whole grains and refined

9.0

They can eat pancakes

7.3

In the principal meal, take in as much grain as possible

9.0

They can eat a sandwich

7.2

Make them tasty

8.8

Try to eat 1 cup breakfast flakes

6.9

Read the nutrition labels

8.8

In each meal you can include 2 oz grains

6.7

Prepare some products at home; for example, make homemade cookies using whole-grain flour rather than buying them

8.6

Try to eat more whole grains

6.5

Make little snacks for kids, like crackers with cheese and ham

8.2

You can eat popcorn

6.4

Prepackaged portions

8.0

You can make pizza

6.4

Educate self and include family in decision making

8.0

You can make your own trail mix

6.3

Newer recipes

8.0

Eat grains you like

5.9

Response by caregivers

Educate children about grains

7.8

Serve more bread at lunch

5.7

Use granola or oats to improve the flavor of other product like yogurt

7.8

Kids should balance out the types of grains they eat

5.7

Use whole-grain toast

7.8

You can eat some of your favorite foods and still be healthy

5.6

The tostada is very typical, use whole grain tostada

7.6

If you like grains you can eat >6 oz every day

5.4

More whole grains choices available in the foods I buy

7.5

You can have a whole-wheat sandwich to take care of 2 oz whole wheat

5.3

Receiving coupons for free grain products

7.4

Understanding good eating habits

7.4

Eat more cereal for breakfast

5.3

Educational, public service announcements, and related marketing materials

6.9

They can eat 100% whole grain

5.1

You can learn to adapt to wheat

5.0

a

Average of the voters’ responses across 6 study sites.

nutrients.18,19 Fruit, vegetables, whole grains, and reduced-fat milk/dairy products were identified by both the 2005 and 2010 DGA as food groups to encourage in the American diet.18,19 The recommendations for each of these food groups were the same for both the 2005 and 2010 DGA. The only difference was that the 2005 DGA used “Milk” as the food group and the 2010 DGA used “Dairy.” 1324

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Specific barriers to meeting dietary recommendations for consumption of milk and milk products (specifically reduced-fat/nonfat), grains (specifically whole grains), fruit, and vegetables can be categorized under two overarching psychosocial dimensions—personal/behavioral barriers and environmental barriers. Lack of parental food preparation skills, preferences and picky eaters, perceived food October 2013 Volume 113 Number 10

RESEARCH Table 6. Ranked votes for reported barriers to meeting fruit recommendations by unrelated adult caregivers and children in a study to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans

Response by caregiver

Average responsea

Response by children

Average responsea

The prices for fruits are too high

8.8

Don’t like fruits

8.6

We have to be the example so the children will eat fruit

8.7

Taste

8.1

Season of fruit out of season hard to buy

8.6

Too many pesticides on fruit

6.6

People might eat too much

8.5

Hard to figure out portion/oz

6.6

It’s hard to eat fruits that are not sweet

8.3

Sometimes kids schedules are just too tight

6.4

Too much junk food is sublimely in their face

8.0

Not buying fruit at all

6.3

Finding and keeping it fresh (eg, some stores seems to be past its prime)

8.0

Choose junk food over fruit

6.1

It is hard to have a variety of fruits

7.8

On the computer day and night

6.0

Eating out—most families on the go and most places don’t have a choice of fruit

7.8

Might forget to eat them

5.9

Hard to store fresh fruit at home when shopping for a week for the family

7.6

Too lazy to go to the store

5.8

You eat more food and you get full

7.5

The kids like to eat sugary foods

5.7

We are not putting the importance on the fruits and we prefer to buy sweets

7.2

Lacking of fruit in the house

5.5

Goes bad quickly

7.0

When kids are on vacation they have to eat out

5.0

Price of fresh fruit

6.6

School lunch doesn’t give kids a lot of fruit

4.8

Preparation time to eat fresh fruits like cutting watermelon

6.6

Busy doing something else

4.8

Too busy/fast food is easier

6.0

Television

4.3

Not in the mood to eat fruit

6.0

Might run out of fruits

4.1

Need to change routine

5.5

Some people might not like 100% juice

4.1

How you ate when you grew up; getting fruit wasn’t a big deal- mostly meat and potatoes getting fruit wasn’t in the forefront like today. Culture grew up in—farming area don’t grow oranges

5.4

Kids forget The bugs are destroying your crops

4.0 4.0

Fruit is expensive

5.3

a

Average of the voters’ responses across 6 study sites.

aesthetics, cost, competing foods, inconvenience and time constraints, lack of concern about health, tradition and cultural issues, misperceptions about foods, and physical intolerance or allergy were the behavior and personal barriers reported by unrelated adult caregivers or the children. A major environmental barrier was lack of knowledge regarding dietary recommendations, health benefits, and identification of whole grains or milk products. Quantities recommended for these foods were perceived as excessive. Other environmental barriers included cost, availability, accessibility, concern about spoilage, and lack of variety. October 2013 Volume 113 Number 10

Barriers to meeting DGA varied across the four key food groups studied, suggesting that targeted strategies may be needed to increase DGA adherence for the different food groups. Although caregivers and children were not from the same household, there were similarities as well as differences in reported barriers. Core barriers reported for adherence to the milk food group recommendations included lack of knowledge, that the recommended amount was too high, and cost. These barriers to milk consumption are consistent with those reported in a 2003 review.28 The review discussed several factors that influenced children’s milk drinking behavior, including competitive foods, eating away from JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH Table 7. Ranked votes for reported facilitators to meeting fruit recommendations by unrelated adult caregivers and children to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans

Response by caregivers

Average responsea

Response by children

Average responsea

Accessibility and affordability

9.8

Tastes good

9.6

Groups/chats like this help us remember the recommendations for healthy eating habits

9.6

Make a fruit smoothie

9.2

Access to fruit that tastes good; that is, sweet and fresh

9.0

Eat combined fruits

8.3

Include a fruit or 100% fruit juice with every meal

8.8

Make protein drinks with fresh fruit

8.0

Have a variety of fruit available

8.6

Turn fruit into juice

7.8

Prominently displayed in the home; for example, bowl on the table

8.6

Follow the nutrition facts

7.4

Information that fruit is pesticide-free, clean, and/or not genetically modified

8.6

Eat healthy things that you like

7.2

Convenient access to local fruit

8.4

Cook fruit-related foods

7.2

Wanting to give a good example to children

8.2

You know that it is healthy

7.0

Substitute fruit for junk food

8.2

Putting fruit in milkshakes

7.0

Make a point to add fruit to each meal; for example, salads, sandwich, and cereal

8.0

Introduced to it when you are young and get used to the taste, enjoy the taste

6.6

Reasonable prices for fresh fruit

7.8

Keep fruit at home

6.6

Ability to taste/sample the fruit before buying

7.6

Put different fruit together for variety

6.4

Buy less snacks and more fruit

7.4

Make a movie about the fruit groups

6.4

Purchase from local vendors for freshness

7.2

Eat some fruit in the morning and some at night

6.3

Family discussions of importance of eating fruit for health

7.2

Make the fruit look festive

6.2

Make fruit shakes/smoothies/blended beverages

7.2

Eat fruits for snack

6.0

To have specific fruit days

7.0

Drink lots of orange juice and apple juice

5.8

Pictures of posters of serving size

6.8

Looks good on the outside

5.8

When this is a recommendation made by the doctor or another person

6.8

Eat fruit with something else you like

5.6

a

Average of the voters’ responses across 6 study sites.

home, nutrition-related concerns with reduced-fat foods, lactose intolerance, adult modeling of milk drinking behaviors and home availability, taste, and lack of knowledge about calcium and dietary sources of nutrients. Core barriers to consumption of whole grains included lack of knowledge on what constitutes whole grains, preparation and planning time, lack of recipes, taste, cost, competing foods, and the inconsistent misperception that people were or were not eating too many grains. To our knowledge, this is the first study to specifically identify barriers to grain (specifically whole grain) consumption by children and unrelated 1326

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adult caregivers. One study29 looked at the association between whole-grain intake, psychosocial variables, and home availability among elementary school children. Whole-grain intake was related to availability in the home, but not to preferences, outcome expectations, self-efficacy, or knowledge, contrary to the identified barriers in our study. Information from our study should be useful when designing interventions or educational materials specifically designed to increase whole-grains consumption. Our findings suggest that barriers and facilitators to consuming each food group should be considered October 2013 Volume 113 Number 10

RESEARCH Table 8. Ranked votes for reported barriers to meeting vegetable recommendations by unrelated adult caregivers and children in a study to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans Average responsea

Response by children

Average responsea

9.9

Get tempted to eat other foods

9.7

Fast food is convenient

8.4

They don’t always taste good

8.1

Not knowing vegetables are healthful

6.9

Sometimes kids would rather eat candy

8.1

Don’t know how to prepare good or fun recipes with vegetables

6.6

Lacking of trying vegetables

7.2

Illness prevents us from eating vegetables

6.6

People don’t notice they are eating too much from other food groups

7.2

Response by caregiver We are not used to eating vegetables since we were young

Preparation

6.4

Other foods smell and taste better

7.2

Kids don’t like the taste, don’t want to fight with kids

6.4

The amount of food they have to eat

7.0

Taste

6.2

people prefer eating junk food

7.0

Bad diet habits or traditions

6.0

There might be other sweets in the house that they rather have

6.6

Don’t know how to cook some vegetables

6.0

Have it as a side of something that you like

6.5

Bad taste

5.7

Fruits are more sweet than vegetables

6.2

Fast food due to working outside the home

5.7

They don’t like vegetables

5.9

Convenience

5.6

They don’t eat them on a daily schedule

5.9

I never have a craving or preference for vegetables

5.2

Some people don’t like vegetables because they taste bad

5.8

Cost

5.0

Some people eat their food a certain way

5.4

We don’t like them when we taste them

4.7

They might not like what the food smells like

4.9

Finance

4.6

People buy vegetables and forget to eat them

4.8

Scared to try new vegetables

4.4

Addiction to salty and sweet snacks

4.6

Don’t like vegetables

4.4

They don’t really want to

4.3

Fast food doesn’t give proper nutrition

4.2

How its prepared at home

4.0

a

Average of the voters’ responses across 6 study sites.

separately. Perhaps the most often-studied DGA components are fruits and vegetables. Recently, focus groups and individual interviews have been used to identify facilitators and barriers to fruit and vegetable intake in urban lowincome African-American adults.30,31 Many of the barriers reported there are consistent with results reported in our study; however, some facilitators, such as safety while shopping, were also identified. To our knowledge, only one study has included the three major race/ethnic groups in the United States.32 Additional barriers reported were access to traditional foods for Hispanic immigrants. Overall, the consistent themes of barriers and facilitators to fruit and vegetable intake reported in these few studies lends strength to the interpretation of the results reported here for whole grains and milk recommendations, both insufficiently explored in the literature. Qualitative research with children on barriers and facilitators specifically is especially limited. October 2013 Volume 113 Number 10

Many studies have reported factors influencing fruit and vegetable consumption33-38 that are consistent with some of the barriers reported by unrelated adult caregivers and children in our study. These include lack of availability and accessibility of reasonably priced, good quality fruit and vegetables; the perception that fruit and vegetables are time consuming to prepare; lack of preparation skills and recipes; taste and preferences; that other competing foods are more convenient; and schools do not give children a lot of fruit. Three other barriers reported by children were lack of time, forgetting to eat fruit and vegetables, or not caring about health. Adult caregivers reported that traditions and lack of familiarity were additional barriers. This is consistent with one study that used NGT with African-American adults and found that although they perceived fruit and vegetables as healthy, they were typically not associated with the African-American food culture or traditional diet.26 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

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RESEARCH Table 9. Ranked votes for reported facilitators to meeting vegetable recommendations by unrelated adult caregivers and children in a study to understand barriers and facilitators to adherence to the Dietary Guidelines for Americans

Response by caregivers

Average responsea

Response by children

Average responsea

Make the consumption of vegetables daily

10.0

It will give us more power

8.6

Liking the vegetables

9.8

Serve it with one of your favorite foods

8.5

Serving vegetables that you love

9.6

Helps you lose weight

7.9

The mother should be the example

9.3

Broccoli provides you to lose weight

7.8

Being knowledgeable about the portion size

9.2

It gives kids more energy

7.7

Include vegetables in every meal

9.0

Has plenty of vitamin C

7.7

Make dishes that have more vegetables

8.7

Makes your body healthy

7.7

Health concerns

8.2

Try different types of vegetables to see what you like

7.7

Eat raw vegetables for snacks

8.0

Make vegetable soup

7.6

Make soup

8.0

Buy fresh vegetables because they taste better

7.2

Talk to the family about the benefits of eating vegetables

8.0

Make a salad

7.1

Make salads

7.8

Makes you grow healthier

6.9

Buying ready-to-steam vegetables

7.8

You be healthy every day

6.8

Make salsas, guacamole

7.7

It makes it easier if you put vegetables in a bag for your lunch

6.8

Eat them fresh, better flavor

7.7

Add spices and other ingredients to make it taste/look better

6.7

Having precut vegetables for snacks

7.6

Hide/add vegetables in your favorite meal

6.7

Adding/hiding vegetable in sauces

7.6

Eating vegetables makes you smart

6.6

Making produce affordable

7.6

Have small servings at each meal

6.5

Adding chicken or steak to salad to make it more appealing

7.4

Try different types of cooking methods to change taste/taste better

6.5

Use seasonal vegetables

7.2

Have good eyesight

6.4

a

Average of the voters’ responses across 6 study sites.

There are several fundamental differences in our study from other studies34,39-41 or systematic reviews42-44 on barriers to healthy eating. A major limitation of previous studies is that healthy eating was never defined and the definition was based solely on the respondents’ perception of healthy eating meant to them personally, with no universal or standard definition. Although most individuals have some conceptualization of a “healthy diet,” it is likely that they are not aware of the specifics of the DGA, given the low rates of DGA adherence among Americans.18,20 One study45 found that more than half of the sample participants (n¼400 adults in Minneapolis, MN) were unaware of federal policy about nutrition and had never heard of a document containing the government’s dietary guidelines. Of the 13 guideline recommendations studied, an average of 2.471.35 recommendations per person were identified by respondents, with the intrusion of several recommendations that were not part of the DGA. In a recent national survey,46 15% of Americans had 1328

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never heard about MyPyramid, and the specific recommendations in MyPyramid were not understood by the majority.46 Consumers were generally confused about what constitutes a whole-grain product, and they had limited ability to identify these products based on the label.29 Twenty-nine percent of Americans had never heard of the DGA and another 48% had heard of the DGA, but knew very little about them.46 Unique to our study, a preamble was developed for each of the eight components in MyPyramid to provide participants in the NGT sessions with a cognitive referent for considering DGA barriers and facilitators. The difference between perceived healthy eating and actually knowing the specific dietary recommendations needs to be taken into consideration when looking at results from other studies. Another fundamental difference between this study and others is the method used for data collection. The majority of studies have looked at barriers specific to healthy eating October 2013 Volume 113 Number 10

RESEARCH using surveys, semi-structured interviews, or focus groups, with only two studies using NGTs.26,47 NGT sessions may be thought of as highly structured focus groups, where data obtained are more comprehensive than the data obtained from focus groups, semistructured interviews, or from predetermined barriers used in surveys. However, there are limitations in using the NGT procedure because it does not allow for elaboration of the reasons why adult caregivers and children nominated or elected specific barriers and facilitators. Thus, several of the responses obtained from the NGT sessions were hard to interpret and some reflect a potential misunderstanding of the DGA. With this methodology there was also no opportunity to explore how the specific barriers and facilitators influenced DGA adherence. Thus, more studies are needed to expand on this research to better understand how we can get more Americans closer to the current DGA. Most of the barriers reported in our study have been reported previously for eating a healthy diet.34,39-44 However, it is unclear from those studies how a healthy diet was defined and if it included dairy, whole grains, and fruit and vegetables. It is also widely assumed that the barriers to healthy eating apply to all of the DGA recommendations. In an effort to understand the barriers to DGA adherence, it is important that the barriers to recommendations be investigated separately for each component of the DGA. To our knowledge, none of the earlier studies focused specifically on facilitators to meeting the DGA for the four nutrient-dense food groups examined in our study. It is of interest that the facilitators reported by the unrelated adult caregivers and children very closely coincided with the reported barriers—and identified modifiable issues that could potentially be addressed to decrease the barriers to meeting the DGA. The overarching facilitators that were reported for several of the food groups included emphasizing health benefits and recommendations, increasing availability and accessibility, affordability, offering more food choices, and guidance on food preparation. These facilitators can be used by health professionals in designing educational programs or even tailored intervention programs. Similarly, food companies can use this information for marketing their products and for consumer messaging.

CONCLUSIONS Findings from our study have important implications for Americans meeting the DGA recommendations for consumption of milk and milk products (specifically reduced-fat/ nonfat), grains (specifically whole grains), fruit, and vegetables. Intervention efforts may need to address barriers specific to changing the consumption of a single food group, rather than focusing on eating behaviors overall. Moreover, intervention efforts may need to also be tailored to age segments of the population. The reflective commonality between reported barriers and facilitators suggests that focusing on the facilitators may minimize the barriers to meeting the DGA. An important research question is the association between barriers and facilitators to DGA adherence (as measured by the Healthy Eating Index 200548) and weight status.

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October 2013 Volume 113 Number 10

RESEARCH AUTHOR INFORMATION T. A. Nicklas is a professor of pediatrics and S. Lopez is a research coordinator, Department of Pediatrics, and Y. Liu is a master biostatistician, US Department of Agriculture/Agricultural Research Service Children’s Nutrition Research Center at Baylor College of Medicine, Houston, TX. L. Jahns is a research nutritionist, US Department of Agriculture/Agricultural Research Service Grand Forks Human Nutrition Research Center, Grand Forks, ND. M. L. Bogle is retired; at the time of the study, she was executive director, US Department of Agriculture/Agricultural Research Service Delta Obesity Prevention Research Unit, Little Rock, AR. D. N. Chester is a national program leader, Division of Nutrition, Institute of Food Safety and Nutrition, National Institute of Food and Agriculture, US Department of Agriculture, Washington, DC; at the time of the study, she was a nutritionist, US Department of Agriculture/Agricultural Research Service Beltsville Human Nutrition Research Center, Beltsville, MD. M. Giovanni is a nutritionist, Nutrition and Food Science Department, California State University-Chico, Chico; at the time of the study, she was a research nutritionist, US Department of Agriculture/Agricultural Research Service Western Human Nutrition Research Center, Obesity and Metabolism Unit, Davis, CA. D. M. Klurfeld is a national program leader (human nutrition), US Department of Agriculture/Agricultural Research Service, Office of National Programs, Beltsville, MD. K. Laugero is a nutritionist, US Department of Agriculture/Agricultural Research Service Western Human Nutrition Research Center, Obesity and Metabolism Unit, Davis, CA. K. L. Tucker is a professor, Department of Health Sciences, Northeastern University, Boston, MA; at the time of the study, she was a senior scientist, US Department of Agriculture/Agricultural Research Service Human Nutrition Research Center on Aging at Tufts University, Boston, MA. Address correspondence to: Theresa A. Nicklas, DrPH, Department of Pediatrics, US Department of Agriculture/Agricultural Research Service Children’s Nutrition Research Center at Baylor College of Medicine, 1100 Bates Ave, Houston, TX 77030. E-mail: [email protected]

STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conflict of interest was reported by the authors.

FUNDING/SUPPORT US Department of Agriculture/Agricultural Research Service and Dairy Management Incorporated provided funding for this work. The funding agencies had no role in the design of the study, analysis, or content of this publication. The contents of this publication do not necessarily reflect the views or policies of the US Department of Agriculture or the Agricultural Research Service, nor does mention of trade names, commercial products, or organizations imply endorsement from the US government.

ACKNOWLEDGEMENTS The authors thank Carol O’Neil, PhD, MPH, LDN, RD, Louisiana State University AgCenter, for providing editorial assistance; Lori Briones for help in preparing the manuscript, and Bee Wong for obtaining research articles. The authors also thank the participating centers and staff members: Beltsville Human Nutrition Research Center: Ellen Harris, Shanthy Bowman; Children’s Nutrition Research Center: Alba Calzada, Maria Papaioannou, Nilda Micheli-Correa; Delta Obesity Prevention Research Unit: Dalia Lovera, Deborah Martin (Service Specialists, Ridgeview, MS); Grand Forks Human Nutrition Research Center: Bonita Hoverson, Bonnie Thompson, Doreen Rolshoven, Doris Zidon, Mary Jo Peltier, Rebecca Stadstad; Human Nutrition Research Center on Aging: Janice Maras, Marina Komarovsky, Stephanie Jo Peterson; and Western Human Nutrition Research Center: Jacqueline Bergman, Shavawn Forester.

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