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Position of the American Dietetic Association: TotalDiet Approach to Communicating Food and Nutrition

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BSTRACTt is the position of the American Di-tetic Association that the total dietr overall pattern of food eaten is theost important focus of a healthful

ating style. All foods can fit withinhis pattern, if consumed in modera-ion with appropriate portion size andombined with regular physical activ-ty. The American Dietetic Associa-ion strives to communicate healthfulating messages to the public thatmphasize a balance of foods, ratherhan any one food or meal.

Public policies that support the to-al diet approach include the Dietaryuidelines for Americans, MyPyra-id, the DASH Diet (Dietary Ap-

roaches to Stop Hypertension), Di-tary Reference Intakes, andutrition labeling. The value of a foodhould be determined within the con-ext of the total diet because classify-ng foods as “good” or “bad” may fosternhealthful eating behaviors. Alter-ative approaches may be necessary

n some health conditions. Eatingractices are dynamic and influencedy many factors, including taste andood preferences, weight concerns,hysiology, lifestyle, time challenges,conomics, environment, attitudesnd beliefs, social/cultural influences,edia, food technology, and food

roduct safety. To increase the effec-iveness of nutrition education in pro-oting sensible food choices, food andutrition professionals should utilizeppropriate behavioral theory and ev-dence-based strategies. A focus on

oderation and proportionality in theontext of a healthful lifestyle, ratherhan specific nutrients or foods, canelp reduce consumer confusion. Pro-ctive, empowering, and practical

0002-8223/07/10707-0021$32.00/0

pdoi: 10.1016/j.jada.2007.05.025

224 Journal of the AMERICAN DIETETIC ASSOCIATI

essages that emphasize the totaliet approach promote positive life-tyle changes.Am Diet Assoc. 2007;107:

224-1232.

OSITION STATEMENTt is the position of the American Die-etic Association that the total diet orverall pattern of food eaten is theost important focus of a healthful

ating style. All foods can fit withinhis pattern, if consumed in modera-ion with appropriate portion size andombined with regular physical activ-ty. The American Dietetic Associationtrives to communicate healthful eat-ng messages to the public that em-hasize a balance of foods, ratherhan any one food or meal.

ver the past 4 decades, Ameri-cans have become more con-scious of diet and nutrition (1).

lthough nearly all consumers be-ieve that body weight, diet, and phys-cal activity influence health, diet sur-eys suggest that their food habitsre not always commensurate withnowledge and beliefs (2). Only halfescribe their diet as healthful, and4% eat five or more servings of fruitsnd vegetables per day. One thirdlassify themselves as sedentary ando not engage in physical activity.ven though more than half of con-umers say they are making dietaryhanges to improve their health, ap-roximately two thirds are over-eight or obese. It is clear that prac-

ical guidance by food and nutritionrofessionals is needed to promoteositive lifestyle changes that areustainable.According to the Shopping forealth 2004 study, nearly six in 10

onsumers are trying hard to eatealthfully so they can avoid health
roblems later in life (3). More than q
ON © 2007

alf of food shoppers strongly agreehat eating healthfully is a better wayo manage illness than medication.nfortunately, this trend toward in-

reasing awareness has been accom-anied by widespread confusion withomplaints that nutrition educations focused on what NOT to eat, in-tead of what TO eat (1). These con-icting messages make it difficult tonow what to do.Eating is an important source of

leasure. As food and nutrition pro-essionals strive to improve the qual-ty of Americans’ dietary and lifestylehoices, challenges are exacerbatedy the widespread perception that in-ividuals must choose between goodaste and nutritional quality. In fact,o single food or type of food ensuresood health, just as no single food orype of food is necessarily detrimentalo health. Rather, the consistent ex-ess of food, or absence of a type ofood over time, may diminish the like-ihood of a healthful diet. For exam-le, habitual, excessive consumptionf energy-dense foods may promoteeight gain and mask possible under-

onsumption of essential nutrients.et small quantities of energy-dense

oods on special occasions have no dis-ernible influence on health.In most situations, nutrition mes-

ages are more effective when focusedn positive ways to make healthfulood choices over time, rather thanndividual foods to be avoided (4,5).nfortunately, the current mix of re-

iable and unreliable information oniet and nutrition from a variety ofources is confusing to the public andlicits negative feelings such as guilt,orry, helplessness, anger, fear, and

naction.The total diet approach is based on

verall eating patterns that have im-ortant benefits and health conse-
uences and that provide adequate
by the American Dietetic Association

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utrients within calorie needs. Thisncludes the concept that foods areot inherently “good” or “bad.” Overhe years, the American Dietetic As-ociation has consistently recom-ended a balanced variety of nutri-

nt-dense foods eaten in moderations the foundation of a health-promot-ng diet (5,6).

EDERAL NUTRITION GUIDANCEUPPORTS THE TOTAL DIET APPROACHhe Dietary Guidelines for Americans

7), which are the centerpiece of fed-ral food, nutrition education, and in-ormation programs, are based on aotal diet approach to food guidance.he DASH (Dietary Approaches totop Hypertension) Eating Plan fromhe US Department of Health anduman Services is one of many re-

ources that are available to assistonsumers in implementing theseecommendations (8-11).

The MyPyramid Food Guidanceystem is another example of a di-tary pattern that uses a total dietpproach to ensure nutritional ade-uacy and healthful food choices. My-yramid was released in 2005 as anpdated graphic to replace the Fooduide Pyramid. The developers of theietary Guidelines for Americans andyPyramid found that consumers

nd educators preferred dietary guid-nce that enables consumers to eat in

way that suits their individualastes and lifestyles (8,12,13). Theoncept of monitoring discretionaryalories (solid fats, added sugars, al-ohol) was introduced to allow con-umers to choose small amounts ofess-nutrient-dense foods while meet-ng nutrient needs within caloric lim-ts (14). For example, consumers canalance a small amount of low-nutri-nt or high-energy-density food oreverage (eg, fried food, butter/mar-arine, jelly, alcohol) with nutrient-ense foods (vegetables, whole grains,onfat milk) to achieve an overallealthful dietary pattern (13). How-ver, the discretionary calorie valuesan be quite low (150 kcal/day), suchhat if an individual ate a friedhicken entree, it would be impossibleo stay within the recommended lim-ts with the addition of other high-nergy foods. Thus, large servings ofoods or beverages high in solid fats,dded sugars, or alcohol are not com-
atible with the Dietary Guidelines t
or Americans, but limited quantitiesould be acceptable, provided thatutrient-dense foods comprise theulk of the day’s choices. This mes-age of the total diet approach muste communicated to consumers byood and nutrition professionals.

utrition Labelsutrition labels are a third tool that

onsumers can use to choose and com-are foods. The Nutrition Facts labelas developed by the Food and Drugdministration and its collaboratinggency partners as a consumer infor-ation system. Food and nutrition

rofessionals have found the label toe an effective educational tool thatelps consumers plan their diets. Forxample, 48% of survey respondentseported that they had changed theirinds about buying or using a food

roduct after reading the nutrition la-el in 1995, as compared with 30% in990 (15).

utrient Intake Recommendationshe Dietary Reference Intakes (DRIs)re reference values that are used tolan and assess diets for healthy pop-lations. The DRIs replaced the Rec-mmended Dietary Allowances,hich had been revised periodically

ince 1941. The new dietary stan-ards emphasize the prevention ofhronic diseases and promotion of op-imal health (16). A positive emphasisas implemented, rather than “focus-

ng solely on the prevention of nutri-ional deficiencies.” In addition to theecommended Daily Allowances

RDAs), DRI categories include Esti-ated Average Requirements

EARs), Adequate Intakes (AIs), andolerable Upper Intake Levels (Uls).ach type of DRI refers to averageaily intake over time—at least 1eek for most nutrients. For macro-utrients, recommendations aretated as Acceptable Macronutrientistribution Ranges (AMDRs). TheMDRs show that there is not justne acceptable value, but rather aroad range within which an individ-al can make diet choices based onheir own preferences, genetic back-rounds, and health status. This con-ept of adequacy of nutrient intakesver time supports the need to helponsumers understand the impor-
ance of the total diet approach. a
July 2007 ● Journal

UCCESSFUL COMMUNICATIONAMPAIGNS AND PROGRAMSeaching consumers to make wise

ood choices in the context of the totaliet is not a simple process. Depend-ng on the audience and the situation,

variety of nutrition information,ommunication, promotion, and edu-ation strategies may be needed forn appropriate and effective nutritionntervention. It may be necessary touggest a change to a more healthfulifestyle in terms of small steps thatre achievable in increments, so thathese can build to broader successesn improving fitness or dietary quality17). In addition, successful cam-aigns often include the coordinatedfforts of a number of agencies andrganizations with similar healthromotion goals (4,17-19).A growing body of evidence sup-

orts the recommendation to designehavior-oriented food and nutritionrograms that are targeted to helpearners adopt a total diet approachhat is sustainable and fits individualreferences. Nutrition education re-earch supports the identification ofomponents that are effective acrossarious types of interventions (17,20).

SYCHOSOCIAL CONSEQUENCES OF GOODND BAD FOOD MESSAGESategorizing foods as good or bad pro-otes dichotomous thinking. Dichot-

mous thinkers make judgments inerms of either/or, black/white, all/one. or good/bad and do not incorpo-ate abstract or complex options intoheir decision strategies.

he Magic Bullet Approachhinking in terms of dichotomous orinary (either/or) categories is com-on in childhood. Almost all elemen-

ary-age and half of middle schoolhildren believe that there are goodnd/or bad foods (21). Although thebility to think in more abstract andomplex modes is prevalent amongdolescents and adults, consumers ofll ages tend to rely on dichotomoushinking in certain situations (22).

An example of dichotomous think-ng is the quick fix or “magic bullet”pproach to weight control. As long asne stays on the diet (target behavior)he person feels a sense of perceivedontrol (self-efficacy). However, when
n individual encounters a high-risk
of the AMERICAN DIETETIC ASSOCIATION 1225

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ituation such as a tempting food (eg,cookie), loss of control may occur,

epending on the individual’s emo-ional state, interpersonal conflict,nd social pressure (23).In this scenario, a cookie would be

egarded as a forbidden food and aieter who yields to a desire for aookie would tend to say, “I ate theookie. I have blown my diet. I mights well finish the rest of the box.” Thisessimistic approach becomes self-ulfilling, as the subject believes thathere is not much that can be donence a loss of control occurs (24). Akilled nutrition counselor might re-uce the probability of relapse by in-reasing awareness of nutritionknowledge), teaching coping skillsalternative behaviors), incorporatingersonal favorites in individualizedating patterns, and promoting ac-eptance of personal responsibilitynd choice (“I can refuse to eat it” or “Ian occasionally enjoy a small por-ion”). The option of providing simple,ne-size-fits-all decision rules may ben expedient approach to educationnd counseling, but it often misleadsonsumers into thinking that a givenype of food is always a positive oregative addition to the diet. The al-ernative of offering more comprehen-ive and targeted education involvesontext-based judgment. This type ofducational message is more difficulto address in language that is easy tonderstand and apply, but it is more

ikely to help the consumer to makeell-reasoned food choices and adoptehavior patterns that are sustain-ble over time (17).ll-Good or All-Bad Foods? Problems oc-ur when a food or food component isversimplified as all good or all bad.he increased risks for cardiovascu-

ar disease associated with ingestionf trans fat produced during process-ng of foods might lead to the classifi-ation of all trans fat as bad. How-ver, a type of trans fat that occursaturally from ruminant animalources (dairy and meat), conjugatedinoleic acid, has far different effectsn metabolic function, genetic regula-ion, and physiological outcomes (25).n contrast to the atherogenic naturef most synthetic forms of trans fat,onjugated linoleic acid has beenhown to have beneficial effects onardiovascular disease, diabetes, im-
une response, energy distribution, h
226 July 2007 Volume 107 Number 7

nd growth. To avoid this confusion,he Food and Drug Administrationas excluded the naturally occurringrans fat that is in a conjugated sys-em from its definition of trans fat forutritional labeling (26).Conversely, even foods associatedith a healthful diet such as egghites and soybeans should not beversimplified as being perfect. Egghites are low in cholesterol and high

n protein, yet they are also so low ininc that they can induce a zinc-defi-iency when used as a primary or soleource of protein in the diet (27). Sim-larly, soybeans have n-3 fatty acids,avonoids, and phytoestrogens withealth-promoting properties, but soylso contains phytates that diminishbsorption of zinc and iron (28,29)nd the health benefits of adding soyo the diet have not been consistentlyupported by research (30). For exam-le, animal studies in which soy in-ake was higher than that found insian diets found an increase in tu-or growth (31). Thus, foods such as

gg white and soy cannot be classifieds completely good or bad, but ratherheir value is determined within theontext of the total diet. Furthermore,ists of good and bad foods were con-idered one of the “Ten Red Flags ofunk Science” by the Food and Nutri-ion Science Alliance, a collaborationf seven scientific professional organi-ations (5).With over 45,000 food items in the

verage supermarket (32) and an in-nite array of recipe combinations,he futility of attempting to sort allood items into dichotomous catego-ies becomes evident, leading to con-usion and frustration. Thus, the totaliet approach, with its emphasis onong-term eating habits and a contex-ual approach to food judgments suchs discretionary calories, providesore useful information to guide

ong-term food choices.

ONTROVERSIES WITH THE TOTAL DIETPPROACHne concern with the total diet ap-roach is that it may be viewed asermitting unlimited inclusion of low-utrient-density foods and beveragesr encouraging overconsumption ofoods with marginal nutritionalalue. In a study using a Dietaryuidelines index as a measure of
ealthful diet quality, heavy con- o
umption of savory, high-fat snacksas associated with poor diet quality

33). In addition, three national sur-eys of the US population have docu-ented that portion sizes and energy

ntakes have increased substantiallyver time both inside and outside theousehold (34). Nutrition education isritical because individuals tend toat more calories when served largeortions of foods, especially energy-ense foods (35). Yet foods low in nu-rient density can fit as part of theotal diet, if these foods are consumeds discretionary calories in combina-ion with appropriate quantities ofther recommended foods (36).Another controversy with the total

iet approach is the emphasis on va-iety. Choosing a variety of foods haseen a cornerstone principle in theietary Guidelines for Americans, but

hat emphasis has changed fromverall variety to varying choicesithin the food groups. Choosing aariety of nutrient-dense foods helpso ensure adequate intakes of morehan 50 nutrients that are needed forrowth, repair, and maintenance ofood health. However, an increase inood availability and variety in foodhoices may be a cause of overeating,specially when applied to energy-ense foods (37). For example, theultitude of choices at a buffet and

he temptation to taste each food canesult in a greater intake of calorieshan from a plated or family-styleeal. When McCrory and colleagues

38) analyzed 1999 food consumptionata, increases in energy intakes andody fatness were associated with in-estion of a high variety of sweets,nacks, condiments, entrees, and car-ohydrate foods, coupled with a lim-ted variety of vegetables. Krebs-mith and colleagues (39) observedhat a variety of foods was associatedith nutrient adequacy to a point, be-ond which there was no improve-ent. When nutrient needs are satis-

ed, eating additional foods providesxcess calories without added healthenefits.

HY WE EAT WHAT WE DOonvenience, Cost, and Confusionlthough 87% of consumers reportedeing very or somewhat concernedbout nutrition, widespread improve-ents in dietary changes have not

ccurred (2). Shoppers say healthful

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oods are not readily accessible atast-food restaurants or take-outlaces and the cost is too high. Also,onfusion exists over conflicting infor-ation about the healthfulness of theide range of foods that are available

40). Americans have made a numberf positive dietary changes in the past0 years (41), such as increased con-umption of fruits, vegetables, andrains. However, many still fail to in-lude adequate servings of fruits,ark green vegetables, orange vegeta-les, mature beans and other le-umes, and low-fat dairy products. Athe same time, added sugars and fatsontribute substantial calories to themerican diet.

aste and Food Preferencesaste is generally the most important

actor influencing food choice. The sixasic taste sensations—sweet, sour,itter, salty, umami (L-amino acid),nd fatty acids—are affected initiallyy genetics, but these can be modifiedy physiological and metabolic vari-bles such as feelings of contentmentnd satiety (42). Taste preferencesre further developed by experienceselated to one’s sex, age, weight, andating behaviors (43). For example,aste preference for sweetness is in-orn. This preference for sweetness,n conjunction with familiarity, is the

ost significant determinant of foodhoices in young children (44). Be-ause young children (45) and evenats (46) can learn to prefer high-en-rgy foods, the avoidance of theseoods may be foiled by feelings of de-rivation because of a well-estab-ished desire to eat sweet and high-alorie foods. Consequently, smallortions of these foods on special oc-asions are permissible within theontext of the total diet approach.

utrition and Weight Controlutrition is a major predictor of food

hoices even though it is less of a per-onal concern for most consumershan taste, convenience, or cost. Aigh level of nutrition knowledge isositively associated with overall dietuality (47) and a greater weight lossn dieting women (48).

Food choices are significantly influ-nced by misdirected concerns overeight control (49). One common con-

equence of many popular weight- b

ontrol diets is a preoccupation withood and eating (50). In the context ofelf-improvement, the dieter may re-trict foods or macronutrients consid-red to be “fattening.” Rather thanocus on total restriction of particularoods, which can lead to feelings ofeprivation (and subsequent recidi-ism), individuals are encouraged tovoid excessive weight gain by under-aking lifestyle changes that repre-ent a balanced and healthful dietnd an exercise pattern that can beaintained throughout life (7,51).

bundance of Foods with Healthfulropertieshe demand for nutritious foods hastimulated the food and agriculturendustries to develop a variety ofroducts, including functional foodshat provide potential health benefitseyond basic nutrition and new agri-ultural and biotechnology tech-iques. Many new biotechnologiesave enhanced the quality, safety,utritional value, and variety of foodsvailable to the consumer (52). Con-ern has been raised that increasingbundance of functional foods mayontribute to increased energy in-akes if individuals tend to think it iscceptable to eat larger quantities ofoods that are good for them (53), suchs reduced-fat cookies. As consumerhoices continue to expand, food andutrition professionals need to stayurrent through continuing educationo meet the needs of an ever-changingociety.

hysiological Influencesigestive decline, poor dental health,

wallowing difficulties, bone deminer-lization, dementia, and/or dimin-shed basal metabolism affect foodhoices of many individuals, espe-ially older adults. Disease states andreatments, such as dialysis forhronic renal failure (54) and chemo-herapy for cancer (55), also changeood habits. For example, patientsith renal failure tend to dislike

weet foods, vegetables, and redeats, whereas protein foods (eggs,

heese, meat) often become unpleas-nt for patients undergoing treat-ent for cancer. More recently, the

rofound significance of one’s genesn obesity and feeding behaviors is
eing investigated (56). Because of 1

he great influence of pathophysiolo-ies on food choices and nutrienteeds, it is important to stress thathe total diet approach is designed forhe general, healthy population,ather than individuals with chroniciseases.

ifestyle Influencesime. One of the most significant in-uences affecting food choices is the

ack of time in our rapidly changingifestyle. In the 2000 American Die-etic Association Trends Survey, 38%ndicated that, “It takes too muchime to keep track of my diet” (57).his is even higher than the 1995merican Dietetic Association Trendsurvey, in which 21% cited time re-traints as an obstacle to change (58).With 60% of American women try-

ng to juggle work with families and aesire to spend less than 15 minuteso prepare a meal (59), there has been

virtual explosion of convenienceoods, take-out, value-added (precut,rewashed), and ready-made foods.he traditional role of mothers pre-aring healthful foods from scratch iseing replaced by parents purchasingake-out foods from a variety ofendors.ulture. Cultural food practices notnly affect taste preferences, but alsohopping habits, manners, communi-ation, and personal interactions. In005, the minority population totaled8 million, or 33%, of a total of 296illion (60). As people from varying

ackgrounds become acculturatednto US society, their dietary habitsend to change from a pattern basedn whole grains and vegetables tooods that are higher in fats and sug-rs (43). Sensitivity to what might beonsidered good or bad by personsrom varying cultures is critical forood and nutrition professionals, whoave the complex job of tailoring ad-ice to each individual within a cul-ural context. For example, to im-rove the diet of Latinos who arerone to diabetes and may overem-hasize some traditional foods, a foodnd nutrition professional could pro-ide guidance on alternate choicesuch as brown rice and whole-wheatortillas and encourage portion con-rol (61).conomics. Food prices vary in theirffects on food choice behaviors. In
993, 53% of Americans thought that

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conomic factors were the most im-ortant issue facing this country; by999, only 12% held this belief (59). Inndividuals with lower incomes, con-enience is rated as a more importantnfluence on food choices as comparedith those with higher incomes (62),

eflecting limitations in transporta-ion, cooking facilities, food prepara-ion skills, grocery store locations,nd availability of healthful foodhoices (63,64). However, financial is-ues were associated with limitedompliance with dietary guidelines inrecent study of low-income women

65).

nvironmental Factorsttitudes and Beliefs. Attitudes and be-iefs about foods tend to reflect cul-ural values, but they change moreuickly with time (66). For example,erceptions, attitudes, and beliefsbout fat have shifted in the last halff this century, much of it because ofocial trends and marketing cam-aigns. Also, the typical “meat andotatoes” plates have been replacedy varying cuisines and preparationechniques (67). An illustration is a950s restaurant meal of beef steak,ried onion rings, lettuce wedge withhousand Island dressing, and bakedotatoes with butter, cheese, and sourream. Today, meals might be lowern fat and reflect changing tastes,uch as pasta with chicken, sun-driedomatoes, and roasted vegetables, ac-ompanied by a salad of mixed fieldreens, dried cranberries, and bal-amic dressing.ocial Influences. Social factors sub-tantially influence eating behaviors.or example, the presence of a friend

but not a stranger) while eating in-reases energy intake by 18%. Thistudy suggested that social facilita-ion of eating is caused by an im-aired ability to self-monitor (68). Instudy of why cardiac patients do not

ollow nutritional advice, 86% re-orted that social and work situationsresented challenges, in addition tonancial barriers to change and diffi-ulty with restraint when facing largemounts of food (69).edia. The media is a powerful force

nfluencing the food choices of Amer-cans. In 2004 approximately $11 bil-ion was spent for food, beverage, andestaurant advertising in magazines,
ewspapers, television, and radio (70). v

hen Kellogg’s high-fiber cerealsrst added health claims about can-er prevention and dietary fiber toheir package label, sales escalated7% within the first 6 months (71).rade association programs have pro-oted generic advertising, such as

he one for fluid milk (“Got Milk?”),hich featured celebrities wearingilk mustaches. Remarkably, these

ampaigns slowed or stopped the de-lining trend of milk consumptionnd 47 lb of milk were purchased forach advertising dollar spent (72).hus, consumers can change theirerceptions of foods and food choiceshen given repeated and positive nu-

rition messages.roduct Safety. Concerns about prod-ct safety can affect food choices pro-oundly. For example, the 1988 scaref Alar (Chemtura Corporation,iddlebury, CT) in apples resulted in

ear hysteria among mothers whohought they had fed their childrenainted foods. Apple sales plummeteds a result, even though the researchehind the scare was controversial.hen Alar (a plant growth regulator)as removed from use in some statesnd the perceived risk of cancer min-mized, consumers returned to eatingpples as in the past (73). Although its essential to acknowledge that trulynsafe foods are never good foodhoices, in this case, positive mes-ages about the benefits of diets withlenty of fruits and vegetables helpestore balance in diet and healthoals.

OMPLEXITIES OF CHANGING EATINGEHAVIORShe impact of nutrition informationn promoting healthful lifestyles de-ends on how effectively nutritionessages are communicated to con-

umers. Nutrition information muste presented with sufficient context torovide consumers with a broader un-erstanding of the issues and to de-ermine whether it applies to theirnique needs (4). Communicationsnd educational programs must em-hasize the importance of consideringfood or meal in terms of its contri-

utions to the total diet. This type ofommunication can be more effectivehen educators use appropriate the-ries and models of factors related touman behavior (18). Although pro-
iding information can be effective in t
romoting healthful behaviors, com-unications designed to build skills

r help learners master more complexoncepts usually benefit from the in-lusion of principles from health-be-avior theories and models (Figure).

dapting Behavior-Oriented Theories forood and Nutrition Communicationnowledge-Attitude-Beliefs. One of theimplest models for food and nutritionommunication is the Knowledge-Atti-ude-Beliefs approach, which is basedn the often-mistaken assumption thathe person who is exposed to new infor-ation will attend to it, gain new

nowledge, change attitude, and im-rove dietary patterns (20). This ap-roach can be effective if the individuals already motivated and the new infor-

ation is easy to follow. For example, aist of foods that are high in iron may besuccessful trigger to dietary improve-ent for someone concerned over a re-

ent diagnosis of anemia. However,ithout such a “teachable moment,” in-

reased knowledge, such as a memo-ized list of high-iron foods, often failso result in changed behavior. This isrue especially if following the advice isot convenient or congruent with per-onal taste preferences.ealth-Belief Model. The Health-Beliefodel is one of the most widely used

heories in health education (74). Anxample is the promotion of foodsigh in folate to reduce the risk ofertain birth defects. This model ex-lains human behavior and readinesso act via four main constructs: per-eived susceptibility (“How likely amto get heart disease and how soon?”),everity (“How bad would it be toave heart disease?”), benefits (“Willfeel better if I change the fats thateat?”), and barriers (“How hard will

t be to make these changes in myat intake?”). A recent addition to theealth-Belief Model is the concept of

elf-efficacy (“How confident am I thatcan succeed in changing the fats

hat I eat?”). The Health-Beliefodel is useful when the target au-

ience perceives a problem behaviorr condition in terms of health mo-ivation. Yet many consumers “tuneut” repeated messages of gloomnd doom for habits that seem com-on and without immediate nega-

ive consequences.

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ocial Cognitive Theory/Transtheoretical The-ry. When problem behaviors arelosely tied to social or economic mo-ivations, more comprehensive theo-ies and models may be effective toolsor planning nutrition interventions75). For instance, if an educatoreeds to promote milk-based foods asources of dietary calcium, Socialognitive (Social Learning) Theoryould support an educational inter-ention addressing behavioral capa-ility (knowledge and skills needed to

I realize that eating whole fruit is a gof fruits and vegetables each day. I amost of my fruit in the form of juice.less juice the next time I go to the suStages and processes of changeTranstheoretical Model

If the vending machines at my officeselect it as a snack.Reciprocal determinismSocial Cognitive Theory

I know that I can eat more fruit andseason and putting those fruits on mSelf-efficacySocial Learning Theory, Transtheor

Whole fruits have fiber that helps meeating whole fruit, I would get less fimy calorie intake. That could lead tomake me feel less attractive. Howeveas often as I want to because it is easomething that’s fast and easy fromstore.Perceived benefits, threats, and barrieHealth-Belief Model

Calorie per calorie, whole fruit has mHealth informationKnowledge-Attitude-Behavior

igure. Example of how behavioral models caor increasing consumption of fruit (eg, eating wmportant concepts to factors addressed by m

elect and prepare milk-based foods), o

eciprocal determinism (availabilityf milk-based foods in vending ma-hines and restaurants), expectationsbeliefs about osteoporosis as a conse-uence of avoiding milk-based foods),elf-efficacy (confidence in one’s abil-ty to use more milk-based foods), ob-ervational learning or modeling (see-ng peers and other role modelsrinking milk), and reinforcementpositive or negative feelings that oc-ur when milk drinking is practiced).The Transtheoretical Model/Stage

way to help me increase my intakerealize that I have been gettingill start buying more whole fruit andmarket.

e fruit, I will be more likely to

juice by learning which fruits are ineekly shopping list.

al, and Health-Belief Models

l full. If I drink juice instead ofand have a harder time managingning excess weight which wouldmay not be able to eat whole fruit

r to find fruit juice when I neednding machine or a convenience

dietary fiber than fruit juice.

e used to provide positive nutrition messagesle fruit more often than juice). Each level addsls on the levels below it.

f Change (76) describes learners in m


erms of their progress through a se-ies of behavioral stages (stages ofhange). It also includes related di-ensions such as processes of change,

elf-efficacy, and decisional balancepros/cons) and allows educators toailor educational messages to learn-rs’ needs and readiness for behav-oral change.ocial Marketing. Social marketing is aehaviorally focused process thatdapts commercial marketing tech-iques to programs designed to influ-nce the behavior of target audienceso improve their well-being. Socialarketers work to create and main-

ain exchanges of target audience re-ources, such as money or time, forerceived benefits such as feeling bet-er or having more independence.ust as educators may use a range ofheoretical concepts to design effec-ive interventions, marketing cam-aigns also may be more effectivehen important determinants of be-avior are identified and used in aedia campaign (77).The Fruits and Veggies: More Mat-

ers campaign and its predecessor,he 5-A-Day for Better Health cam-aign, are examples that adapt mar-eting theory to food and nutritionommunication (78). Designers ofhese campaigns studied the prefer-nces and habits of various audienceegments; developed messages thatould be perceived as relevant, com-rehensible, and actionable; and thenistributed these to consumers in set-ings such as supermarkets, restau-ants, and the Internet (79). The ef-ectiveness of these campaigns inncreasing Americans’ consumptionf fruits and vegetables is wellnown.Regardless of the theoretical basis

f communications, messages must beonsistent with an emphasis on a to-al dietary pattern that is balancednd moderate, and guard against in-dvertent use of oversimplified mes-ages such as good/bad foods. Other-ise, communicators may not be

ffective in achieving their educa-ional goals (80).

he Socio-Ecological Dimensionn addition to programs that targetehavioral practices and dietarynowledge/skills of individuals andamilies, it is often appropriate to pro-

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mprovements at the broader organi-ational or societal levels. A socio-eco-ogical model has been developed touide programs that facilitate choicesf targeted systems, environment,nd public policy change within orga-izations at the community and state

evels (81).

EDUCING NUTRITION CONFUSIONo reduce confusion from the higholume and apparent inconsistenciesf nutrition advice, the followinghould be considered when designingutrition education for the public:

Promote variety, proportionality,moderation, and gradual improve-ment. Variety refers to an eatingpattern that includes foods from allMyPyramid food groups and sub-groups. Proportionality, or balance,means eating more of some foods(fruits, vegetables, whole grains,fat-free or low-fat milk products),and less of others (foods high in sat-urated or trans fats, added sugars,cholesterol, salt, and alcohol). Mod-eration may be accomplishedthrough advice to consumers tolimit overall portion size and tochoose foods that will limit intake ofsaturated or trans fats, added sug-ars, cholesterol, salt, and alcohol.To make gradual improvement, in-dividuals can take small steps toimprove their diet and lifestyleeach day (16).Emphasize food patterns, ratherthan individual nutrients or indi-vidual foods, as key considerationsin evaluating and planning one’sfood choices. Be aware of the social,cultural, economic, and emotionalmeanings that may be attached tosome foods and allow for flexibilitywhenever possible. Understandthat social and cultural aspects offood consumption are essential forplanning educational programs tohelp correct nutritional problems ofindividuals and population groups(82).Acknowledge the importance of ob-taining nutrients from foods, ratherthan relying on nutrients from sup-plements or fortified foods. Al-though nutrient modifications arerecommended when food intake isinadequate to meet specific needs(eg, iron, folic acid, vitamins B-12
and D for some population groups), f

it is important to stress that a dietbased on a wide variety of foods re-mains the preferred overall sourceof nutrients (83). Numerous bioac-tive compounds in foods such asphytochemicals and ultra trace ele-ments have been identified thathave potential health benefits. Yetthe precise role, dietary require-ments, influence on other nutrients,and toxicity levels of these dietarycomponents are still unclear. Fur-thermore, foods may contain addi-tional nutritional substances thathave not yet been discovered. Thus,appropriate food choices, ratherthan supplements, should be thefoundation for achieving nutri-tional adequacy (7).Stress that physical activity com-plements the total diet approachbecause it permits individuals tohelp manage weight and lowers therisk of premature diseases. Theminimum amount recommendedfor health benefits by MyPyramidand the Dietary Guidelines forAmericans is 30 minutes, prefera-bly each day. To avoid weight gain,60 minutes per day may be neces-sary, and this may increase up to 90minutes to maintain weight loss.

OLE OF FOOD AND NUTRITIONROFESSIONALSood and nutrition professionals haveresponsibility to communicate unbi-sed food and nutrition informationhat is culturally sensitive, scientifi-ally accurate, medically appropriate,nd feasible for the target audience.ome health and nutrition expertsnd many “pseudo-experts” promotepecific foods or types of food to chooser avoid in order to improve health. Aore responsible and effective ap-

roach is to help consumers under-tand and apply the principles ofealthful diet and lifestyle choices.nless there are extenuating circum-

tances (eg, individuals with severeognitive or physical limitations suchs dementia or renal failure), the to-al diet approach is preferred becauset is more consistent with research onffective communication and inclu-ive of cultural/personal differences.o achieve this goal, the Board of themerican Dietetic Association ap-roved the objective to focus nutritionessages on total diet, not individual

oods (84).

ffective Communication Strategieso be communicated effectively, edu-ational messages and counseling in-erventions should:

focus on high-priority personaland/or public health needs;provide a proactive, positive, andpractical approach;promote an enjoyable pattern ofdiet and activity choices as part of along-term overall healthful life-style;use successful educational strate-gies based on theories and modelsthat promote behavioral change;andevaluate and share information oneffectiveness of food and nutritionprograms.

As leaders in nutrition communica-ion, food and nutrition professionalseed to continue strengthening skills,pdating competencies, and docu-enting outcomes. Suggested tech-

iques to achieve these goals are:

build coalitions with industry, gov-ernment, academia, and organiza-tions;use a full range of available andappropriate communication tech-nologies and take advantage of op-portunities to communicate withprofessional colleagues and thepublic, such as giving presentationsand writing publications to influ-ence social norms and public policy;act as role models of active partici-pation in local and professional as-sociations;maintain state-of-the-art knowl-edge through continuing education;andtake a professional and unbiasedapproach to promoting healthfuleating and physical activitypatterns.

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1. Gregson J, Foerster SB, Orr R, Jones L,Benedict J, Clarke B, Hersey J, Lewis J,

ADA position adopted by the HouSeptember 13, 2001, and on June 30December 31, 2011. The ADA authorment/support paper, in its entirety, pRequests to use portions of the posititers at 800/877-1600, ext. 4835, or p

Authors: Susan Nitzke, PhD, RD (Uison, WI) and Jeanne Freeland-GraveAustin, Austin, TX).

Reviewers: Mary Anne Burkman, MOakland, CA); Nutrition Education(Laura Chalela, MPH, RD, EdelmanFinn, PhD, RD, FADA (Finn/ParksKerver, PhD, RD (Michigan StateKnol, PhD, RD (University of AlabamPhD, RD (Alabama State Departmensan M. Sanders, RN, MPH, RD (The

Association Positions Committee W
Patricia Schaaf, MS, RD; Barbara Olen
Zotz K. System, environmental, and policychanges: Using the social-ecological modelas a framework for evaluating nutritioneducation and social marketing programswith low-income audiences. J Nutr Educ Be-hav. 2001;33(suppl 1):S4-S15.

2. Devine CM, Sobal J, Bisogni CA Connors M.Food choices in three ethnic groups; interac-tions of ideals, identities and roles. J NutrEduc. 1999;31:86-93.

3. Committee on Dietary Reference Intakes.Dietary Reference Intakes for Vitamin C, Vi-tamin E, Selenium, and Carotenoids. Wash-ington, DC: National Academies Press;2000.

4. Derelian D. President’s Page: Nutrition ed-ucation philosophies—Why we do the thingswe do. J Am Diet Assoc. 1996;96:191.

of Delegates Leadership Team on005. This position is in effect untils republication of the position state-ided full and proper credit is given.must be directed to ADA [email protected] of Wisconsin-Madison, Mad-PhD, RD (The University of Texas at

H, RD (Dairy Council of California,the Public dietetics practice groupblic Relations, Chicago, IL); Susansociates, Columbus, OH); Jean M.iversity, East Lansing, MI); LindaTuscaloosa, AL); Mary Kay Meyer,f Education, Montgomery, AL); Su-ca-Cola Company, Atlanta, GA).group: Dianne Polly, JD, RD (chair);

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Health & Medicine

Total diet approach