My Plate Jounral

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Supplemental Article

Evaluating MyPlate: An Expanded Framework Using

Traditional and Nontraditional Metrics for Assessing

Health Communication CampaignsElyse Levine, PhD, RD1; Jodie Abbatangelo-Gray, ScD2; Amy R. Mobley, PhD, RD3;Grant R. McLaughlin, MA1; Jill Herzog, BA1

ABSTRACT

MyPlate, the icon and multimodal communication plan developed for the 2010 Dietary Guidelines forAmericans (DGA), provides an opportunity to consider new approaches to evaluating the effectivenessof communication initiatives. A review of indicators used in assessments for previous DGA communica-tion initiatives finds gaps in accounting for important intermediate and long-term outcomes. This evalu-ation framework for the MyPlate Communications Initiative builds on well-known and underused modelsand theories to propose a wide breadth of observations, outputs, and outcomes that can contribute to a fullerassessment of effectiveness. Two areas are suggested to focus evaluation efforts in order to advance under-

standing of the effectiveness of the MyPlate Communications Initiative: understanding the extent to whichmessages and products from the initiative are associated with positive changes in social norms toward thedesired behaviors, and strategies to increase the effectiveness of communications about DGA in vulnerablepopulations.

Key Words: MyPlate, dietary guidelines, health communication, program evaluation, nutrition policy(J Nutr Educ Behav. 2012;44:S2-S12.)

INTRODUCTION

In June, 2011, the MyPlate icon and itssupporting multicomponent commu-nications plan were unveiled by theUnited States Department of Agricul-ture (USDA) Center for NutritionPolicyand Promotion(CNPP) as a plat-form to support the translation of the2010DietaryGuidelines for Americans(DGA).1 MyPlate replaces MyPyramidas USDA's healthy eating communica-tions initiative. Like its predecessors,the Food Guide Pyramid and MyPyra-mid, MyPlate illustrates the foodgroups and is supported by communi-cation tools and materials thatunderlie the DGA.However,accordingto USDA, MyPlate is a substantial

communications departure from theprevious approach. The Pyramid was

designed to be a teaching tool to com-municate the DGA as a whole and rep-resented what and how much to eatover the course of a day. In contrast,the MyPlate icon is a simple, yet pow-erful, visual cue to prompt consumersto think about their food choicesacross food groups and to builda healthy plate at meal times.2 Tothat end, MyPlate is part of a multi-modal communication strategy thatincludes the MyPlate Web site withthe SuperTracker tool to personalizefood plans, consumer educationalmaterials and e-tools, social media en-gagement, and a partnership initiativeto help coordinate and disseminateconsistent messages of the DGA.1,3

The MyPlate initiative has been de-

signed for maximum visibility. Likethe USDA efforts that preceded it,

MyPlate will be incorporated intohealth curriculum resources createdfor nutrition education purposes forchildren and adults, translated intoseveral languages, and promoted bynutrition communicators, educators,and the food industry. The MyPlatecommunications initiative also shareswith its predecessors high expecta-tions for performance, and the evalua-tion of its effectiveness will bechallengingan aspect shared by allhealth communication campaigns.Evaluation must be appropriate forits intended use and realistic basedon the stage of the communicationsinitiative. Yet with constant scrutinyof monies allocated for health educa-tion,4 communication researchers

need to demonstrate the worthinessof interventions, especially whencommunication plan componentshave indirect connections to long-term goals. Indeed, when it comestime to re-examine the DGA and thecommunication tactics, how will re-searchers know whether the MyPlateinitiative is effective? How will the ini-tiative's success be measured, and overwhat period of time?

The objective of this manuscript isto propose a framework for evaluating

the DGA communications initiative,

1Booz Allen Hamilton, McLean, VA2Summit Research Associates, New York, NY3Department of Nutritional Sciences, University of Connecticut, Storrs, CT

STATEMENT OF POTENTIAL CONFLICT OF INTEREST AND FUNDING/

SUPPORT: See page S10.

Address for correspondence: Elyse Levine, PhD, RD, Booz Allen Hamilton, 1 Preserve

Parkway, Rockville, MD 20852; Phone: (240) 453-5387; Fax: (301) 838-3606; E-mail:

[email protected]

2012 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR

doi:10.1016/j.jneb.2012.05.011

S2 Journal of Nutrition Education and Behavior Volume 44, Number 4, 2012
mailto:[email protected]://dx.doi.org/10.1016/j.jneb.2012.05.011http://dx.doi.org/10.1016/j.jneb.2012.05.011mailto:[email protected]


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including the MyPlate icon, the con-cepts of which can be applied to otherhealth communication efforts de-signed for the general population. Itis hoped that the framework will stim-ulate various approaches to evaluatingthe effectiveness of the DGA commu-nication and highlight the impor-

tance of even small changes thatoccur before long-term goals arereached, for example, changes in per-ceptions of what a healthy amountof meat looks like for a meal. This pro-cess will, in turn, inform improvementof the initiative and provide a widertoolbox to share lessons learned. Tobuild the case for the framework, thenext section summarizes challengesof evaluating health communicationcampaigns and shows how communi-cation initiatives built around DGA

serve as good case studies. This sectionis followed by the proposed frame-work for evaluating the MyPlate com-munication initiative and a discussionon considerations for acceptableevidence of effectiveness in healthcommunications. Finally, applica-tions for the framework are suggested,focusing on areas that would advanceunderstanding of the effectivenessof the 2010 DGA communicationsinitiative.

Health Communication

Evaluation Challenges

Hornik notes evaluations of publichealth communication programs willrarely produce the unequivocal evi-dence promised in randomized con-trolled trials of pills.5 This truismcan be explained by 3 main observa-tions. First, many consider behavioralchanges the most important outcomeof communication campaigns, butcommunication most frequently

works as an indirect contributorto be-havior change outcomes.6-8 Forexample, seat belt use was aided bymessages featuring car crashdummies, but real change cameabout through incentives frominsurance companies and click it orticket regulations, which were alsoinuenced by communication toindustry and policy makers.9

Second, in interventions that ndevidence of behavior change attrib-uted to communication, the magni-

tude of the effects is much smaller

than those observed in medical trials.This nding was illustrated bySnyder's systematic analysis of healthcampaigns, which yielded an averageeffect size of about 5 percentagepoints.10 Although often seen as in-sufcient among critics, small effectsizes, she argues, can actually have

a big impact at the population level,particularly in dietary health.

Finally, messages need substantiveexposure and sufcient time to work,yet many health communicationcampaigns cannot achieve the levelof saturation needed to produce mea-surable results.11 Real change, likethat seen in seat belt use, is typicallymeasured over decades, whereasmost behavioral researchers canhope to secure funding for only 3-5years.

The Food Guide Pyramid and itssuccessor MyPyramid serve as goodillustrations of these challenges. Bothgraphics benetted from formative re-search, especially the communicationplan for the MyPyramid infographicsymbol, corresponding consumermes-sages, and Web content.12,13 However,evaluation efforts were scarce, andmeasures that were reported relied ononly a few indicators, as will bediscussed in more detail below.Published ndings indicate that manyAmericans report recognizing thePyramid and having knowledgeof itsspecic recommendations.12,14 Infact, the criterion that most use tojudge the effectiveness of communi-cation about the DGA is dietaryquality among Americans, which didnot improve during the 2-decade reignof the Pyramid.8,15,16 Regardless ofwhether dietary intake is the bestmeasure of effectiveness, the lack ofinformation on other, intermediateoutcomes raises questions that can bebetter addressed within an evaluation

framework. For example, whatexplains the apparent ineffectivenessof MyPyramid and its communi-cations? Was it overly complex? Didit send misleading messages, such asall fats are bad, as was reportedduring news coverage of the MyPlatelaunch?17,18 Despite a lack of information on why, how, and withwhom the MyPyramid communi-cations needed improvement, anexpert roundtable assembled after therelease of the 2010 DGA reached

consensus that consumer messages

around nutrition and especiallyweight loss need to be even simplerthan the past communications of theDGA.8

MyPlate Communication

Initiative

In response to the perceived short-comings of the MyPyramid communi-cations, health professionals hopethat the MyPlate icon and corre-sponding communications will betterbridge the gap between knowledgeand behavior. The agency withprimary responsibility for setting nu-trition policy for USDA and its nutri-tion promotion, USDA's CNPP,developed a comprehensive commu-nication initiative to disseminate the

key messages of the DGA for optimaluse, and it set goals and objectivesfor the effort within the scope oftheory-based communication inter-ventions. The goal of the initiative isto support Americans in buildinghealthy diets.1 The USDA will try toaccomplish this goal by providingan easy-to-understand icon that willhelp deliver a series of healthy eatingmessages that highlight key consumeractions based on the 2010 DGAandempowering people with informa-tion they need to make healthy foodchoices.1

Toward these objectives, the USDACNPP designed the MyPlate icon to bea visual cue prompting consumers tobuild healthy plates at meal times.2

The plate icon with the 5 food groupsit symbolizes (fruit, vegetables, grains,protein food, and dairy food), alongwith a new Web site, were pretestedfor comprehension and overall ap-peal, as were the 7 key selected mes-sages, prioritized from 16 testedmessages.19 The icon and communi-

cations initiative that supportsMyPlate includes a comprehensiveWeb site with interactive featuresand resources for educators, healthprofessionals, and consumers to putthe messages into practice, and 2other elements supported by commu-nication theory. The rst element isa plan to release 1 key message ata time through multiple channels tohelp ensure maximum exposure, rais-ing awareness and building a founda-tion for subsequent messages.3 The

second feature is a 2-level partnership

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plan to help disseminate the messagesthrough a wide range of like-mindedgroups and institutions with closeproximity to the public.

Although using partners to amplifyexposure and reach for public healthmessages can be benecial,20-22 theMyPyramid initiative was criticized

for its over-reliance on industrysources, which could weaken thevalidity of the message.23 TheCommunity Partnerlevel is open toall who wish to help spread the wordthrough their communication vehicles;at the time of writing, the Web site tosign on as a Community Partnercounted over 6,000 individuals and or-ganizations. Organizations committedat the National Partner level, whichincludes over 85 representatives fromhealth associations,research andprofes-

sional organizations, food service andrestaurant chains, the food industry,food retailers, and media with missionsconsistent with the USDA's, providein-kind resources to further the successof the communication initiative.24

Why Develop an Evaluation

Framework for the MyPlate

Communications Initiative?

Grounded in evidence-based nutritionscience and pretested for optimal us-ability, the USDA CNPP used soundpractices to create the MyPlate initia-tive.19 However, current options avail-able for evaluating its effectiveness arelimited. Findings can be gleaned fromnational databases, including theNational Health and Nutrition Exami-nation Survey,25 the Healthy EatingIndex,26 the Centers for DiseaseControl and Prevention's (CDC)Behavioral Risk Factor SurveillanceSystem,27 as well as the InternationalFood Information Council Founda-

tion's annual Food and HealthSurvey.14 Proprietary sources of data,such as Porter Novelli's HealthStyles,28

Gallup-Healthway's Well-Being In-dex,29 and panel data managed bythe NDP Group,30 may provide addi-tional information. Specic questionsthat have been used for previousDGA communication initiatives fromnonproprietary instruments are pre-sented inTable 1.

A quick survey of this compilationshows it taps a limited set of con-

structs. Most items ask about aware-

ness of the DGA and/or MyPyramid,or they alternatively tap the antici-pated long-term outcomesfood con-sumption (eg, how many fruits andvegetables consumed) and measuresof obesity. Thesedata are undisputedlyimportant, but they are insufcient toascertain what works and what needs

improvement. As discussed earlier,food consumption and obesity are, atbest, uncertain measures of communi-cation effectiveness because changesin these outcomes cannot be attrib-uted exclusively to the communica-tions; rather, they result frommultiple determinants includingpolicy and environment. It is furthersuggested that careful tracking of con-tributing factors along a more compre-hensive causal pathway can helpidentify promising elements that can

best contribute to MyPlate communi-cations plan goals, which can also beleveraged in communication initia-tives or campaigns of related intent.

The limited measures availablefrom ongoing national surveys pro-vides an opportunity for partners ofthe MyPlate initiative and academicinstitutions to help evaluate the cam-paign through independent research.The MyPlate effort also offers a newopportunity for partnering organi-zations and nutrition and healtheducators to contribute to a pool ofknowledge that will help developand rene evaluation measures oflarge health communication initia-tives. To that end, a framework is pre-sented to help visualize the breadth ofinterventions and observations thatcan contribute to a fuller evaluationof campaign effectiveness.

A PROPOSED

EVALUATION

FRAMEWORK FOR THEMYPLATE

COMMUNICATION

INITIATIVE

The primary goal of this comprehen-sive, use-focused evaluation frame-work, illustrated in the Figure, is toencourage consideration of a wideperspective of evidence when healthcommunicators seek to measure effec-tiveness of MyPlate and other healthcommunication initiatives. A multi-

faceted evaluation framework is pro-

posed that invites qualitative andquantitative research methods to mea-sure both communications imple-mentation and outcomes. With thisapproach, health communicators canbetter identify the links between pro-gram inputs, activities, and outcomesthat can guide communications im-

provement andhelp to assess the over-all effectiveness of the initiative.

The terms framework andmodel are sometimes used inter-changeably, but for the purpose ofthis article, a framework is dened asarubrictoprovideacommonsetofvar-iables to use in the design, collection,analysis, and application ofndings.31

As described by Ostrom, Withouta common framework to organizend-ings, isolated knowledge does not cu-mulate.Models for health education

research and practice are dened ascausal linkages among a set of con-cepts; models are often informed bymore than 1 theory, as well as by em-pirical ndings.32 To use a familiarand tting metaphor, frameworkshave been compared to maps thatshow thelay ofthe land,theories repre-sent the highways and routes that leadto the destination, and models use 1 ormore theories as the preferred route.For the purposes of this illustration,the institutions that shape recommen-dations andthe communities in whichpeople interact canbe compared to thecities and landmarks that mark prog-ress. Observations at each of theselevels will all contribute toward a col-lective pattern ofwhat works.

Theframework is composed of well-tested elements in the eld of healthinterventions. The structure of a logicmodel is used to organize the majorcomponents into possible sources ofdata and the context from which in-formation will be derived (inputs), an-ticipated interventions (activities),

and expected outcomes. The consen-sus of an expert panel convened atthe CDC posits that campaign plan-ners should use their logic model toidentify issues of relevance to specicaudiences (current beliefs, practices,group identication) before educationefforts commence.6 Messages shouldthen be tailored to meet the needs ofunique segments of the population.

Major classications of researchformative, process, outcome researchare also represented in the model and

inform each key componentof thelogic

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model. Examples of specic questionsrelated to the use-focused evaluationare presented inTable 2.

Formative research assesses the po-tential feasibility and desirability ofplanned program inputs within thecontext of the resources that theMyPlate communications initiativecan leverage to achieve its goals. For-

mative research uses qualitative andquantitative research to obtain stake-holder feedback on knowledge,beliefs, attitudes and practices, moti-vators and barriers to desired out-comes, specic activities or outputsplanned for the campaign, and base-line information to measure changefor specic audiences. It is often an it-erative process of revising and solicit-ing further feedback within theconstraints of the research timeframeand resources. The USDA conducted

formative research to develop the

icon and the messages that supportit from the DGA,19 however, it is ex-pected that more formative researchwill be forthcoming to tailor the useof MyPlate and other communicationinputs for special populations, as wellas to make the best use of emerging orchanging resources (eg, partnerships,new media applications).

Process evaluation is conceptualizedunder the activities header in theframework, and focuses on the imple-mentation of the initiative, assessingthe extent to which all program activ-ities (outputs) are being conducted asplanned. The systematic collection ofprocess information over time willhelp the MyPlate initiative andUSDA partners to modify componentsand activities as needed. Research ef-forts should be designed to answerquestions such as: Is the initiative be-

ing implemented as intended? Is it

reaching intended audiences? Haveexternal factors (policy and otherenvironmental factors that mightinuence nutrition patterns) emergedduring the communication period?Which components are showingmost promise? Are there communica-tion plan elements that need to be al-tered in some way or even eliminated

altogether? Are community-levelpartners receiving the materials andsupport they need to educate popula-tions of special interest?

Outcome research allows identica-tion of links between communicationcomponents and desired outcomes inboth audience knowledge and dietarybehaviors. This research will enableresearchers to answer questions suchas: What are the short-term, interme-diate, and long-term outcomes of theinitiative? Are desired outcomes being

reached and, and to what extent?

Figure. Evaluation framework for the MyPlate communication initiative. BMI indicates body mass index; DGA, Dietary Guidelines for

Americans; USDA, United States Department of Agriculture.



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As discussed earlier, a goal of theframework is to expand knowledgeof important intermediate outcomes,such as changes in self-efcacy forchoosing healthy food, or the numberand quality of organizational partner-ships that promote the messages thatsupport MyPlate. The intermediateoutcomes not only contribute to de-sired long-term outcomes, but theycan be identied as short-term cam-paign successes in and of themselves.The framework illustrates that com-bining process and outcome measures

widens the range of factors contribut-ing to program successes and failures.

Another overarching structure in-corporated into the framework is thesocio-ecological (SE) model, which isreferenced widely with respect toinuences on food choices and wasnotably used in the development ofthe DGA. The SE model provided or-ganizing frameworks for systematicreviews conducted by Contento andby Thomson.7,33 Story et al basedapproaches to healthy food

environments on the SE model,34

and Medeiros et al used the SE modelto develop a logic model for commu-nity nutrition education.35 The inclu-sion of the SE model in the proposedevaluation framework for the MyPlatecommunications initiative acknow-ledges many levels of inuenceaffecting food choices, including indi-vidual, household, and communitydynamics; work and school environ-ments; access to healthy food; poli-cies; and market forces. The SEmodel populates each of the compo-nents of the framework with exam-

ples specic to the MyPlate initiative.In arguing for the importance of

program theory, Contento presentsevidence gleaned from over 300nutrition-related communicationstudies, which suggest that nutritioneducation is more likely to be effectivewhen it . systematically links rele-vant theory, research and practice.7

Thus, the major constructs withineach level of the framework are de-rived from theories of behaviorchange, including the Health Belief

Model,36

the Theory of Reasoned

Action,37 and the Theory of PlannedBehavior38 for studies at the personaland interpersonal level. Theories thatare useful at the levels of environmen-tal settings include Social CognitiveTheory and Diffusion of Innova-tions.39,40 Reciprocal determinism,a concept from Social CognitiveTheory that acknowledges continu-ous interactions between personalfactors and the environment, isillustrated in the framework (Figure)with arrows depicting multiple inter-actions that can be realized for favor-

able behavior change to occur. Thisconcept was also noted by Contento,who emphasized that interactions be-tween biological, behavioral, and en-vironmental factors are at play indiet-related health.7 An expert panelassembled by the CDC also notedthat some mass media communica-tion efforts reverberate at multiplelevels of the sociopolitical environ-mentand thus may change the con-text within which individuals receiveand process campaign messages.6 In

fact, as discussed below, altering social

Table 2. Sample Research Questions for a Use-Based Approach to Evaluation Research

Levels of Influence

Research Type

Formative Process Outcome

Personal/ interpersonal What social media tools

designed to communicate

MyPlate initiative-relatedmessages are desired and

would be used by targeted

populations?

How many MyPlate initiative

social media tools have been

developed?How often are MyPlate initiative

social media tools used by

targeted populations?

Have social media tools

influenced knowledge/

awareness of MyPlateinitiative-related messages?

Environmental How can MyPlate initiative-

related messages best be

incorporated into the school

system (eg, school cafeteria)?

What proportion of institutions

schools, pre-school and after-

school programshave

adopted MyPlate initiative-

related materials/messages?

To what extent have schools

adopted DGA

recommendations? (eg, has

dietary quality of menus for

schools improved?)

Is successful implementation and

adoption of DGA in schools

associated with improvements

in childrens dietary intake?

Systems and policy What are the costs and benefitsof agribusiness to align

systems and policies to

support wide adoption and

maintenance of DGA?

To what extent have agribusinessand manufacturers changed

food ingredients to reflect

DGAs?

To what extent are changes inagribusiness and policy to

support adoption of DGA

associated with improved

dietary quality, decreased

prevalence of overweight and

obesity, and decreased health

care costs?

DGA indicates Dietary Guidelines for Americans.

Note: Selected questions are presented as examples; this is not an exhaustive list.



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norms and popular culture around di-etary attitudes, beliefs, and ultimatelybehaviors is a desired consequence ofthe MyPlate initiative.

At the systems and policy level,theories can be used to assess leverag-ing of public and political will. Thesetheories include Framing Theory, for

which framing is dened as the pro-cess by which people develop a partic-ular conceptualization of an issue orreorient their thinking about an is-sue.41 Framing theory can be usedwith other communication theoriesto examine how changes in the pre-sentation of an issue or an event canproduce (sometimes large) changesof opinion. Logic models, sometimescalled theories of change modelsare also used at this level to help visu-alize how resources and strategies can

be used to achieve change.42

In order to help describe the rangeof possible outcomes that can resultfrom a communications initiativeas far-reaching as MyPlate, the RE-AIM dimensions of reach, efcacy,adoption, implementation, and main-tenance developed by Glasgow andcolleagues could be used.43 The reachand efcacy dimensions capture de-sired impact at the personal/interper-sonal level. Reach refers to theproportion of the target audiencethat was exposed to DGA andMyPlate-related communications,and efcacy refers to the rate of suc-cess, which can include behaviorchange, among those who wereexposed if the guidelines were imple-mented as intended. The dimensionsof adoption and implementation cap-ture impact at the environmental andsystem/policy levels. Adoption refersto the proportion of settings, such asworksites, health departments, orcommunities that adopt theMyPlate-related messages. Implemen-

tation refers to the extent to whichthe intervention is executed as in-tended in the real world. Maintenancerefers to the extent to which MyPlate-related messages and guidelines aresustained over time. This dimensionacts at the personal/interpersonallevel and at the systems and policylevel. All are crucial constructs forevaluating programs intended forwide-scale dissemination. Althoughthe evaluation framework is not de-signed to accommodate scoring or

quantifying the outcomes of the

MyPlate communication initiative tocompare with other programs, as hasbeen suggested by Glasgow et al,43

RE-AIM dimensions, or similar modelsthat focus on overall population-based impact, are useful in their fullassessment of strengths and limita-tions of public health interventions.

So how does one evaluate successfor an iconic communication initia-tive? A multifaceted framework ex-pands the paradigm for determiningcommunications success beyonda singular focus on positive behaviorchanges. In retrospect, MyPyramidcould have been said to be successfulin dimensions of reach to individualsand adaptation by institutions, butnot in other dimensions that areneeded to achieve the anticipatedoutcomes from increased dietary

quality. Although communicationcampaigns can contribute meaning-fully to long-term outcomes,10 thisframework illustrates that successmay also be found in small, positivechanges at each level of the socio-ecological model and within inter-mediate outcomes. Also, it is hopedthat the proposed evaluation frame-work will enhance evidence of suc-cess for the key purposes of healthcommunication initiativesto raiseawareness, increase knowledge ofbenets and risks, shape attitudes,heighten self-efcacy toward desiredactions, and motivate healthfulbehaviors.

The framework also helps identifyhow success for MyPlate communica-tions (or lack of success) depends onthe context of upstream factorsand the downstream effects. Up-stream factors are those that contrib-ute to adverse health practices, suchas low health literacy or poor socio-economic conditions, whereas down-stream refers to interventions that

aim to change adverse behaviors.44

As discussed below in more detail, itis equally important to understandthe mediating effects of upstream fac-tors on downstream effects of MyPlatecommunications.

This explanation does not meanthat health communications havebeen without frameworks. Rather,frameworks can and must evolveover time, in the same way that be-havior change theories such as SocialCognitive Theory39 and Theory of

Reasoned Action37

can be considered

evolutionary renements of the basicknowledge-attitude-behavior model.

DEFINING EVIDENCE IN

EVIDENCE-BASED

HEALTH

COMMUNICATIONEVALUATION

Not surprisingly, there are more struc-tures and processes in place for ad-vancing nutrition science than thereare for the art and science of nutritioncommunication. Frameworks formedical science have evolved to opti-mize evidence-based ndings. Severalorganizations for nutrition profes-sionals, such as the Academy of Nutri-tion and Dietetics, American Societyfor Parenteral and Enteral Nutrition,and health and medical researchagencies including the United StatesAgency for HealthCare Research andQuality, the Cochrane Collaboration,and the Natural Standard ResearchCollaboration, have publishedevidence-based practice guidelines.45-49

Recommendations from the DietaryGuidelines for Americans AdvisoryCommittee are, appropriately, evi-dence based. However, no suchevidence-based or even practice-basedreport exists as it relates to what

works for communicating the DGAand/or MyPlate to change consumerdietary behavior. According to theroundtable discussion summarized byRowe et al, USDA and other govern-ment agencies apply [the] equivalentof clinical judgmentto develop con-sumer guidance and implementationtools.8

Swinburn and colleagues recog-nized the importance of evidence-based/practice-based processes andcampaigns, but they also acknowl-

edged the limitations of what is con-sidered acceptable evidence whenthey developed an evaluationframe-work for obesity prevention.50 CitingRychetnik et al and Kroke et al,51,52

they observed:

The term evidence-baseda termnow quite familiar to health pro-fessionals and policy makershas become somewhat problematicbecause (i) it tends to be under-stood as referring only to frame-works used in evidence-based

medicine

(EBM), which heavily



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weights internal validity as the de-ning characteristic of evidence,and (ii) it largely ignores, andtherefore devalues, the importanceof external validity as well asa host of additional social, politi-cal, and commercial consider-ations that actually drive decision

making on policies and programs.

Similar calls for more comprehen-sive approaches and dimensions tobroaden admissible or appropri-ateevidence of effectiveness, includ-ing contextual and organizationalinformation, as well as informed opin-ion,43,50 have been noted outside ofhealth initiatives. An example of thistype of thinking to advance mathand science teaching was articulatedin the National Science Foundationpublication Footprints: Strategies forNon-Traditional Evaluation.53 The titleof this compilation refers to the elu-sive nature of evidence of a program'simpact. The introduction suggests thefollowing questions as indicators forknowing (p. 5):

How do we know we have collectedall the evidence? Where are thelikely places to look for missing ev-idence? For example: What are theuntouched areas of research?What is not being done or is being

done ineffectively? Are there keytarget groups that are not beingserved or are being served inade-quately? What rival hypothesescan we formulate, e.g., wherewould we have been if this programdid not exist?

These questions are especially rele-vant for public health communica-tion initiatives like MyPlate, andthey support the need for an inclusiveframework that encourages applica-tion of a greater diversity of models

and theories to health communica-tion and its evaluation. The CDC's ex-pert panel recommended exploringa wide range of theories, which pur-portedly are currently underused, in-cluding communication theories thataddress attention, attitudes, and sub-jective norms;54 theories of languagecomprehension and information pro-cessing;55 and theories examining theeffects of emotion on communica-tion.56 Social network theory57-59

and network analysis60 also hold un-

realized promise for illuminating the

social dynamics within which com-munication operates. The ideationmodel,61 which takes into accountcognitive, emotional, and social fac-tors and is frequently used abroad,also has great potential use withinUS-based studies. Further, Davis sug-gests that the outcomes derived from

using the Memorable Message Frame-work62 have the potential to enhancecampaign evaluation efforts and evenredene how we measure campaignsuccess.63 These theories and modelsare amenable for a use-focused evalua-tion approach, and their applicationscan t within the proposed frame-work for evaluating the MyPlate com-munications initiative illustrated inthe Figure. Used collectively, theysupport the basic premise of healthcommunication theory as detailed

earlier: that it is important to collectevidence of small changes occurringalong the pathway toward long-termgoals.

What More Should be

Measured, and in What

Context?

Beyond recall of initiative messagesand components and reportedchanges in diet-related behaviors, theauthors suggest more attention to

overlooked measurement opportuni-ties that can provide evidence ofsuccess particular to the MyPlatecommunication effort.

Focus on social norms. Having animpact at the level of social normsshould be considered an important in-termediary outcome for the MyPlateinitiative, and its evidence shouldthus be identied as markers ofcampaign success. The icon status ofMyPlate is a strength of the initiative

that is challenging to measure, as thefootprints are often woven intothe very fabric of society (vis a vispop culture and secular trends) ratherthan easily identied in traditionaldata sources. However, evidenceabounds of social normalization ofDGA. For example, Sesame Street'sCookie Monster singing that ACookie is a Sometime Food echoedthe anytime and sometime foodconcepts associated with the Pyramidmessages and responded to a growing

awareness that a popular children's

character eating only cookies was nolonger acceptable in a child obesityepidemic.64 In charting the pervasive-ness of the MyPlate icon resultingfrom efforts, researchers may considerindicators of cultural adjustment thatcan be used cumulatively for trackingnational sentiment: general refer-

ences to MyPlate in pop culture (socialmedia and traditional media venuementions, including both intendedand unintended product placementwithin programming, etc); smart-phone and other electronic mediaapplications; active counter-movement activities and rhetoric(for example, Harvard School of Pub-lic Health's alternative to the USDA'sMyPlate, Healthy Eating Plate);65

environmental scans to track in-creased depictions of meals that look

like the DGA; specic policy outcomes(eg, subsidization of healthy food andtaxation of unhealthy food); changesin sentiment toward agriculturalsubsidies and nutrition program regu-lations that do not reect DGA;changes in food manufacturing prac-tices; and/or changes in fast-food res-taurant menus to be more inclusiveof DGA recommendations.

This list is by no means exhaustivefor possible footprints left by MyPlatein the culture, but hopefully theseideas can inspire creative means of ac-counting for the initiative's potentialto affect social norms.

Focus on vulnerable populations.Another area that is often overlookedwhen evaluating health campaignsfor the general public is the effective-ness with vulnerable populations. Itis hoped that research on the effec-tiveness of the MyPlate communica-tion initiative will be conductedamong populations in greatest need

of healthier food consumption, in-cluding those with low health liter-acy, low socioeconomic status, and/or with language barriers. Few exam-ples of this focus on upstream fac-tors that mediate food choices canbe found in the literature; a notablestudy conducted by Zoellner et al inthe Lower Mississippi Delta illustratesthe need for greater attention tosocioeconomic status and culturalbackground, which mediate the effec-tiveness of campaigns like MyPlate.66

A survey of 177 adults from the region



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revealed that only 12% of adults sur-veyed could identify the MyPyramidgraphic about 2 years after it was re-leased. The authors noted that the In-ternet was the least used and leasttrusted source of nutrition informa-tion among the respondents, yetMyPyramid was the cornerstone of

the DGA communication campaign.However, more recent work indicatesthat some segments of the low-income population are using theInternetto search for nutrition infor-mation.67 Thus, several factors needto be taken into account to tailor com-munication strategies to the needsand preferences of vulnerable audi-ences. In terms of identifying the the-oretical underpinnings of a logicmodel for a campaign, one must alsoconsider whether factors of interest

will operate as predicted among eth-nic minority and/or limited resourcepopulations as they will among gen-eral audiences. If not, logic modelsand measures should be adjusted,and supplemental theories incorpo-rated (such as theories of culturalassimilation).6

Expand the range of strategic analy-ses. Improved understanding of theeffectiveness of MyPlate across theframework can be realized with analy-ses that account for latent or underly-ing relationships between factors.These methods include analysis ofupstream and downstream factors asmediators, moderators, covariates, orconfounders. All of these terms referto variables that help explain nuancesin the relationship between an inde-pendent variable and the dependentor outcome variable. A good reviewof these analyses as they pertain tonutrition research is presented byLockwood et al.68 Conjoint analysis

is frequently used in marketing,69

but it may also be applicable to studiesof individual decision making aroundfood choices. Conjoint analysis as-sesses how people make tradeoffs insituations in which one has to chooseamong options with criteria of impor-tance, for example, nutrition, taste, orconvenience. Multilevel modeling,hierarchal linear analysis, or mixedmethods70 are analytical methodsthat account for group or nestingeffects, which is important in studies

focusing on environmental settings.

At the systems and policy level,analytical methods such as socialnetworking, which uses a structuralapproach to illustrate patterns of link-ages between actors,58 can help assessthe interplay of institutions and pol-icy makers working for (and against)policy change amenable to the DGA.

IMPLICATIONS FOR

RESEARCH AND

PRACTICE

Assessing the effectiveness of nutri-tion communication initiatives is dif-cult, even for narrowly targetedpopulations in controlled environ-ments like school classrooms. Initia-tives such as MyPlate, which arebroadcast to the general population,

present myriad challenges to ade-quately capture measures of success.The USDA's CNPP has appealed to itspartners and academia to conductstudies and share ndings that assesseffectiveness of this carefully plannedinitiative. The framework presentedhere takes this approach a step furtherby suggesting a version of professionalcrowd sourcing,71 inviting not onlywell-executed studies, but also docu-mentation of MyPlate's effectivenessin practice-based evidence and itsfootprint in policies, markets, andthe culture. By widening the net, it ishoped that health communicatorscan capture more evidence of effec-tiveness. The accumulated evidencecan provide more guidance than iscurrently available in communicatingDGA. Two important areas warrantingmore research and observation areMyPlate's message use in vulnerablepopulations, and signs of its impacton social norms.

The framework is untesteda ma-jor limitationbut it is composed of

validated social science characteris-tics, most notably the overallstructure of a logic model, the socio-ecological model, and constructsfrom theories of behavior change. Itis presented as a starting point to facil-itate hypothesis generation, study de-sign, indicator denition, and datacollection from disparate sources ofevidence for the purpose of docu-menting the effectiveness of MyPlate.It is expected that health communica-tion frameworks will continue to

evolve with the progress of social sci-

ence, and the framework will also berened as information on the perfor-mance of MyPlate communicationsbecomes available.

STATEMENT OF

POTENTIAL CONFLICT OF

INTEREST

This supplemental article was fundedin part by Booz Allen Hamilton(authors EL, GRM, and JH) for themanuscript preparation. JAG works inconsultation with Booz Allen Hamil-ton. The opinions expressed are thoseof the authors and do not necessarilyrepresent the views or recommenda-tions of their respective institutions.

FUNDING/SUPPORT

This work was funded in part by BoozAllen Hamilton. The Society for Nutri-tion Education and Behavior, whichpublishes theJournal of Nutrition Edu-cation and Behavior, is a National Part-ner of the MyPlate CommunicationInitiative.

ACKNOWLEDGMENTS

Our thanks also to Dr. Timothy Tinkerand Jim Bender of Booz Allen

Hamilton, whose review of earlierdrafts provided helpful edits. Finally,the authors thank staff from theUSDA, Center for Nutrition Policyand Promotion, who reviewed anearlier version of the manuscript foraccuracy in describing the MyPlateCommunications Initiative.

REFERENCES

1. United States Department of Agriculture:

Center for Nutrition Policy and Promo-

tion. MyPlate Background. http://www.cnpp.usda.gov/Publications/MyPlate/

Backgrounder.pdf. Accessed January

6, 2012.

2. Post R. A new approach to Dietary

Guidelines communications: make

MyPlate, your plate. Child Obes. 2011;

7:349-351.

3. United States Department of Agricul-

ture, Center for Nutrition Policy and

Promotion. USDA 2010 Dietary

Guidelines Communication Message

Calendar. http://www.cnpp.usda.gov/

Publications/MyPlate/Communications

http://www.cnpp.usda.gov/Publications/MyPlate/Backgrounder.pdfhttp://www.cnpp.usda.gov/Publications/MyPlate/Backgrounder.pdfhttp://www.cnpp.usda.gov/Publications/MyPlate/Backgrounder.pdfhttp://www.cnpp.usda.gov/Publications/MyPlate/CommunicationsMessageCalendar.pdfhttp://www.cnpp.usda.gov/Publications/MyPlate/CommunicationsMessageCalendar.pdfhttp://www.cnpp.usda.gov/Publications/MyPlate/CommunicationsMessageCalendar.pdfhttp://www.cnpp.usda.gov/Publications/MyPlate/CommunicationsMessageCalendar.pdfhttp://www.cnpp.usda.gov/Publications/MyPlate/Backgrounder.pdfhttp://www.cnpp.usda.gov/Publications/MyPlate/Backgrounder.pdfhttp://www.cnpp.usda.gov/Publications/MyPlate/Backgrounder.pdf


10/11

MessageCalendar.pdf. Accessed March

30, 2012.

4. Mendoza M. Nutrition education inef-

fective. USA TodayJuly 4, 2007;http://

www.usatoday.com/news/health/2007-

07-04-fightingfat_N.htm. Accessed

January 4, 2012.

5. Hornik RC. Public health communica-

tion: making sense of contradictory ev-idence. In: Hornik RC, ed. Public

Health Communication: Evidence for Be-

havior Change. Mahwah, NJ: Lawrence

Erlbaum Associates Inc; 2002:1-22.

6. Abbatangelo-Gray J, Cole GE,

Kennedy MG. Guidance for evaluating

mass communication health initiatives:

summary of an expert panel discussion

sponsored by the Centers for Disease

Control and Prevention. Eval Health

Prof. 2007;30:229-253.

7. Contento IR. Nutrition education: link-

ing research, theory, and practice. AsiaPac J Clin Nutr. 2008;17(suppl1):176-179.

8. Rowe S, Alexander N, Almeida NG,

et al. Translating the Dietary Guidelines

for Americans 2010 to bring about real

behavior change.J Am Diet Assoc. 2011;

111:28-39.

9. Williams AF, Wells JK. The role of en-

forcement programs in increasing seat

belt use. J Safety Res. 2004;35:175-180.

10. Snyder LB. Health communication

campaigns and their impact on behav-

ior. J Nutr Educ Behav. 2007;39(2

suppl):S32-S40.

11. Hornik R, Kelly B. Communication

and diet: an overview of experience

and principles. J Nutr Educ Behav.

2007;39(2 suppl):S5-S12.

12. Britten P, Haven J, Davis C. Consumer

research for development of educa-

tional messages for the MyPyramid

Food Guidance System.J Nutr Educ Be-

hav. 2006;38(6 suppl):S108-S123.

13. Haven J, Burns A, Britten P, Davis C.

Developing the consumer interface for

the MyPyramid Food Guidance Sys-

tem. J Nutr Educ Behav. 2006;38(6

suppl):S124-S135.14. International Food Information Council

Foundation. 2011 Food & Health Sur-

vey. Consumer Attitudes Toward Nu-

trition, Food Safety & Health. http://

www.foodinsight.org/Content/3840/

2011%20IFIC%20FDTN%20Food%

20and%20Health%20Survey.pdf. Ac-

cessed January 2, 2012.

15. Krebs-Smith S. Diet Quality of Ameri-

cans in 1994-96and 2001-02as Measured

by the Healthy Eating Index-2005.

Nutrition Insight 37. http://www

.cnpp.usda.gov/Publications/Nutrition

Insights/Insight37.pdf. Accessed January

5, 2012.

16. Krebs-Smith SM, Guenther PM,

Subar AF, Kirkpatrick SI, Dodd KW.

Americans do not meet federal dietary

recommendations. J Nutr. 2010;140:

1832-1838.

17. Carollo K, ABC News Medical Unit.

No more Pyramid: nutritional icon isnow a plate. http://abcnews.go.com/

Health/food-pyramid-food-plate/story?

id13743137. Accessed January 5, 2012.

18. JalonickMC, NBC news. Foodpyramid

dumped for MyPlate. http://www

.msnbc.msn.com/id/43253092/ns/health-

diet_and_nutrition/t/food-pyramid-

dumped-my-plate/. Accessed January

5, 2012.


ture: Center for Nutrition Policy and

Promotion. Development of 2010

Dietary Guidelines for Americans Con-sumer Messages and New Food Icon.

Executive Summary of Formative Re-

search. June 2011; http://www.choose

myplate.gov/food-groups/downloads/

MyPlate/ExecutiveSummaryOfForm

ativeResearch.pdf. Accessed January

4, 2012.

20. Donato KA. National health education

programs to promote healthy eating

and physical activity. Nutr Rev. 2006;

64(2 Pt 2):S65-S70.

21. Pivonka E, Foerster SB, Di Sogra L,

Chapelsky Massimilla D. Industry

Initiatives5 A Day for Better Health Pro-

gram. Bethesda, MD: National Institutes

of Health, National Cancer Institute;

2001.

22. Reich MR. Public-private partnerships

for public health. Nat Med. 2000;6:

617-620.

23. Brownell KD, Ludwig DS. Fighting

Obesity and the Food Lobby. The

Washington Post June 9, 2002. http://

www.washingtonpost.com/ac2/wp-dyn/

A15232-2002Jun7?languageprinter.Ac-


24. United States Department of Agriculture,Center for Nutrition Policy and Promo-

tion. ChooseMyPlate.gov Partnering

Program. http://www.choosemyplate

.gov/partnering-program.html. Accessed

February 11, 2012.

25. Department of Health and Human Ser-

vices, Centers for Disease Control and

Prevention, National Center for Health

Statistics, National Health and Nutri-

tion Examination Survey. National

Health and Nutrition Examination Sur-

vey: questionnaires, datasets, and related

documentation. http://www.cdc.gov/

nchs/nhanes/nhanes_questionnaires.htm.

Accessed March 30, 2012.


ture, Center for Nutrition Policy and

Promotion. Healthy Eating Index.

http://www.cnpp.usda.gov/healthyeating

index.htm. Accessed March 30, 2012.


ture, Centers for Disease Control andPrevention, Office of Surveillance, Ep-

idemiology, and Laboratory Services,

Public Health Surveillance Program

Office. Behavioral Risk Factor Surveil-

lance System. http://www.cdc.gov/

brfss/. Accessed March 30, 2012.

28. Centers for Disease Control and

Prevention, Porter Novelli. Health

styles survey. http://www.cdc.gov/

healthcommunication/ToolsTemplates/

EntertainmentEd/HealthstylesSurvey

.html. Accessed March 30, 2012.

29. Gallup Inc. Gallup Healthways Well-Being Index. https://www.npd.com/

wps/portal/npd/us/industryexpertise/

foodandbeverage/. Accessed March

30, 2012.

30. NPD Group. Food and beverage mar-

ket research. http://www.npd.com.

Accessed March 30, 2012.

31. Ostrom E. A general framework for an-

alyzing sustainability of social-ecological

systems.Science. 2009;325:419-422.

32. Earp JA, Ennett ST. Conceptual models

forhealth education research and prac-

tice.Health Educ Res. 1991;6:163-171.

33. Thomson C. Fruits, vegetables and be-

havior change: a scientific overview.

Produce for Better Health Foundation.

http://www.pbhfoundation.org/about/

res/pbh_res/. Accessed May 23, 2012.

34. Story M, Kaphingst KM, Robinson-

OBrien R, Glanz K. Creating healthy

food and eating environments: policy

and environmental approaches. Annu

Rev Public Health. 2008;29:253-272.

35. Medeiros LC, Butkus SN, Chipman H,

Cox RH, Jones L, Little D. A logic

model framework for community nu-

trition education. J Nutr Educ Behav.2005;37:197-202.

36. Becker MH. The Health Belief Model

and Personal Health Behavior. San Fran-

cisco, CA: Society for Public Health

Education; 1974.

37. Fishbein M. Readings in Attitude Theory

and Measurement. New York, NY: Wi-

ley; 1967.

38. Ajzen I. The Theory of Planned Behav-

ior. Organ Behav Hum Decis Process.

1991;50:179-211.

39. Bandura A. Social Foundations of

Thought and Action: A Social Cognitive

http://www.cnpp.usda.gov/Publications/MyPlate/CommunicationsMessageCalendar.pdfhttp://www.usatoday.com/news/health/2007-07-04-fightingfat_N.htmhttp://www.usatoday.com/news/health/2007-07-04-fightingfat_N.htmhttp://www.usatoday.com/news/health/2007-07-04-fightingfat_N.htmhttp://www.foodinsight.org/Content/3840/2011&percnt;20IFIC&percnt;20FDTN&percnt;20Food&percnt;20and&percnt;20Health&percnt;20Survey.pdfhttp://www.foodinsight.org/Content/3840/2011&percnt;20IFIC&percnt;20FDTN&percnt;20Food&percnt;20and&percnt;20Health&percnt;20Survey.pdfhttp://www.foodinsight.org/Content/3840/2011&percnt;20IFIC&percnt;20FDTN&percnt;20Food&percnt;20and&percnt;20Health&percnt;20Survey.pdfhttp://www.foodinsight.org/Content/3840/2011&percnt;20IFIC&percnt;20FDTN&percnt;20Food&percnt;20and&percnt;20Health&percnt;20Survey.pdfhttp://www.cnpp.usda.gov/Publications/NutritionInsights/Insight37.pdfhttp://www.cnpp.usda.gov/Publications/NutritionInsights/Insight37.pdfhttp://www.cnpp.usda.gov/Publications/NutritionInsights/Insight37.pdfhttp://abcnews.go.com/Health/food-pyramid-food-plate/story?id=13743137http://abcnews.go.com/Health/food-pyramid-food-plate/story?id=13743137http://abcnews.go.com/Health/food-pyramid-food-plate/story?id=13743137http://abcnews.go.com/Health/food-pyramid-food-plate/story?id=13743137http://www.msnbc.msn.com/id/43253092/ns/health-diet_and_nutrition/t/food-pyramid-dumped-my-plate/http://www.msnbc.msn.com/id/43253092/ns/health-diet_and_nutrition/t/food-pyramid-dumped-my-plate/http://www.msnbc.msn.com/id/43253092/ns/health-diet_and_nutrition/t/food-pyramid-dumped-my-plate/http://www.msnbc.msn.com/id/43253092/ns/health-diet_and_nutrition/t/food-pyramid-dumped-my-plate/http://www.choosemyplate.gov/food-groups/downloads/MyPlate/ExecutiveSummaryOfFormativeResearch.pdfhttp://www.choosemyplate.gov/food-groups/downloads/MyPlate/ExecutiveSummaryOfFormativeResearch.pdfhttp://www.choosemyplate.gov/food-groups/downloads/MyPlate/ExecutiveSummaryOfFormativeResearch.pdfhttp://www.choosemyplate.gov/food-groups/downloads/MyPlate/ExecutiveSummaryOfFormativeResearch.pdfhttp://www.washingtonpost.com/ac2/wp-dyn/A15232-2002Jun7?language=printerhttp://www.washingtonpost.com/ac2/wp-dyn/A15232-2002Jun7?language=printerhttp://www.washingtonpost.com/ac2/wp-dyn/A15232-2002Jun7?language=printerhttp://www.washingtonpost.com/ac2/wp-dyn/A15232-2002Jun7?language=printerhttp://www.choosemyplate.gov/partnering-program.htmlhttp://www.choosemyplate.gov/partnering-program.htmlhttp://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htmhttp://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htmhttp://www.cnpp.usda.gov/healthyeatingindex.htmhttp://www.cnpp.usda.gov/healthyeatingindex.htmhttp://www.cdc.gov/brfss/http://www.cdc.gov/brfss/http://www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/HealthstylesSurvey.htmlhttp://www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/HealthstylesSurvey.htmlhttp://www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/HealthstylesSurvey.htmlhttp://www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/HealthstylesSurvey.htmlhttps://www.npd.com/wps/portal/npd/us/industryexpertise/foodandbeverage/https://www.npd.com/wps/portal/npd/us/industryexpertise/foodandbeverage/https://www.npd.com/wps/portal/npd/us/industryexpertise/foodandbeverage/http://www.npd.com/http://www.pbhfoundation.org/about/res/pbh_res/http://www.pbhfoundation.org/about/res/pbh_res/http://www.pbhfoundation.org/about/res/pbh_res/http://www.pbhfoundation.org/about/res/pbh_res/http://www.npd.com/https://www.npd.com/wps/portal/npd/us/industryexpertise/foodandbeverage/https://www.npd.com/wps/portal/npd/us/industryexpertise/foodandbeverage/https://www.npd.com/wps/portal/npd/us/industryexpertise/foodandbeverage/http://www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/HealthstylesSurvey.htmlhttp://www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/HealthstylesSurvey.htmlhttp://www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/HealthstylesSurvey.htmlhttp://www.cdc.gov/healthcommunication/ToolsTemplates/EntertainmentEd/HealthstylesSurvey.htmlhttp://www.cdc.gov/brfss/http://www.cdc.gov/brfss/http://www.cnpp.usda.gov/healthyeatingindex.htmhttp://www.cnpp.usda.gov/healthyeatingindex.htmhttp://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htmhttp://www.cdc.gov/nchs/nhanes/nhanes_questionnaires.htmhttp://www.choosemyplate.gov/partnering-program.htmlhttp://www.choosemyplate.gov/partnering-program.htmlhttp://www.washingtonpost.com/ac2/wp-dyn/A15232-2002Jun7?language=printerhttp://www.washingtonpost.com/ac2/wp-dyn/A15232-2002Jun7?language=printerhttp://www.washingtonpost.com/ac2/wp-dyn/A15232-2002Jun7?language=printerhttp://www.washingtonpost.com/ac2/wp-dyn/A15232-2002Jun7?language=printerhttp://www.choosemyplate.gov/food-groups/downloads/MyPlate/ExecutiveSummaryOfFormativeResearch.pdfhttp://www.choosemyplate.gov/food-groups/downloads/MyPlate/ExecutiveSummaryOfFormativeResearch.pdfhttp://www.choosemyplate.gov/food-groups/downloads/MyPlate/ExecutiveSummaryOfFormativeResearch.pdfhttp://www.choosemyplate.gov/food-groups/downloads/MyPlate/ExecutiveSummaryOfFormativeResearch.pdfhttp://www.msnbc.msn.com/id/43253092/ns/health-diet_and_nutrition/t/food-pyramid-dumped-my-plate/http://www.msnbc.msn.com/id/43253092/ns/health-diet_and_nutrition/t/food-pyramid-dumped-my-plate/http://www.msnbc.msn.com/id/43253092/ns/health-diet_and_nutrition/t/food-pyramid-dumped-my-plate/http://www.msnbc.msn.com/id/43253092/ns/health-diet_and_nutrition/t/food-pyramid-dumped-my-plate/http://abcnews.go.com/Health/food-pyramid-food-plate/story?id=13743137http://abcnews.go.com/Health/food-pyramid-food-plate/story?id=13743137http://abcnews.go.com/Health/food-pyramid-food-plate/story?id=13743137http://abcnews.go.com/Health/food-pyramid-food-plate/story?id=13743137http://www.cnpp.usda.gov/Publications/NutritionInsights/Insight37.pdfhttp://www.cnpp.usda.gov/Publications/NutritionInsights/Insight37.pdfhttp://www.cnpp.usda.gov/Publications/NutritionInsights/Insight37.pdfhttp://www.foodinsight.org/Content/3840/2011&percnt;20IFIC&percnt;20FDTN&percnt;20Food&percnt;20and&percnt;20Health&percnt;20Survey.pdfhttp://www.foodinsight.org/Content/3840/2011&percnt;20IFIC&percnt;20FDTN&percnt;20Food&percnt;20and&percnt;20Health&percnt;20Survey.pdfhttp://www.foodinsight.org/Content/3840/2011&percnt;20IFIC&percnt;20FDTN&percnt;20Food&percnt;20and&percnt;20Health&percnt;20Survey.pdfhttp://www.foodinsight.org/Content/3840/2011&percnt;20IFIC&percnt;20FDTN&percnt;20Food&percnt;20and&percnt;20Health&percnt;20Survey.pdfhttp://www.usatoday.com/news/health/2007-07-04-fightingfat_N.htmhttp://www.usatoday.com/news/health/2007-07-04-fightingfat_N.htmhttp://www.usatoday.com/news/health/2007-07-04-fightingfat_N.htmhttp://www.cnpp.usda.gov/Publications/MyPlate/CommunicationsMessageCalendar.pdf


11/11

Theory. Englewood Cliffs, NJ: Prentice

Hall; 1986.

40. Rogers EM. Diffusion of Innovations. 4th

ed. New York, NY: Free Press; 1995.

41. Austin L, Mitchko J, Freeman C,

Kirby S, Milne J. Using framing theory

to unite the field of injury and violence

prevention and response: Adding

Power to Our Voices. Soc Mar Q.2009;15(S1):35-54.

42. Harvard Graduate School of Education.

Harvard Family Research Project. A

users guide to advocacy planning.http://

www.hfrp.org/evaluation/publications-

resources. Accessed April 6, 2012.

43. Glasgow RE, Vogt TM, Boles SM.

Evaluating the public health impact of

health promotion interventions: the

RE-AIM framework. Am J Public

Health. 1999;89:1322-1327.

44. Kelly MP, McDaid D, Ludbrook A, Po-

well J. Economic appraisal of publichealth interventions, Briefing paper.

http://www.nice.org.uk/aboutnice/who

weare/aboutthehda/hdapublications/

hda_publications.jsp?o707. Accessed

January 22, 2012.

45. Academy of Nutrition and Dietetics.

Evidence Analysis Library. http://

www.adaevidencelibrary.com/default

.cfm?auth1. Accessed January 6, 2012.

46. Agency for Healthcare Research and

Quality. Evidence-based practice.

http://www.ahrq.gov/clinic/epcix.htm.

Accessed January 6, 2012.

47. American Society for Enteral and

Parenteral Nutrition. Clinical Guide-

lines. http://www.nutritioncare.org/

Professional_Resources/Guidelines_and_

Standards/Guidelines_and_Standards_

Library_Features/. Accessed January

6, 2012.

48. Natural Standard Research Collabora-

tion. Natural Standard database.

http://www.naturalstandard.com/. Ac-


49. The Cochrane Collaboration. Cochrane

Reviews. http://www.cochrane.org/

cochrane-reviews. Accessed January6, 2012.

50. Swinburn B, Gill T, Kumanyika S.

Obesity prevention: a proposed frame-

work for translating evidence into ac-

tion.Obes Rev. 2005;6:23-33.

51. Rychetnik L, Hawe P, Waters E,

Barratt A, Frommer M. A glossary for

evidence basedpublic health.J Epidemiol

Community Health. 2004;58:538-545.

52. Kroke A, Boeing H, Rossnagel K,

Willich SN. History of the concept of

levels of evidence and their current

status in relation to primary prevention

through lifestyle interventions. Public

Health Nutr. 2004;7:279-284.

53. Frechtling JA: National Science Foun-

dation (US). Footprints: Strategies for

Non-Traditional Program Evaluation.Arlington, VA: National Science Foun-

dation; 1995.

54. Petty RE, Cacioppo JT. Issue involve-

ment can increase or decrease persua-

sion by enhancing message-relevant

cognitive responses. J Pers Soc Psychol.

1979;37:1915-1926.

55. McGuire W. Theoretical foundations

of campaigns. In: Rice R, Paisley W,

eds. Public Communication Campaigns.

Thousand Oaks, CA: Sage Publica-

tions; 1981:41-70.

56. Brehm JW. A Theory of PsychologicalReactance. New York, NY: Holt, Rine-

hart & Winston; 1966.

57. Boulay M, Valente TW. The selection of

family planning discussion partners in

Nepal.J Health Commun. 2005;10:519-536.

58. Luke DA, Harris JK. Network analysis

in public health: history, methods, and

applications. Annu Rev Public Health.

2007;28:69-93.

59. Valente TW, Saba WP. Mass media and

interpersonal influence in the Bolivia

National Reproductive Health Cam-

paign.Communic Res. 1998;25:96-124.

60. Kincaid DL. From innovation to social

norm: bounded normative influence. J

Health Commun. 2004;9(suppl 1):37-57.

61. Kincaid DL. Mass media, ideation, and

behavior: a longituduinal analysis of

contraceptive change in the Philippines.

Communic Res. 2000;27:723-763.

62. Knapp ML, Stohl C, Reardon KK.

Memorable messages.Journal of Com-

munication. 1981;31:27-41.

63. Davis LA.Beyond 5-a-Day: An Exami-

nation of Memorable Messages in a Nutri-

tion Education Program for Low-Income

African Americans [dissertation]. WestLafayette, IN: Purdue University; 2011.

64. Newsweek. Sesame Street: the show

that counts. http://www.thedailybeast

.com/newsweek/2009/05/22/sesame-

street.html. Accessed March 30, 2012.

65. Harvard Health Publications. Compari-

son of the Healthy Eating Plate and

the USDAs MyPlate. http://www

.health.harvard.edu/plate/comparison-of-

healthy-eating-plate-and-usda-myplate.

Accessed May 6, 2012.

66. Zoellner J, Connell C, Bounds W,

Crook L, Yadrick K. Nutrition literacy

status and preferred nutrition commu-

nication channels among adults in the

Lower Mississippi Delta. Prev Chron

Dis. 2009;6:1-11.

67. Neuenschwander LM, Abbott A,Mobley AR. Assessment of low-

income adults access to technology:

implications for nutrition education.

J Nutri Educ Behav. 2012;44:60-65.

68. Lockwood CM, DeFrancesco CA,

Elliot DL, Beresford SA, Toobert DJ.

Mediation analyses: applications in nu-

trition research and reading the litera-

ture.J Am Diet Assoc. 2010;110:753-762.

69. Green PE, Srinivasan V. Conjoint anal-

ysis in consumer research: issues and

outlook.J Consum Res. 1990;5:103-123.

70. Fisher JO, Mennella JA, Hughes SO,LiuY, MendozaPM,Patrick H. Offering

dip promotes intake of a moderately

liked raw vegetables among preschoolers

withgenetic sensitivity to bitterness.J Am

Diet Assoc. 2012;112:235-245.

71. Howe J, WIRED. The rise of crowd-

sourcing. http://www.wired.com/

wired/archive/14.06/crowds.html?pg

1&topiccrowds&topic_set. Ac-


72. Department of Health and Human Ser-

vices, Centers for Disease Control and

Prevention, National Center for Health

Statistics, National Health and Nutrition

Examination Survey. Flexible Con-

sumer Behavior Module. http://www

.cdc.gov/nchs/data/nhanes/nhanes_09_

10/FCBS_f.pdf. Accessed March

30, 2012.

73. Centers for Disease Control and Pre-

vention. State-Added Question Data-

base, 1995-1997. https://www.ark.org/

adh_brfss_questions/results.aspx. Ac-


74. United States Department of Health

and Human Services, Centers for Dis-

ease Control and Prevention. YouthRisk Factor Surveillance System Sur-

vey Questionnaire, 2009. http://www

.cdc.gov/healthyyouth/yrbs/index.htm.

Accessed January 4, 2012.

75. UCLA Center for Health Policy Re-

search. California Health Interview

Survey CHIS, 2012. http://www.chis

.ucla.edu/main/PUF/default.asp. Ac-


http://www.hfrp.org/evaluation/publications-resourceshttp://www.hfrp.org/evaluation/publications-resourceshttp://www.hfrp.org/evaluation/publications-resourceshttp://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/hda_publications.jsp?o=707http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/hda_publications.jsp?o=707http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/hda_publications.jsp?o=707http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/hda_publications.jsp?o=707http://www.adaevidencelibrary.com/default.cfm?auth=1http://www.adaevidencelibrary.com/default.cfm?auth=1http://www.adaevidencelibrary.com/default.cfm?auth=1http://www.adaevidencelibrary.com/default.cfm?auth=1http://www.ahrq.gov/clinic/epcix.htmhttp://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines_and_Standards_Library_Features/http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines_and_Standards_Library_Features/http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines_and_Standards_Library_Features/http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines_and_Standards_Library_Features/http://www.naturalstandard.com/http://www.cochrane.org/cochrane-reviewshttp://www.cochrane.org/cochrane-reviewshttp://www.thedailybeast.com/newsweek/2009/05/22/sesame-street.htmlhttp://www.thedailybeast.com/newsweek/2009/05/22/sesame-street.htmlhttp://www.thedailybeast.com/newsweek/2009/05/22/sesame-street.htmlhttp://www.health.harvard.edu/plate/comparison-of-healthy-eating-plate-and-usda-myplatehttp://www.health.harvard.edu/plate/comparison-of-healthy-eating-plate-and-usda-myplatehttp://www.health.harvard.edu/plate/comparison-of-healthy-eating-plate-and-usda-myplatehttp://www.wired.com/wired/archive/14.06/crowds.html?pg=1&topic=crowds&topic_set=http://www.wired.com/wired/archive/14.06/crowds.html?pg=1&topic=crowds&topic_set=http://www.wired.com/wired/archive/14.06/crowds.html?pg=1&topic=crowds&topic_set=http://www.wired.com/wired/archive/14.06/crowds.html?pg=1&topic=crowds&topic_set=http://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/FCBS_f.pdfhttp://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/FCBS_f.pdfhttp://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/FCBS_f.pdfhttps://www.ark.org/adh_brfss_questions/results.aspxhttps://www.ark.org/adh_brfss_questions/results.aspxhttp://www.cdc.gov/healthyyouth/yrbs/index.htmhttp://www.cdc.gov/healthyyouth/yrbs/index.htmhttp://www.chis.ucla.edu/main/PUF/default.asphttp://www.chis.ucla.edu/main/PUF/default.asphttp://www.chis.ucla.edu/main/PUF/default.asphttp://www.chis.ucla.edu/main/PUF/default.asphttp://www.cdc.gov/healthyyouth/yrbs/index.htmhttp://www.cdc.gov/healthyyouth/yrbs/index.htmhttps://www.ark.org/adh_brfss_questions/results.aspxhttps://www.ark.org/adh_brfss_questions/results.aspxhttp://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/FCBS_f.pdfhttp://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/FCBS_f.pdfhttp://www.cdc.gov/nchs/data/nhanes/nhanes_09_10/FCBS_f.pdfhttp://www.wired.com/wired/archive/14.06/crowds.html?pg=1&topic=crowds&topic_set=http://www.wired.com/wired/archive/14.06/crowds.html?pg=1&topic=crowds&topic_set=http://www.wired.com/wired/archive/14.06/crowds.html?pg=1&topic=crowds&topic_set=http://www.wired.com/wired/archive/14.06/crowds.html?pg=1&topic=crowds&topic_set=http://www.health.harvard.edu/plate/comparison-of-healthy-eating-plate-and-usda-myplatehttp://www.health.harvard.edu/plate/comparison-of-healthy-eating-plate-and-usda-myplatehttp://www.health.harvard.edu/plate/comparison-of-healthy-eating-plate-and-usda-myplatehttp://www.thedailybeast.com/newsweek/2009/05/22/sesame-street.htmlhttp://www.thedailybeast.com/newsweek/2009/05/22/sesame-street.htmlhttp://www.thedailybeast.com/newsweek/2009/05/22/sesame-street.htmlhttp://www.cochrane.org/cochrane-reviewshttp://www.cochrane.org/cochrane-reviewshttp://www.naturalstandard.com/http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines_and_Standards_Library_Features/http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines_and_Standards_Library_Features/http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines_and_Standards_Library_Features/http://www.nutritioncare.org/Professional_Resources/Guidelines_and_Standards/Guidelines_and_Standards_Library_Features/http://www.ahrq.gov/clinic/epcix.htmhttp://www.adaevidencelibrary.com/default.cfm?auth=1http://www.adaevidencelibrary.com/default.cfm?auth=1http://www.adaevidencelibrary.com/default.cfm?auth=1http://www.adaevidencelibrary.com/default.cfm?auth=1http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/hda_publications.jsp?o=707http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/hda_publications.jsp?o=707http://www.nice.org.uk/aboutnice/whoweare/aboutthehda/hdapublications/hda_publications.jsp?o=707http://ww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My Plate Jounral