- Email: [email protected]
The IFIC Foundation Food & Health Survey 2015: 10-Year Trends and Emerging Issues
PRACTICE APPLICATIONS
Topics of Professional Interest
The IFIC Foundation Food & Health Survey 2015: 10-Year Trends and Emerging Issues
T
HE NUTRITION AND DIETETICS community is committed to improving the health of the population. To maximize our effectiveness in working toward that goal requires an understanding of the factors that determine individual behaviors in an increasingly complex world and an understanding of how behaviors, attitudes, and beliefs change over time. The year 2015 marks the 10th consecutive Annual Food & Health (F&H) Survey conducted by the International Food Information Council (IFIC) Foundation. It provides a unique resource to track key nutrition, food, and health trends annually and over a decade that has experienced numerous changes in consumer behavior, environmental concerns, and the nature of nutrition communications. The data provide an opportunity to identify positive trends and areas in which new approaches are needed. It allows us to explore current consumer food and nutrition behaviors, long-term changes since the survey was first administered in 2006, and progress toward achieving changes recommended in the 5-year retrospective published in 2013.1 This manuscript focuses on five areas with clear implications
This article was written by Jeanne P. Goldberg, PhD, RD, a professor, and Lindsay A. Tanskey, MS, MEd, a doctoral candidate, both at The Friedman School of Nutrition Science & Policy, Tufts University, Boston, MA; Elizabeth A. Sanders, MPH, RD, an associate director, International Food Information Council Foundation, Washington, DC; and Marianne Smith Edge, MS, RD, LD, FADA, FAND, president, MSE & Associates, LLC, Owensboro, KY; at the time of the study, she was a senior advisor, Nutrition and Food Safety, International Food Information Council Foundation, Washington, DC. http://dx.doi.org/10.1016/j.jand.2016.05.012 Available online 6 July 2016
ª 2017 by the Academy of Nutrition and Dietetics.
for practitioners. The full survey results are available on the IFIC website.2
METHODS IFIC Foundation F&H surveys conducted from 2012 to 2015 were administered by Greenwald & Associates, using Research Now’s consumer panel. The 2006 to 2010 surveys were administered by Cogent Research. A detailed description of survey methods is provided in the 5-year retrospective, along with a summary of overarching themes for each.1 The 2015 national online survey explored how consumers evaluate health in relation to other factors that affect their lives. It was completed by 1,007 Americans aged 18 to 80 years. Results were weighted using a multi-stage, multivariate weighting scheme so that the results are reflective of the US population as seen in the 2014 Current Population Survey. The stages include weighting the data by 1) education by age by sex, 2) ethnicity by age by sex, and 3) region by age. Before administration, cognitive interviews were conducted to ensure that the language of the questions would be understood by respondents.
Americans’ Perceptions of Health Do Not Align with Self-Reported Height and Weight On the 2015 survey, 17% of respondents ranked their health as excellent, 40% as very good, 33% as good, 8% as fair, and just 1% as poor. Positive personal health ratings were associated with being female, having a college degree, and having a higher income. An excellent health rating was also associated with a lower body mass index and absence of noncommunicable diseases. These findings are in close agreement with those from the 2012 National Health Interview Survey, conducted annually by the Centers for Disease Control and Prevention, that collects similar information through in-person interviews.3
Perceived health status has been assessed on the F&H survey annually since 2006. Responses were consistent from 2006 to 2011. A shift toward better perceived health was observed in 2012, and it has remained steady thereafter. The most plausible explanation is that in 2012, a different contractor administered the survey, and the order of response categories was reversed. “Excellent” became the first choice, and “poor” became last. This explanation seems defensible because findings have remained consistent within the two time spans, and the demographics of the survey respondents have remained reflective of the overall US population. As expected on the 2015 survey, respondents who reported a normal weight ranked their health as excellent or very good more frequently (73%) than those who reported that they were overweight or obese (54% and 45%, respectively). However, a large proportion of overweight or obese respondents did not perceive their weight status to be related to their overall health status (Figure 1). The disconnect between weight status and perceived health has been documented in some population subgroups for more than 20 years.4-6 Clear evidence suggests that maintaining one’s recommended weight or losing weight can positively impact length and quality of life. Moderate weight loss has been associated with improved physical health7 and with prevention and treatment of type 2 diabetes8 and cardiovascular disease.9 The health benefits of weight loss are endorsed by major health organizations.9-12 Many approaches have produced short-term weight loss, but significant weight maintenance over time remains an elusive goal for most dieters.13,14 Unfortunately, sensible approaches to weight loss are frequently lost in the abundance of inaccurate information available to consumers, increasingly communicated online.15 To improve weight loss and weight maintenance outcomes, strategies to
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
355
PRACTICE APPLICATIONS Normal or Low BMI
Excellent
27%
Very Good
46%
Good
23%
Overweight BMI
Excellent
16%
Obese BMI
Excellent
8%
Very Good
38%
Very Good
36%
Good
37%
Good
39%
Fair
3%
Fair
Poor
1%
Poor
8% 1%
Fair Poor
14% 3%
Figure 1. Perceived health status by self-reported weight status, International Food Information Council Foundation Food & Health Survey, 2015. motivate individual behavior change are essential. This requires understanding consumer perceptions about what motivates them to stay on track. In the 2015 survey, three factors were equally important motivators for weight management: improved physical appearance, increased energy and physical mobility, and improved health and wellbeing. Physical appearance has consistently been the top motivator for weight loss and maintenance, especially among women, increasing slightly from 51% in 2011 to 56% in 2015. Increased energy has remained the second most important factor, but the percentage of individuals who chose this has risen from 43% in 2011 to 55% in 2015. Most striking is the change in the relative importance of improved health and wellbeing, which has risen from 41% in 2011 to 53% in 2015, surpassing increased self-esteem as the third most frequent motivational factor. These three factors—appearance, energy, and health—represent the top motivators of weight management for 85% of respondents. However, only 21% of respondents selected all three, suggesting that intended behavioral drivers are quite individual. Respondents were asked to select factors that would contribute to or have contributed to successful weight loss or maintenance. The top factors—changing the types and amounts of foods eaten and getting adequate physical activity— remained consistent from 2011 to 2015. The percentage of respondents who said 356
they controlled higher-calorie foods and beverages increased from 15% in 2011 to 30% in 2015. Other strategies, such as regular weighing and tracking calories, remained stable. Key barriers to weight loss in the 2015 survey included lack of willpower, not seeing results quickly enough, stress, lack of time and energy, and cost. These findings changed little since 2011. Notably, disliking healthful foods and beverages and disliking physical activity were less important weight loss barriers, each at 13% in 2015. The latest IFIC Foundation survey provides important guidance for nutrition and dietetics practitioners working with a wide range of individuals and larger audiences. Drawing on the Stages of Change constructs from the Transtheoretical Model,16 the survey inquired about participants’ readiness to improve their diets. In both 2014 and 2015, more than 50% reported taking action to improve their diet; an additional 36% said they had maintained at least one healthier behavior for more than a year. These findings suggest a high level of interest in healthier diets and a willingness to make and maintain changes. What these changes were and what consumers believe would be the next logical step in improving their diets remains to be explored. Motivational interviewing offers promise at both individual and group levels. It focuses on client-centered perspectives rather than on framing issues through the practitioner’s lens. The role of the practitioner shifts from providing information to
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
enabling individuals to make their own decisions about what to change and how to proceed. The approach has been adapted to working with groups as well as individuals.17 In larger groups and whole communities, the importance of understanding and responding to the needs and desires of the target population cannot be overstated.18
How Americans Get Food to the Table: An Emerging Picture Suggests Diverse Approaches Americans have access to a food supply that can deliver a diet that is nutritionally adequate and gastronomically satisfying. Whether diets meet both goals depends on myriad factors specific to individuals and their unique environments. The 2015 F&H survey found that 19% of respondents spend less than 15 minutes preparing dinner, 52% spend 15 to 44 minutes, and 29% spend 45 minutes or more. Men spent the least amount of time in the kitchen. Hispanics and African Americans were more likely than whites to spend an hour or more preparing dinner. Improved diet quality has recently been associated with more time spent in the kitchen.19 One question not addressed in this research is the influence of food preparation skills on diet quality. Theoretically, individuals with greater skills should be better able to select foods and prepare meals that are more healthful and well-accepted than those with fewer skills. One must March 2017 Volume 117 Number 3
PRACTICE APPLICATIONS 90%
Expiration date
80%
Nutrition Facts panel
70%
Ingredients list
60%
Servings size and amount per container
50%
Calorie and other nutrition information Brand name
40% Cooking instructions/preparation time
30%
Statements about nutrition benefits
20%
Country of origin labeling
10%
Statements about health benefits
0% 2007
2008
2009
2010
2011
2012
2013
2014
2015
Statement about the absence of certain food ingredients
Figure 2. Changes in consumer use of packaging information over time, International Food Information Council Foundation Food & Health Survey, 2007-2015.
better understand how food handling skills affect diet quality, and how they vary among different subgroups. The food supply has changed dramatically over the past several decades, with increased availability of prepared and partially prepared foods.20 This has enabled Americans who can afford to, and choose to do so, to spend less time in food preparation.21 The 2015 F&H survey shows that 51% of Americans rank convenience as the most important benefit of processed foods. Prolonged freshness (44%) and greater affordability (40%) were also important. A 2010 Harris Poll suggests that as many as 40% of Americans prepare meals at home at least five times per week, and threequarters of those who prepare meals at home use some pre-prepared foods and appliances that ease preparation and cleanup.22 For these individuals, skill in selecting among available choices is critical. Identification of healthful, affordable processed foods that facilitate preparation can help consumers with limited time and resources. The role of pre-prepared and convenience items in home-prepared meals deserves further study. How can this evidence guide interventions to improve diet quality among Americans? Promoting increased time in the kitchen may be unrealistic. When asked how they would spend an extra 4 hours every week, only 11% of participants in the March 2017 Volume 117 Number 3
2015 F&H survey said they would use the additional time for cooking. This group was already spending at least 45 minutes preparing dinner. Given the low level of interest in spending more time in the kitchen, focusing on food selection in the marketplace and on skills to facilitate more efficient preparation of healthful family meals appears to be more realistic. Registered dietitian nutritionists (RDNs) need to understand how family meals are assembled and focus on family preferences, constraints, and behaviors. For some households, educational efforts will continue to address foods prepared from scratch, whereas others will need to consider approaches that integrate prepared and convenience foods and restaurant meals. The food industry continues to generate new ideas and products to help streamline food preparation for consumers. RDNs must continue to monitor these innovations to guide their clients toward healthier choices.
Knowing More and Using That Knowledge Effectively: Helping Consumers Make the Most of Available Nutrition Information Questions about consumer use of labeling information have been included since the second F&H Survey in 2007, and they provide some interesting observations. The three most frequently used types of nutrition information have consistently been the
expiration date, Nutrition Facts Panel, and ingredients list. Although small shifts have occurred from year to year, since 2013 focus on labeling information has declined. Specifically, use of expiration date information peaked in 2013 and declined sharply thereafter. In addition, fewer consumers are looking at the Nutrition Facts panel, ingredients list, and calorie and other nutrition information (Figure 2). Increasingly, participants have completed the survey on a mobile phone, which is less user-friendly than a large screen for completing questions with a large number of responses. That may have affected results. The F&H survey does, however, provide reason to be optimistic about how consumers use nutrition information. More than 50% of respondents said they try to consume whole grains, fiber, and protein. More than 40% make an effort to get enough calcium. With the exception of protein, which most of the population consumes in adequate amounts,23 these nutrients of concern are consistent with those that health professionals acknowledge are consumed in amounts outside of recommended ranges.24 Respondents were most likely to try to limit or avoid added sugars, sodium, trans fats, saturated fats, calories, cholesterol, low-calorie sweeteners, and fats and oils. Given media coverage of the consequences of excess consumption of added sugars, sodium, trans and
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
357
PRACTICE APPLICATIONS saturated fats, and calories, that Americans say they try to avoid these food components is not surprising. In general, Americans seem to report behaviors consistent with widely disseminated nutrition advice. The data suggest several lines of inquiry about how or whether selfreported behaviors with respect to specific nutrients or food components (eg, whole grains or saturated fat) are integrated to drive behavior and how they affect diet quality overall. The example of whole grains illustrates this point. First, to what extent is selfreport of wanting to consume more whole grains associated with consumption? Second, among those who report wanting to consume more whole grains, do they select more? Third, what is the overall nutrient profile of the whole-grain products they purchase? Is front-of-package labeling more likely to lead to choice of nutritious whole-grain foods? Finally, how are different groups of consumers using nutrition labels to guide purchase decisions? That information could inform the targeting of messages for different groups. The single most important question is not whether people use information on nutrition packages, but how they use it in the behavioral context. We do not know, for example, whether those individuals who focus primarily on calories to guide their choice of individual items put that information into the context of portion size and, more importantly, whether this information guides consumption. Choosing a balanced diet goes beyond reading food labels. Consumers must understand the nutritional contributions of foods with no labeling, including fruits and vegetables and many protein-rich foods, including meat and seafood. Furthermore, arguments for choosing foods rather than supplements can apply equally well to guiding consumers to use whole foods rather than individual nutrients in foods as the basis of their food choices.25,26 Using individual nutrients or components in food as the key to food choice, however well intentioned, can subvert the goal of achieving a well-balanced diet. RDNs must empower consumers to look beyond a single indicator of a food’s nutritional value and to focus on total diet. With a unique and in-depth knowledge about foods and how to 358
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
prepare them, they are uniquely positioned to help clients integrate and use food and nutrition information effectively. In formulating communications, they must respect the clear consumer demand for positive guidance rather than messages about foods to avoid.
Emerging Issues in the Food Choice Equation: Sustainable Diets and Technological Changes in Food Production Four factors are known to guide food choice for most consumers. Taste remains fixed in first place. Price ranks second, and it tends to fluctuate with economic trends. Healthfulness is next, and it has remained in third place since the first IFIC Foundation survey in 2006. Finally, convenience has remained in fourth place. This evidence must be integrated with current knowledge about how consumers want to learn about food. Consistent with earlier findings, the 2015 survey showed that consumers prefer positive messaging focused on integrating healthy foods into the diet, rather than negative messaging focused on foods to restrict or avoid. This preference has increased from 56% in 2009 to 78% in 2013 and has remained stable. This observation is also reflected in the 2011 Academy of Nutrition and Dietetics (Academy) “Nutrition & You” survey.27 A newer addition to the equation is individual perception of the link between what people eat and the environment. A relatively small percentage of respondents in the 2015 IFIC survey (20%) said they focused a lot on whether their foods and beverages were produced in an environmentally sustainable way, whereas 30% paid no attention to the issue. That focus has not changed significantly from the prior 2 years. Parents and millennials (aged 18-34 years) were relatively more likely to say they thought a lot about the environmental sustainability of food production methods. Responses to detailed questions suggest that consumer knowledge of these issues is limited. For example, when presented with a list of factors that might or might not be included in a description of sustainable foods, fewer than one in four thought that sustainable foods “have a smaller impact on the environment.” Just 13% thought that March 2017 Volume 117 Number 3
PRACTICE APPLICATIONS sustainable foods created less food waste or used fewer natural resources to produce. When asked how much they thought about how their foods and beverages are farmed or produced, just one in four respondents said they thought about it a lot, whereas half said they thought about it a little. Parents, women, and younger adults were more likely to give a lot of thought to these issues. Understanding of labeling terms related to food production is limited. Despite the lack of an official definition of “natural,” that term is most likely to influence purchase decisions (40%). Nearly an equal number of respondents (37%) said they were not influenced by sustainability-related descriptors on the food label. Consumer understanding of biotechnology is similarly limited. More than one-third of respondents said they were not sure what purpose biotechnology serves in producing foods and beverages. The gap in public understanding in both areas suggests a need for balanced communication going forward. RDNs are uniquely positioned to communicate accurately about these topics— specifically, how they relate to food selection and preparation. This will require that, as professionals, they keep up to date with changes in food production and policies that directly affect consumers.
The Mismatch between Frequently Used Sources of Health Information and Trusted Sources of Health Information Continues Since it began in 2006, the F&H survey has explored consumer trust in sources of diet and health information. In the most recent survey, respondents were asked to identify up to three trusted sources. Seventy percent chose their personal health care professional, 34% chose friends or family members, and 25% put their trust in information from the US government or television food experts and food, health, or nutrition bloggers. Thirty-two percent turn to family and friends as a resource to improve the healthfulness of their diet; only 20% reported having seen a medical professional, and just 6% reported having seen an RDN. With regard to weight control, four of five respondents
March 2017 Volume 117 Number 3
said they were working to lose or maintain weight, but only 5% said that seeing a health professional helped or would help them meet their goals. The 2011 Academy survey produced similar results.27 Sixty-seven percent of respondents identified television as the top source of nutrition information, followed by the Internet at 40%. Only 16% of respondents got information from their doctor and just 1% from RDNs. These data suggest that we need to do more to promote RDNs as preferred and most widely used sources of nutrition guidance. However, speculating that respondents did not consider the fact that these experts are the information source in many media outlets is reasonable. This question deserves further exploration. To reach a larger audience, RDNs must meet consumers where they access information, particularly on television and the Internet. Promoting RDNs as the most credible sources of nutrition information has long been a goal of the Academy, but much more needs to be done. The rise of social media has intensified the challenge of separating professional expertise from pseudoscience and unfounded opinion. That trend will continue. To rise above the clutter of misinformation, RDNs must be able to interpret the results of late-breaking research as quickly as their noncredentialed counterparts. They must do it in the context of the larger body of knowledge in relevant areas and continue to reinforce the underlying principle that nutrition science is evolutionary, not revolutionary. They must consider the potential value of new technologies in connecting and interacting with consumers. RDNs must be ready to provide consumers with direct, clear, and actionable messages that give them the confidence to make decisions about what to eat, how much to eat, and what to avoid. This is what differentiates the unique value of nutrition and dietetics practitioners.
THE CHALLENGE AHEAD The IFIC Foundation F&H Survey has provided a valuable context for understanding the determinants of food choice in the United States for 10 years. It has allowed researchers and communicators to understand the more stable influences on individual choices
and the emerging issues that affect behavior. The data provide guidance for nutrition and dietetics practitioners to work with clients more effectively and for researchers to enhance our understanding of the issues. Several limitations of the survey should be acknowledged. Its cross-sectional nature limits conclusions about changes over time or causation. The sample size is adequate to address many issues, but it includes no exploration of food insecurity or consideration of individuals with special health needs. Nonetheless, it provides important insights about many issues that affect the diets of millions of Americans. The 5-year retrospective1 challenged RDNs to increase their role as the major resource for consumers to obtain accurate, actionable, and relevant nutrition information. Since then, the challenge to reach individuals and groups has grown. The communication landscape has become increasingly cluttered with information of varying quality. The list of issues that must be considered in the context of obtaining a healthy diet has expanded to include factors that affect specific groups of individuals, such as those following vegan, gluten-free, and other specialized dietary patterns. It extends to growing concern over the sustainability of the food supply and the related issue of food waste, emerging technologies in food production, and more. In short, the challenge to the nutrition and dietetics practitioner of providing actionable, accurate, and relevant information will continue to grow. Going forward, nutrition communicators must stay abreast of the latest evidence-based nutrition guidance, as well as emerging issues that affect food choice and availability. They must tailor messages to their audience, and draw on their creative resources to develop communications that influence behavior, and subsequently health, in a sustained way.
References 1.
Hornick BA, Childs NM, Smith Edge M, Kapsak WR, Dooher C, White C. Is it time to rethink nutrition communications? A 5-year retrospective of Americans’ attitudes toward food, nutrition, and health. J Acad Nutr Diet. 2013;113(1):14-23.
2.
International Food Information Council Foundation. The 2015 Food & Health Survey: Consumer Attitudes toward Food Safety, Nutrition & Health. http://www.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
359
PRACTICE APPLICATIONS foodinsight.org/2015-food-health-surveyconsumer-research. Accessed March 2, 2016. 3.
4.
Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National health interview survey, 2012. Vital and health statistics. Series 10, Data from the National Health Survey; 2014:1-161. Loprinzi PD. Factors influencing the disconnect between self-perceived health status and actual health profile: Implications for improving self-awareness of health status. Prev Med. 2015;73:37-39.
5.
Goldberg J, Rudd RE, Dietz W. Using 3 data sources and methods to shape a nutrition campaign. J Am Diet Assoc. 1999;99(6):717-722; quiz 723-714, 776.
6.
Gregory CO, Blanck HM, Gillespie C, Maynard LM, Serdula MK. Perceived health risk of excess body weight among overweight and obese men and women: Differences by sex. Prev Med. 2008;47(1):46-52.
7.
8.
9.
Warkentin LM, Das D, Majumdar SR, Johnson JA, Padwal RS. The effect of weight loss on health-related quality of life: Systematic review and meta-analysis of randomized trials. Obes Rev. 2014;15(3): 169-182. Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. J Acad Nutr Diet. 2015;115(8):1323-1334. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation. 2010;122(4):406-441.
10.
Centers for Disease Control and Prevention. Losing Weight. http://www.cdc.gov/ healthyweight/losing_weight/. Accessed January 4, 2016.
11.
Seagle HM, Strain GW, Makris A, Reeves RS; American Dietetic A. Position of the American Dietetic Association: Weight management. J Am Diet Assoc. 2009;109(2):330-346.
12.
Jortberg B, Myers E, Gigliotti L, et al. Academy of Nutrition and Dietetics: Standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in adult weight management. J Acad Nutr Diet. 2015;115(4):609-618. e640.
13.
Bray GA, Wadden TA. Improving longterm weight loss maintenance: can we do it? Obesity. 2015;23(1):2-3.
14.
MacLean PS, Wing RR, Davidson T, et al. NIH working group report: Innovative research to improve maintenance of weight loss. Obesity. 2015;23(1):7-15.
15.
Modave F, Shokar NK, Penaranda E, Nguyen N. Analysis of the accuracy of weight loss information search engine results on the internet. Am J Public Health. 2014;104(10):1971-1978.
16.
Di Noia J, Prochaska JO. Mediating variables in a transtheoretical model dietary intervention program. Health Educ Behav. 2010;37(5):753-762.
17.
Wagner C, Ingersol K. Motivational Interviewing in Groups. New York, NY: The Guilford Press; 2013.
18.
Goldberg J, Peterson L. Role of communication in changing nutrition behaviors to promote healthy lifestyles. In: Rippe JM, ed. Lifestyle Medicine, Second Edition. Boca Raton, FL: CRC Press; 2013.
19.
Monsivais P, Aggarwal A, Drewnowski A. Time spent on home food preparation and
indicators of healthy eating. Am J Prev Med. 2014;47(6):796-802. 20.
Freeland-Graves JH, Nitzke S. Academy of Nutrition and Dietetics. Position of the Academy of Nutrition and Dietetics: Total diet approach to healthy eating. J Acad Nutr Diet. 2013;113(2):307-317.
21.
Folliard JN, Duncan-Goldsmith DM. Opportunities to improve snacks and beverages in schools. J Acad Nutr Diet. 2013;113(9):1145-1151.
22.
Harris Interactive. The Harris Poll: Three in Ten Americans Love to Cook, While One in Five Do Not Enjoy It or Don’t Cook. http:// www.theharrispoll.com/health-and-life/ Three_in_Ten_Americans_Love_to_Cook__ While_One_in_Five_Do_Not_Enjoy_It_or_ Don_t_Cook.html. Accessed January 4, 2016.
23.
Fulgoni VL 3rd. Current protein intake in America: Analysis of the National Health and Nutrition Examination Survey, 20032004. Am J Clin Nutr. 2008;87(5):1554S1557S.
24.
US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans 20152020, 8th edition. Washington, DC: US Department of Health and Human Services.
25.
Lichtenstein AH, Russell RM. Essential nutrients: Food or supplements? Where should the emphasis be? JAMA. 2005;294(3):351-358.
26.
Jacobs DR, Tapsell LC. Food synergy: The key to a healthy diet. Proceedings Nutr Soc. 2013;72(2):200-206.
27.
Academy of Nutrition & Dietetics. Nutrition and You: Trends 2011. http://www. eatrightpro.org/resources/media/trendsand-reviews/trends-survey. Accessed March 18, 2016.
DISCLOSURES STATEMENT OF POTENTIAL CONFLICT OF INTEREST J. P. Goldberg was an International Food Information Council (IFIC) Foundation Trustee at the time of development. L. A. Tanskey received compensation from the IFIC Foundation for developing the manuscript. E. A. Sanders and M. Smith Edge were full-time and full-time employees, respectively, of the IFIC Foundation during the development of the paper. The IFIC Foundation is a 501(c) (3) not-for-profit public education organization that is primarily supported by the broad-based food, beverage, and agricultural industries and also receives a variety of government grants.
FUNDING/SUPPORT This research was commissioned and funded by the International Food Information Council (IFIC) Foundation and conducted by Matthew Greenwald & Associates, Washington, DC. More details about the IFIC Foundation can be found at www.foodinsight.org/pages/faqs.
ACKNOWLEDGEMENTS The authors acknowledge the following people for their contributions to this manuscript: Doug Kincaid, research director, Greenwald & Associates; Kimberly A. Reed, JD, president, IFIC Foundation; David B. Schmidt, CEO, IFIC Foundation (at the time of development), principal, Schmidt Commonwealth Strategies, LLC, Leesburg, VA; and IFIC Foundation Trustees Regan Bailey, PhD; Lowell Catlett, PhD; and Fergus Clydesdale, PhD.
360
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
March 2017 Volume 117 Number 3
Topics of Professional Interest
The IFIC Foundation Food & Health Survey 2015: 10-Year Trends and Emerging Issues
T
HE NUTRITION AND DIETETICS community is committed to improving the health of the population. To maximize our effectiveness in working toward that goal requires an understanding of the factors that determine individual behaviors in an increasingly complex world and an understanding of how behaviors, attitudes, and beliefs change over time. The year 2015 marks the 10th consecutive Annual Food & Health (F&H) Survey conducted by the International Food Information Council (IFIC) Foundation. It provides a unique resource to track key nutrition, food, and health trends annually and over a decade that has experienced numerous changes in consumer behavior, environmental concerns, and the nature of nutrition communications. The data provide an opportunity to identify positive trends and areas in which new approaches are needed. It allows us to explore current consumer food and nutrition behaviors, long-term changes since the survey was first administered in 2006, and progress toward achieving changes recommended in the 5-year retrospective published in 2013.1 This manuscript focuses on five areas with clear implications
This article was written by Jeanne P. Goldberg, PhD, RD, a professor, and Lindsay A. Tanskey, MS, MEd, a doctoral candidate, both at The Friedman School of Nutrition Science & Policy, Tufts University, Boston, MA; Elizabeth A. Sanders, MPH, RD, an associate director, International Food Information Council Foundation, Washington, DC; and Marianne Smith Edge, MS, RD, LD, FADA, FAND, president, MSE & Associates, LLC, Owensboro, KY; at the time of the study, she was a senior advisor, Nutrition and Food Safety, International Food Information Council Foundation, Washington, DC. http://dx.doi.org/10.1016/j.jand.2016.05.012 Available online 6 July 2016
ª 2017 by the Academy of Nutrition and Dietetics.
for practitioners. The full survey results are available on the IFIC website.2
METHODS IFIC Foundation F&H surveys conducted from 2012 to 2015 were administered by Greenwald & Associates, using Research Now’s consumer panel. The 2006 to 2010 surveys were administered by Cogent Research. A detailed description of survey methods is provided in the 5-year retrospective, along with a summary of overarching themes for each.1 The 2015 national online survey explored how consumers evaluate health in relation to other factors that affect their lives. It was completed by 1,007 Americans aged 18 to 80 years. Results were weighted using a multi-stage, multivariate weighting scheme so that the results are reflective of the US population as seen in the 2014 Current Population Survey. The stages include weighting the data by 1) education by age by sex, 2) ethnicity by age by sex, and 3) region by age. Before administration, cognitive interviews were conducted to ensure that the language of the questions would be understood by respondents.
Americans’ Perceptions of Health Do Not Align with Self-Reported Height and Weight On the 2015 survey, 17% of respondents ranked their health as excellent, 40% as very good, 33% as good, 8% as fair, and just 1% as poor. Positive personal health ratings were associated with being female, having a college degree, and having a higher income. An excellent health rating was also associated with a lower body mass index and absence of noncommunicable diseases. These findings are in close agreement with those from the 2012 National Health Interview Survey, conducted annually by the Centers for Disease Control and Prevention, that collects similar information through in-person interviews.3
Perceived health status has been assessed on the F&H survey annually since 2006. Responses were consistent from 2006 to 2011. A shift toward better perceived health was observed in 2012, and it has remained steady thereafter. The most plausible explanation is that in 2012, a different contractor administered the survey, and the order of response categories was reversed. “Excellent” became the first choice, and “poor” became last. This explanation seems defensible because findings have remained consistent within the two time spans, and the demographics of the survey respondents have remained reflective of the overall US population. As expected on the 2015 survey, respondents who reported a normal weight ranked their health as excellent or very good more frequently (73%) than those who reported that they were overweight or obese (54% and 45%, respectively). However, a large proportion of overweight or obese respondents did not perceive their weight status to be related to their overall health status (Figure 1). The disconnect between weight status and perceived health has been documented in some population subgroups for more than 20 years.4-6 Clear evidence suggests that maintaining one’s recommended weight or losing weight can positively impact length and quality of life. Moderate weight loss has been associated with improved physical health7 and with prevention and treatment of type 2 diabetes8 and cardiovascular disease.9 The health benefits of weight loss are endorsed by major health organizations.9-12 Many approaches have produced short-term weight loss, but significant weight maintenance over time remains an elusive goal for most dieters.13,14 Unfortunately, sensible approaches to weight loss are frequently lost in the abundance of inaccurate information available to consumers, increasingly communicated online.15 To improve weight loss and weight maintenance outcomes, strategies to
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
355
PRACTICE APPLICATIONS Normal or Low BMI
Excellent
27%
Very Good
46%
Good
23%
Overweight BMI
Excellent
16%
Obese BMI
Excellent
8%
Very Good
38%
Very Good
36%
Good
37%
Good
39%
Fair
3%
Fair
Poor
1%
Poor
8% 1%
Fair Poor
14% 3%
Figure 1. Perceived health status by self-reported weight status, International Food Information Council Foundation Food & Health Survey, 2015. motivate individual behavior change are essential. This requires understanding consumer perceptions about what motivates them to stay on track. In the 2015 survey, three factors were equally important motivators for weight management: improved physical appearance, increased energy and physical mobility, and improved health and wellbeing. Physical appearance has consistently been the top motivator for weight loss and maintenance, especially among women, increasing slightly from 51% in 2011 to 56% in 2015. Increased energy has remained the second most important factor, but the percentage of individuals who chose this has risen from 43% in 2011 to 55% in 2015. Most striking is the change in the relative importance of improved health and wellbeing, which has risen from 41% in 2011 to 53% in 2015, surpassing increased self-esteem as the third most frequent motivational factor. These three factors—appearance, energy, and health—represent the top motivators of weight management for 85% of respondents. However, only 21% of respondents selected all three, suggesting that intended behavioral drivers are quite individual. Respondents were asked to select factors that would contribute to or have contributed to successful weight loss or maintenance. The top factors—changing the types and amounts of foods eaten and getting adequate physical activity— remained consistent from 2011 to 2015. The percentage of respondents who said 356
they controlled higher-calorie foods and beverages increased from 15% in 2011 to 30% in 2015. Other strategies, such as regular weighing and tracking calories, remained stable. Key barriers to weight loss in the 2015 survey included lack of willpower, not seeing results quickly enough, stress, lack of time and energy, and cost. These findings changed little since 2011. Notably, disliking healthful foods and beverages and disliking physical activity were less important weight loss barriers, each at 13% in 2015. The latest IFIC Foundation survey provides important guidance for nutrition and dietetics practitioners working with a wide range of individuals and larger audiences. Drawing on the Stages of Change constructs from the Transtheoretical Model,16 the survey inquired about participants’ readiness to improve their diets. In both 2014 and 2015, more than 50% reported taking action to improve their diet; an additional 36% said they had maintained at least one healthier behavior for more than a year. These findings suggest a high level of interest in healthier diets and a willingness to make and maintain changes. What these changes were and what consumers believe would be the next logical step in improving their diets remains to be explored. Motivational interviewing offers promise at both individual and group levels. It focuses on client-centered perspectives rather than on framing issues through the practitioner’s lens. The role of the practitioner shifts from providing information to
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
enabling individuals to make their own decisions about what to change and how to proceed. The approach has been adapted to working with groups as well as individuals.17 In larger groups and whole communities, the importance of understanding and responding to the needs and desires of the target population cannot be overstated.18
How Americans Get Food to the Table: An Emerging Picture Suggests Diverse Approaches Americans have access to a food supply that can deliver a diet that is nutritionally adequate and gastronomically satisfying. Whether diets meet both goals depends on myriad factors specific to individuals and their unique environments. The 2015 F&H survey found that 19% of respondents spend less than 15 minutes preparing dinner, 52% spend 15 to 44 minutes, and 29% spend 45 minutes or more. Men spent the least amount of time in the kitchen. Hispanics and African Americans were more likely than whites to spend an hour or more preparing dinner. Improved diet quality has recently been associated with more time spent in the kitchen.19 One question not addressed in this research is the influence of food preparation skills on diet quality. Theoretically, individuals with greater skills should be better able to select foods and prepare meals that are more healthful and well-accepted than those with fewer skills. One must March 2017 Volume 117 Number 3
PRACTICE APPLICATIONS 90%
Expiration date
80%
Nutrition Facts panel
70%
Ingredients list
60%
Servings size and amount per container
50%
Calorie and other nutrition information Brand name
40% Cooking instructions/preparation time
30%
Statements about nutrition benefits
20%
Country of origin labeling
10%
Statements about health benefits
0% 2007
2008
2009
2010
2011
2012
2013
2014
2015
Statement about the absence of certain food ingredients
Figure 2. Changes in consumer use of packaging information over time, International Food Information Council Foundation Food & Health Survey, 2007-2015.
better understand how food handling skills affect diet quality, and how they vary among different subgroups. The food supply has changed dramatically over the past several decades, with increased availability of prepared and partially prepared foods.20 This has enabled Americans who can afford to, and choose to do so, to spend less time in food preparation.21 The 2015 F&H survey shows that 51% of Americans rank convenience as the most important benefit of processed foods. Prolonged freshness (44%) and greater affordability (40%) were also important. A 2010 Harris Poll suggests that as many as 40% of Americans prepare meals at home at least five times per week, and threequarters of those who prepare meals at home use some pre-prepared foods and appliances that ease preparation and cleanup.22 For these individuals, skill in selecting among available choices is critical. Identification of healthful, affordable processed foods that facilitate preparation can help consumers with limited time and resources. The role of pre-prepared and convenience items in home-prepared meals deserves further study. How can this evidence guide interventions to improve diet quality among Americans? Promoting increased time in the kitchen may be unrealistic. When asked how they would spend an extra 4 hours every week, only 11% of participants in the March 2017 Volume 117 Number 3
2015 F&H survey said they would use the additional time for cooking. This group was already spending at least 45 minutes preparing dinner. Given the low level of interest in spending more time in the kitchen, focusing on food selection in the marketplace and on skills to facilitate more efficient preparation of healthful family meals appears to be more realistic. Registered dietitian nutritionists (RDNs) need to understand how family meals are assembled and focus on family preferences, constraints, and behaviors. For some households, educational efforts will continue to address foods prepared from scratch, whereas others will need to consider approaches that integrate prepared and convenience foods and restaurant meals. The food industry continues to generate new ideas and products to help streamline food preparation for consumers. RDNs must continue to monitor these innovations to guide their clients toward healthier choices.
Knowing More and Using That Knowledge Effectively: Helping Consumers Make the Most of Available Nutrition Information Questions about consumer use of labeling information have been included since the second F&H Survey in 2007, and they provide some interesting observations. The three most frequently used types of nutrition information have consistently been the
expiration date, Nutrition Facts Panel, and ingredients list. Although small shifts have occurred from year to year, since 2013 focus on labeling information has declined. Specifically, use of expiration date information peaked in 2013 and declined sharply thereafter. In addition, fewer consumers are looking at the Nutrition Facts panel, ingredients list, and calorie and other nutrition information (Figure 2). Increasingly, participants have completed the survey on a mobile phone, which is less user-friendly than a large screen for completing questions with a large number of responses. That may have affected results. The F&H survey does, however, provide reason to be optimistic about how consumers use nutrition information. More than 50% of respondents said they try to consume whole grains, fiber, and protein. More than 40% make an effort to get enough calcium. With the exception of protein, which most of the population consumes in adequate amounts,23 these nutrients of concern are consistent with those that health professionals acknowledge are consumed in amounts outside of recommended ranges.24 Respondents were most likely to try to limit or avoid added sugars, sodium, trans fats, saturated fats, calories, cholesterol, low-calorie sweeteners, and fats and oils. Given media coverage of the consequences of excess consumption of added sugars, sodium, trans and
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
357
PRACTICE APPLICATIONS saturated fats, and calories, that Americans say they try to avoid these food components is not surprising. In general, Americans seem to report behaviors consistent with widely disseminated nutrition advice. The data suggest several lines of inquiry about how or whether selfreported behaviors with respect to specific nutrients or food components (eg, whole grains or saturated fat) are integrated to drive behavior and how they affect diet quality overall. The example of whole grains illustrates this point. First, to what extent is selfreport of wanting to consume more whole grains associated with consumption? Second, among those who report wanting to consume more whole grains, do they select more? Third, what is the overall nutrient profile of the whole-grain products they purchase? Is front-of-package labeling more likely to lead to choice of nutritious whole-grain foods? Finally, how are different groups of consumers using nutrition labels to guide purchase decisions? That information could inform the targeting of messages for different groups. The single most important question is not whether people use information on nutrition packages, but how they use it in the behavioral context. We do not know, for example, whether those individuals who focus primarily on calories to guide their choice of individual items put that information into the context of portion size and, more importantly, whether this information guides consumption. Choosing a balanced diet goes beyond reading food labels. Consumers must understand the nutritional contributions of foods with no labeling, including fruits and vegetables and many protein-rich foods, including meat and seafood. Furthermore, arguments for choosing foods rather than supplements can apply equally well to guiding consumers to use whole foods rather than individual nutrients in foods as the basis of their food choices.25,26 Using individual nutrients or components in food as the key to food choice, however well intentioned, can subvert the goal of achieving a well-balanced diet. RDNs must empower consumers to look beyond a single indicator of a food’s nutritional value and to focus on total diet. With a unique and in-depth knowledge about foods and how to 358
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
prepare them, they are uniquely positioned to help clients integrate and use food and nutrition information effectively. In formulating communications, they must respect the clear consumer demand for positive guidance rather than messages about foods to avoid.
Emerging Issues in the Food Choice Equation: Sustainable Diets and Technological Changes in Food Production Four factors are known to guide food choice for most consumers. Taste remains fixed in first place. Price ranks second, and it tends to fluctuate with economic trends. Healthfulness is next, and it has remained in third place since the first IFIC Foundation survey in 2006. Finally, convenience has remained in fourth place. This evidence must be integrated with current knowledge about how consumers want to learn about food. Consistent with earlier findings, the 2015 survey showed that consumers prefer positive messaging focused on integrating healthy foods into the diet, rather than negative messaging focused on foods to restrict or avoid. This preference has increased from 56% in 2009 to 78% in 2013 and has remained stable. This observation is also reflected in the 2011 Academy of Nutrition and Dietetics (Academy) “Nutrition & You” survey.27 A newer addition to the equation is individual perception of the link between what people eat and the environment. A relatively small percentage of respondents in the 2015 IFIC survey (20%) said they focused a lot on whether their foods and beverages were produced in an environmentally sustainable way, whereas 30% paid no attention to the issue. That focus has not changed significantly from the prior 2 years. Parents and millennials (aged 18-34 years) were relatively more likely to say they thought a lot about the environmental sustainability of food production methods. Responses to detailed questions suggest that consumer knowledge of these issues is limited. For example, when presented with a list of factors that might or might not be included in a description of sustainable foods, fewer than one in four thought that sustainable foods “have a smaller impact on the environment.” Just 13% thought that March 2017 Volume 117 Number 3
PRACTICE APPLICATIONS sustainable foods created less food waste or used fewer natural resources to produce. When asked how much they thought about how their foods and beverages are farmed or produced, just one in four respondents said they thought about it a lot, whereas half said they thought about it a little. Parents, women, and younger adults were more likely to give a lot of thought to these issues. Understanding of labeling terms related to food production is limited. Despite the lack of an official definition of “natural,” that term is most likely to influence purchase decisions (40%). Nearly an equal number of respondents (37%) said they were not influenced by sustainability-related descriptors on the food label. Consumer understanding of biotechnology is similarly limited. More than one-third of respondents said they were not sure what purpose biotechnology serves in producing foods and beverages. The gap in public understanding in both areas suggests a need for balanced communication going forward. RDNs are uniquely positioned to communicate accurately about these topics— specifically, how they relate to food selection and preparation. This will require that, as professionals, they keep up to date with changes in food production and policies that directly affect consumers.
The Mismatch between Frequently Used Sources of Health Information and Trusted Sources of Health Information Continues Since it began in 2006, the F&H survey has explored consumer trust in sources of diet and health information. In the most recent survey, respondents were asked to identify up to three trusted sources. Seventy percent chose their personal health care professional, 34% chose friends or family members, and 25% put their trust in information from the US government or television food experts and food, health, or nutrition bloggers. Thirty-two percent turn to family and friends as a resource to improve the healthfulness of their diet; only 20% reported having seen a medical professional, and just 6% reported having seen an RDN. With regard to weight control, four of five respondents
March 2017 Volume 117 Number 3
said they were working to lose or maintain weight, but only 5% said that seeing a health professional helped or would help them meet their goals. The 2011 Academy survey produced similar results.27 Sixty-seven percent of respondents identified television as the top source of nutrition information, followed by the Internet at 40%. Only 16% of respondents got information from their doctor and just 1% from RDNs. These data suggest that we need to do more to promote RDNs as preferred and most widely used sources of nutrition guidance. However, speculating that respondents did not consider the fact that these experts are the information source in many media outlets is reasonable. This question deserves further exploration. To reach a larger audience, RDNs must meet consumers where they access information, particularly on television and the Internet. Promoting RDNs as the most credible sources of nutrition information has long been a goal of the Academy, but much more needs to be done. The rise of social media has intensified the challenge of separating professional expertise from pseudoscience and unfounded opinion. That trend will continue. To rise above the clutter of misinformation, RDNs must be able to interpret the results of late-breaking research as quickly as their noncredentialed counterparts. They must do it in the context of the larger body of knowledge in relevant areas and continue to reinforce the underlying principle that nutrition science is evolutionary, not revolutionary. They must consider the potential value of new technologies in connecting and interacting with consumers. RDNs must be ready to provide consumers with direct, clear, and actionable messages that give them the confidence to make decisions about what to eat, how much to eat, and what to avoid. This is what differentiates the unique value of nutrition and dietetics practitioners.
THE CHALLENGE AHEAD The IFIC Foundation F&H Survey has provided a valuable context for understanding the determinants of food choice in the United States for 10 years. It has allowed researchers and communicators to understand the more stable influences on individual choices
and the emerging issues that affect behavior. The data provide guidance for nutrition and dietetics practitioners to work with clients more effectively and for researchers to enhance our understanding of the issues. Several limitations of the survey should be acknowledged. Its cross-sectional nature limits conclusions about changes over time or causation. The sample size is adequate to address many issues, but it includes no exploration of food insecurity or consideration of individuals with special health needs. Nonetheless, it provides important insights about many issues that affect the diets of millions of Americans. The 5-year retrospective1 challenged RDNs to increase their role as the major resource for consumers to obtain accurate, actionable, and relevant nutrition information. Since then, the challenge to reach individuals and groups has grown. The communication landscape has become increasingly cluttered with information of varying quality. The list of issues that must be considered in the context of obtaining a healthy diet has expanded to include factors that affect specific groups of individuals, such as those following vegan, gluten-free, and other specialized dietary patterns. It extends to growing concern over the sustainability of the food supply and the related issue of food waste, emerging technologies in food production, and more. In short, the challenge to the nutrition and dietetics practitioner of providing actionable, accurate, and relevant information will continue to grow. Going forward, nutrition communicators must stay abreast of the latest evidence-based nutrition guidance, as well as emerging issues that affect food choice and availability. They must tailor messages to their audience, and draw on their creative resources to develop communications that influence behavior, and subsequently health, in a sustained way.
References 1.
Hornick BA, Childs NM, Smith Edge M, Kapsak WR, Dooher C, White C. Is it time to rethink nutrition communications? A 5-year retrospective of Americans’ attitudes toward food, nutrition, and health. J Acad Nutr Diet. 2013;113(1):14-23.
2.
International Food Information Council Foundation. The 2015 Food & Health Survey: Consumer Attitudes toward Food Safety, Nutrition & Health. http://www.
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
359
PRACTICE APPLICATIONS foodinsight.org/2015-food-health-surveyconsumer-research. Accessed March 2, 2016. 3.
4.
Blackwell DL, Lucas JW, Clarke TC. Summary health statistics for U.S. adults: National health interview survey, 2012. Vital and health statistics. Series 10, Data from the National Health Survey; 2014:1-161. Loprinzi PD. Factors influencing the disconnect between self-perceived health status and actual health profile: Implications for improving self-awareness of health status. Prev Med. 2015;73:37-39.
5.
Goldberg J, Rudd RE, Dietz W. Using 3 data sources and methods to shape a nutrition campaign. J Am Diet Assoc. 1999;99(6):717-722; quiz 723-714, 776.
6.
Gregory CO, Blanck HM, Gillespie C, Maynard LM, Serdula MK. Perceived health risk of excess body weight among overweight and obese men and women: Differences by sex. Prev Med. 2008;47(1):46-52.
7.
8.
9.
Warkentin LM, Das D, Majumdar SR, Johnson JA, Padwal RS. The effect of weight loss on health-related quality of life: Systematic review and meta-analysis of randomized trials. Obes Rev. 2014;15(3): 169-182. Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. J Acad Nutr Diet. 2015;115(8):1323-1334. Artinian NT, Fletcher GF, Mozaffarian D, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation. 2010;122(4):406-441.
10.
Centers for Disease Control and Prevention. Losing Weight. http://www.cdc.gov/ healthyweight/losing_weight/. Accessed January 4, 2016.
11.
Seagle HM, Strain GW, Makris A, Reeves RS; American Dietetic A. Position of the American Dietetic Association: Weight management. J Am Diet Assoc. 2009;109(2):330-346.
12.
Jortberg B, Myers E, Gigliotti L, et al. Academy of Nutrition and Dietetics: Standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in adult weight management. J Acad Nutr Diet. 2015;115(4):609-618. e640.
13.
Bray GA, Wadden TA. Improving longterm weight loss maintenance: can we do it? Obesity. 2015;23(1):2-3.
14.
MacLean PS, Wing RR, Davidson T, et al. NIH working group report: Innovative research to improve maintenance of weight loss. Obesity. 2015;23(1):7-15.
15.
Modave F, Shokar NK, Penaranda E, Nguyen N. Analysis of the accuracy of weight loss information search engine results on the internet. Am J Public Health. 2014;104(10):1971-1978.
16.
Di Noia J, Prochaska JO. Mediating variables in a transtheoretical model dietary intervention program. Health Educ Behav. 2010;37(5):753-762.
17.
Wagner C, Ingersol K. Motivational Interviewing in Groups. New York, NY: The Guilford Press; 2013.
18.
Goldberg J, Peterson L. Role of communication in changing nutrition behaviors to promote healthy lifestyles. In: Rippe JM, ed. Lifestyle Medicine, Second Edition. Boca Raton, FL: CRC Press; 2013.
19.
Monsivais P, Aggarwal A, Drewnowski A. Time spent on home food preparation and
indicators of healthy eating. Am J Prev Med. 2014;47(6):796-802. 20.
Freeland-Graves JH, Nitzke S. Academy of Nutrition and Dietetics. Position of the Academy of Nutrition and Dietetics: Total diet approach to healthy eating. J Acad Nutr Diet. 2013;113(2):307-317.
21.
Folliard JN, Duncan-Goldsmith DM. Opportunities to improve snacks and beverages in schools. J Acad Nutr Diet. 2013;113(9):1145-1151.
22.
Harris Interactive. The Harris Poll: Three in Ten Americans Love to Cook, While One in Five Do Not Enjoy It or Don’t Cook. http:// www.theharrispoll.com/health-and-life/ Three_in_Ten_Americans_Love_to_Cook__ While_One_in_Five_Do_Not_Enjoy_It_or_ Don_t_Cook.html. Accessed January 4, 2016.
23.
Fulgoni VL 3rd. Current protein intake in America: Analysis of the National Health and Nutrition Examination Survey, 20032004. Am J Clin Nutr. 2008;87(5):1554S1557S.
24.
US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans 20152020, 8th edition. Washington, DC: US Department of Health and Human Services.
25.
Lichtenstein AH, Russell RM. Essential nutrients: Food or supplements? Where should the emphasis be? JAMA. 2005;294(3):351-358.
26.
Jacobs DR, Tapsell LC. Food synergy: The key to a healthy diet. Proceedings Nutr Soc. 2013;72(2):200-206.
27.
Academy of Nutrition & Dietetics. Nutrition and You: Trends 2011. http://www. eatrightpro.org/resources/media/trendsand-reviews/trends-survey. Accessed March 18, 2016.
DISCLOSURES STATEMENT OF POTENTIAL CONFLICT OF INTEREST J. P. Goldberg was an International Food Information Council (IFIC) Foundation Trustee at the time of development. L. A. Tanskey received compensation from the IFIC Foundation for developing the manuscript. E. A. Sanders and M. Smith Edge were full-time and full-time employees, respectively, of the IFIC Foundation during the development of the paper. The IFIC Foundation is a 501(c) (3) not-for-profit public education organization that is primarily supported by the broad-based food, beverage, and agricultural industries and also receives a variety of government grants.
FUNDING/SUPPORT This research was commissioned and funded by the International Food Information Council (IFIC) Foundation and conducted by Matthew Greenwald & Associates, Washington, DC. More details about the IFIC Foundation can be found at www.foodinsight.org/pages/faqs.
ACKNOWLEDGEMENTS The authors acknowledge the following people for their contributions to this manuscript: Doug Kincaid, research director, Greenwald & Associates; Kimberly A. Reed, JD, president, IFIC Foundation; David B. Schmidt, CEO, IFIC Foundation (at the time of development), principal, Schmidt Commonwealth Strategies, LLC, Leesburg, VA; and IFIC Foundation Trustees Regan Bailey, PhD; Lowell Catlett, PhD; and Fergus Clydesdale, PhD.
360
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
March 2017 Volume 117 Number 3