Chapter Overview of Determinants of Food Choice and Dietary

Change: Implications for Nutrition Education

2
Overview This chapter provides readers with an overview of the numerous influences
on food choice and dietary practices and their implications for nutrition
education. It also provides a description of the desired competencies
outlined by professional nutrition societies for nutrition educators.

Chapter Outline • Introduction

• Determinants of food choice and dietary behavior
• Food-related determinants
• Person-related determinants
• Social and environmental determinants
• Economic determinants
• Information environment
• Implications for nutrition education
• Implications for competencies and skills for nutrition educators
• Summary

Learning Objectives At the end of the chapter, you will be able to:
• Describe the research evidence for the influences of biological predispo-
sitions, experience with food, personal factors, and environmental factors
on human food choice and dietary behaviors
• Understand the key role of intra- and interpersonal processes in food
choice and dietary behaviors
• Appreciate the importance of these understandings for nutrition educators
• State the competencies needed to be an effective nutrition educator

Nutrition education often is seen as the process of translating the

88 Introduction: Knowledge Is Not Enough findings of nutrition science to various audiences using methods from
You have known a person like Alicia: she knows a lot about nutrition, the fields of education and communication. If only the public knew all
and, in particular, she knows that she should eat more fruits and veg- that we did, nutrition educators think, surely they would eat better.
etables. She just can’t seem to do it. Or Ray, who wants to lose weight Thus, nutrition educators believe that their task is to provide the public
and knows what he is supposed to do, but just can’t seem to get to it. with information to eat well. They plan sessions on MyPyramid and
Or maybe it is yourself—there is some eating habit you want to change food label reading. They provide lists of high-fat or high-fiber foods,
but don’t. or food sources of nutrients such as calcium or vitamins. They discuss

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 Chapter 2  Overview of Determinants of Food Choice and Dietary Change: Implications for Nutrition Education 27

managing food budgets. However, studies show that simply providing

this kind of knowledge is not enough. People often know to eat well
but do not—just like Alicia and Ray.
A survey by a consumer research group has found that whereas about
one quarter of the public consider nutrition to be very important and are
very careful about what they eat, the rest fall almost equally into two
groups that either don’t want to be bothered or that know what they
ought to do but will not or cannot do it (Balzer 1997). A U.S. Department
of Agriculture (USDA) analysis found that 40% of the people surveyed
said their diet needed no improvement. Of the remaining 60%, 23%
were interested in improving their diet, whereas 37% were not (U.S.
Department of Agriculture 2000). Similarly, another survey found that 7
of 10 consumers said their diet needed some improvement. Guilt, worry,
fear, helplessness, and anger were the primary emotions expressed about
their diets. However, they said they knew enough about nutrition: “Don’t
tell us more” (IFIC Foundation 1999). Clearly, then, although many
Americans say their diets need improvement, they also indicate that they
are knowledgeable about nutrition and are just unable to change or are
uninterested in changing. Thus, many other factors besides knowledge
The number of influences on our diet choices is endless.
must influence their food choices and diet-related behaviors.
This is not to say that knowledge is not important: knowledge in
some form is a prerequisite for intentional healthful eating. However, Many factors within each of these categories influence our eat-
food is more than nutrients, and eating is about more than health. ing. These influences are explored in greater detail in the following
Eating is a source of pleasure and is related to many of life’s social sections.
functions. Eating behaviors are acquired over a lifetime, and changing
them requires alterations in these behaviors for the long term—indeed,
permanently. Unlike other health-related behaviors such as smoking, 88 Food-Related Determinants: Biology and
eating is not optional. People have to eat, and any changes they make Experience
are undertaken with a great deal of ambivalence. They want to eat to When asked, most people say their food choices are largely determined
satisfy physical hunger and psychological desires and yet want to be by “taste” (Glanz et al. 1998; Clark 1998; Food Marketing Institute 2002).
healthy, which may require adopting eating patterns that conflict with By taste, they mean flavor, which includes smell and the oral percep-
these desires. tion of food texture as well (Small & Prescott 2005). Sensory-affective
Nutrition education ultimately has to be about food and eating. Un- responses to the taste, smell, sight, and texture of food are a major
derstanding people, their behavior, and the context of their behavior is influence on food preferences and food choices. What are people born
one of the keys to effective nutrition education programs. Thus, it is very with and what is learned?
important for nutrition educators to understand the various forces that
influence an individual’s or a community’s decision to eat in a particular Biologically Determined Behavioral Predispositions
way. This chapter provides a brief overview of the factors influencing
food choice and dietary behaviors for the purpose of helping nutrition The Basic Tastes
educators design more effective nutrition education programs. Humans are born with unlearned biological predispositions toward lik-
ing the sweet taste and rejecting sour and bitter tastes (Desor, Mahler,
& Greene 1977; Mennella & Beauchamp 1996). The liking for the sweet
88 Determinants of Food Choice and taste remains throughout life and appears to be universal to all cultures
Diet-Related Behavior: An Overview (Pepino & Mennella 2005). The liking for salt seems to develop several
People make decisions about food several times a day: when to eat, months after birth, when infants have matured somewhat (Bernstein
what to eat, with whom, and how much. Whether the act of eating is 1990). It has been suggested that these predispositions may have had
a meal or a snack, the decisions are complex and the influences many. adaptive value: the liking for the sweet taste because it signals a safe
Biologically determined behavioral predispositions such as liking of carbohydrate source of calories, and the rejection of bitterness because
specific tastes are, of course, important influences. However, these can it may signal potential poisons (Box 2-1).
be modified by experience with food as well as by various intraper- Preference for fat appears early in infancy or childhood. Fat is less a
sonal and interpersonal factors. In addition, the environment either flavor than a contributor to texture (Mattes 2009). It imparts different
facilitates or impedes the ability of people to act on their biological textures to different foods: it makes dairy products such as ice cream
predispositions, preferences, or personal imperatives. The influences are seem creamy, meat juicy and tender, pastries flaky, and cakes moist.
so numerous as to be overwhelming to try to understand! This chapter Many high-fat foods are those in which fat is paired with sugar (desserts)
simplifies matters by examining these influences in three categories that or salt (potato chips), enhancing their palatability. Foods containing
are commonly used in studying food choice: factors related to food, to fat are more varied, rich tasting, and higher in energy density than are
the individuals making the choices, and to the external physical and nonfat foods and hence are more appealing.
social environment—factors related to food, person, and environment A fifth taste has been identified: umami, a Japanese word for deli-
(Shepherd 1999). ciousness, which is associated with the brothiness of soup or the meati-

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 28 part I  Linking Research, Theory, and Practice: The Foundations

Hunger and Satiety

Box
Many genetic and biological mechanisms control hunger and satiety,
2-1 Meditation on Taste: A Nineteenth-Century ensuring that people will eat enough to meet their energy needs (de
Castro 1999). Throughout most of human history, getting enough food
Viewpoint was the primary challenge. The human body developed to function
in an environment where food was scarce and high levels of physi-
Taste, such as Nature has given to us, is yet one of our senses cal activity were mandatory for survival. This situation resulted in the
(among others such as hearing and sight) that, all things con- development of various physiological mechanisms that encourage the
sidered, procures to us the greatest of enjoyments: body to deposit energy (i.e., fat) and defend against energy loss (Neel
1. Because the pleasure of eating is the only one that, taken 1962; Eaton, Eaton, & Konner 1997; Lowe 2003; Chakravarthy & Booth
in moderation, is never followed by fatigue. 2004). Today’s environment, however, is one in which food is widely
2. Because it belongs to all times, all ages, and all condi- available, inexpensive, and often high in energy density, while minimal
tions. physical activity is required for daily living. Researchers have proposed
3. Because it occurs necessarily at least once a day, and may that the “modern environment has taken body weight control from
be repeated without inconvenience two or three times in an instinctual (unconscious) process to one that requires substantial
this space of time. cognitive effort. In the current environment, people who are not devot-
4. Because it can be combined with all our other pleasures, ing substantial conscious effort to managing body weight are probably
and even console us for their absence. gaining weight” (Peters et al. 2002). This means that nutrition education
5. Because the impressions it receives are at the same time has an important role.
more durable and more dependent on our will.
Sensory-Specific Satiety
6. Finally, because in eating we receive a certain indefin-
able and special comfort, which arises from the intuitive Humans also appear to have a built-in biologically determined sensory-
consciousness that we repair our losses and prolong our specific satiety mechanism whereby they get tired of one taste and
existence by the food we eat. move on to another one over a short time span, such as while eating a
meal (Rolls 2000). Such a mechanism probably had adaptive value for
Source: Brillat-Savarin, A. S. 1825. The physiology of taste: Meditations on
humans because it ensures that people eat a variety of different-tasting
transcendental gastronomy. Reprinted 1949. Translated by M. F. K. Fisher.
foods and thus obtain all the nutrients they need from these foods. Stud-
New York: Heritage Press. Reprinted 2000. Washington, DC: Counterpoint
ies also reveal that for adults, the variety of foods available influences
Press.
meal size, with greater variety stimulating greater intake. Again, this
mechanism might have been very useful in a situation of scarce food
supply. However, in today’s food environment, the variety possible in
meals because of the wide array of foods available may contribute to
overweight.
These biologically determined predispositions contribute to some
degree to preference and to food intake, particularly in children, and
ness in mushrooms. It seems to be related to glutamate, an amino acid,
are shown in Figure 2-1. However, as you shall see in the next section,
and captures what is described as the taste of protein in food (de Araujo
et al. 2003). In addition, because some taste buds are surrounded by
free nerve endings of the trigeminal nerve, people are able to experi-
ence the burn from hot peppers and the coolness of menthol (Mela &
Mattes 1988).
Biologically
Individual Differences: Nontasters and Supertasters Determined
Behavioral
Some genetic differences in sensitivity to tastes exist between individu-
Predispositions
als. Research shows that people differ in their responses to two bitter
compounds called phenylthiocarbamide (PTC) and 6-n-propylthiouracil • Taste/pleasure
(PROP). When given PTC-impregnated paper or PROP in liquid form, • Sweet, sour, salt, and bitter
• Hunger/satiety mechanisms
some people cannot taste it and are labeled nontasters, others are me-
• Sensory-specific satiety
dium tasters, and still others are supertasters. These individuals differ in
the number of fungiform taste buds they have, with supertasters having
the most taste buds and nontasters the least (Tepper & Nurse 1997).
Such differences between individuals may be related to differences in
being able to discriminate between different foods and may result in
differences in liking for certain foods, such as some bitter vegetables, Food Choice
alcohol, citrus fruit, and fatty or sugary foods (Tepper & Nurse 1997; and Diet-Related
Preferences/dislikes:
Behaviors
Duffy & Bartoshuk 2000; Kaminski, Henderson, & Drewnowski 2000). Sensory-affective factors
It has been suggested that such differences in responses to food may be
related to food intake patterns and body weight variation (Tepper 1998, Figure 2-1  Our biologically determined behavioral predispositions that
2008; Keller & Tepper 2004). influence food choices and dietary behaviors.

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 Chapter 2  Overview of Determinants of Food Choice and Dietary Change: Implications for Nutrition Education 29

most preferences are learned or conditioned—which is good news for

nutrition educators because that means they can be modified.

Experience with Food

Research in this area suggests that people’s liking for specific foods and
food acceptance patterns are largely learned (Birch 1999; Mennella,
Griffin, & Beauchamp 2004; Mennella & Beauchamp 2005; Beauchamp
& Mennella 2009). Thus, what humans seem to inherit primarily is the
innate capacity to learn about the consequences of eating particular
foods. Learning, in this context, does not mean cognitive learning, but
rather physiological learning or conditioning arising from the positive or
negative consequences that people experience from repeated exposure
to a food.

Pre- and Postnatal Experience

Such learning begins early, possibly even prenatally. Flavors such as
garlic and alcohol have been detected in mothers’ milk, possibly fa-
miliarizing infants with these flavors (Beauchamp & Mennella 2009).
In one study, breastfed infants whose mothers were fed carrot juice
during pregnancy or during lactation showed increased acceptance of
Neophobia increases through early childhood.
carrot flavor in their cereal at weaning (Mennella, Jagnow, & Beau-
champ 2001). In another study, infants who were fed a formula made
of an unpleasant-tasting, sour and bitter protein hydrosylate from birth
(from necessity because they did not tolerate milk) drank it well when is safe to eat and what is not. However, neophobia can be reduced by
tested with the hydrosylate formula at 7 months, whereas those fed milk repeated opportunities to sample new foods, sometimes requiring 12 to
formula rejected it (Mennella et al. 2004). Infants fed hydrosylate liked 15 exposures (Birch & Marlin 1982; Birch 1998, 1999), probably through
sour tastes into early childhood (Liem & Mennella 2002). a “learned safety mechanism.” That is, when eating a food is not fol-
lowed by negative consequences, increased food acceptance results.
Learning from the Physiological Consequences of Once the foods are familiar, the preferences tend to persist (Skinner
Eating: Preferences and Aversions et al. 2002). In addition, tasting or actual ingestion has been found to
How humans feel physiologically after eating a food can have a power- be necessary—not just looking at or smelling the food (Birch, McPhee,
ful impact on food preferences. If eating is followed by negative effects, Shoba, Pirok et al. 1987). Picky or fussy eating is somewhat different—
such as a feeling of nausea, a conditioned aversion follows. Conditioned it is the rejection of a large proportion of familiar (as well as novel)
aversions can be quite powerful. A one-time experience of illness fol- foods, tending to result in a diet that is lower in variety (Dovey et al.
lowing eating a food can turn individuals off that food for decades. On 2008). This quality tends to persist, even into adulthood, and may have
the other hand, liking for foods usually develops more slowly through a genetic component. Here, even more frequent food exposures may be
a process of learned or conditioned preference, whereby repeated eating necessary for acceptance to occur, presenting a challenge to parents and
of a food, or familiarity, is followed by pleasant consequences such as nutrition educators alike.
a feeling of fullness or satiety. In sum, with repeated consumption, preference for initially novel
Conditioning of food preferences continues throughout a person’s foods tends to increase. Thus, if children are exposed to many high-
life, but early experience with food and eating is especially crucial in sugar, high-fat, and high-salt foods at home, at school, and in other
the development of eating patterns, in terms of both the kinds of food settings, then these foods will become more familiar and will become
the person comes to like and the amount he or she eats. Experience preferred over those that remain relatively unfamiliar, such as vegetables
with food influences the development of eating patterns of children and or whole grains.
adults in several ways.
Experience and the Basic Tastes
Exposure, Familiarity, and Learning to Accept New Foods Biologically determined behavioral propensities can be modified by
Humans, like other omnivores, experience the “omnivore’s dilemma”: experience in adults as well (Pliner, Pelchat, & Grabski 1993; Pelchat &
they need to seek variety in their diets to meet nutritional requirements, Pliner 1995). For example, those who eat lower-salt diets come to like
but ingesting new substances can be potentially dangerous (Rozin 1988). them more (Beauchamp, Bertino, & Engelman 1983; Mattes 1997). The
This dilemma can be resolved through familiarity and conditioning as dislike for bitterness can be overcome, as shown by the infant study de-
described in the following sections. scribed earlier and by the fact that people come to like a variety of bitter
tastes, such as coffee, dark chocolate, or bitter vegetables such as broc-
Neophobia and Picky/Fussy Eating coli. Sour tastes, such as vinegar and grapefruit, can also become liked.
Although food neophobia, or negative reactions to new foods, is minimal Likewise the liking for dietary fat can be modified. Studies have found that
in infants, it increases through early childhood so that 2- to 5-year-olds, those who switched from a high-fat diet to naturally low-fat foods such
like other young omnivores, demonstrate neophobia (Birch 1999). This as grains and vegetables (Mattes 1993) or to reduced-fat foods (Ledikwe
would have adaptive value because infants are fed by adults, but tod- et al. 2007) came to like the fat taste less. Maintaining these changed
dlers are beginning to explore their world and have not learned yet what preferences involved continuing to eat these new foods.

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 30 part I  Linking Research, Theory, and Practice: The Foundations

Learning What Fullness Means: Conditioned Satiety cleaning up the toys. Here, have some peanuts.” The opposite is true
Research shows that in both young children and adults, a feeling of full- if the child is asked to eat a food to obtain a reward: “If you eat your
ness or satiety is also influenced by associative conditioning (Johnson, spinach, you can watch TV.” In particular, requiring eating of a less-liked
McPhee, & Birch 1991; Birch & Fisher 1995). The ability to learn about food to obtain a better-liked food (“You can have dessert if you eat your
how full familiar foods can make you feel may explain how meals can spinach”) can decrease even further the liking for the initially less-liked
be terminated before people have yet experienced the physiological cues food because children reason (as do adults) that the food must taste
that signal satiety. Thus, as a result of repeatedly consuming familiar bad if they have to be bribed to eat it. In addition, because the foods
foods, people learn about the “filling” and the “fattening” quality of used as rewards are typically those high in sugar, fat, and salt (e.g.,
familiar foods and normally make adjustments in what they eat in an- desserts and salty snacks), such a practice may enhance even further
ticipation of the end of the meal (Stunkard 1975). the preference for these items.

Our Preference for Calorie-Dense Foods The Way Parents Offer Foods
Humans seem to prefer calorie-dense foods over calorie-dilute versions Pressure to eat has been associated with lower levels of children’s intake
of the same foods (Birch, McPhee, Shoba, Steinberg et al. 1987; Birch and weight and higher levels of pickiness. It could be the other way
1992). The biological mechanism that assists people to like calorie-dense around also: that parents of picky eaters and thin children may apply
foods was very adaptive when food, and especially calorie-dense food, pressure to eat (Ventura & Birch 2008). Excessive restriction of foods
was scarce and probably explains the universal liking for calorie-dense can make the restricted foods more attractive. Thus, highly restrictive
foods in adults. The finding that tasty high-fat and high-sugar foods parental controls limit the opportunities for children to practice self-
induce overeating and obesity in animals (Sclafani & Ackroff 2004) regulation and maintain a healthy weight (Birch, Fisher, & Davison
suggests that this feature is less adaptive for humans in today’s environ- 2003; Faith et al. 2004). This can also result in overeating in the absence
ment, where calorie-dense foods are widely available. of hunger when given free access to an array of tasty snacks (Birch et
al. 2003). However, in some populations, mothers’ own flexible restraint
Learning from Social-Affective Context: can result in more healthful food choices for themselves and their
Social Conditioning children (Robinson et al. 2001; Contento, Zybert, & Williams 2005),
The social-affective environment also has a powerful impact on food this control being interpreted as expressing parental responsibility and
preferences and on the regulation of how much people eat. Food is eaten caring (Lin & Liang 2005). At the same time, parents’ own practices in
many times a day, providing opportunities for individuals’ emotional terms of eating more fruits and vegetables highly influence what their
responses to the social context of eating to become associated with the daughters eat (Fisher et al. 2002). It has been concluded that the best
specific foods being eaten. This is particularly true in children. practice is for adults to offer an array of healthful foods and for chil-
dren to choose which of them to eat (Satter 2000). Thus, the practices
Social Modeling of parents, child-care centers, and nutrition educators who work with
Children learn about food not only from direct experience of eating but young children can have important influences on the children’s body
also from observing the behaviors of peers and adults (Birch 1999). Fa- weight and eating habits (Birch & Fisher 2000). Many of these same
miliar adults have been found to be more effective than unfamiliar ones, findings apply to adults as well and can inform the work of nutrition
and having the adults themselves eat the same foods is more effective educators (Pliner et al. 1993).
than when adults offer the foods without eating the foods themselves
(Harper & Sanders 1975; Addessi et al. 2005). Food preferences also Summary of Our Experience with Food
increase when adults offer the foods in a friendly way (Birch 1999). Biologically determined behavioral propensities, physiological mecha-
nisms, and conditioning through experience with food all influence
Parenting Practices people’s sensory experience of food and food preferences. These influ-
Parenting practices related to food are strategies used to provide for the ences are summarized in Figure 2-2. Given that energy-dense, high-fat,
nourishment of children. The practices of parents, family, and other high-sugar foods are widely available in the environment, tend to be
caregivers can encourage healthful eating or modify and interfere with used as rewards, are most often offered in positive social contexts such
the child’s ability to respond to food appropriately. Parents and caregiv- as celebrations and holidays, are liked by other family members, satisfy
ers who offer healthful foods in appropriate portion sizes and enjoy the biological predispositions, and produce positive feelings of being full,
foods themselves are likely to facilitate healthful eating in their children. it is not surprising that they become highly preferred by adults and
For example, children who are led to pay attention to their internal cues children alike. On the other hand, fewer opportunities are provided for
(feelings of hunger and being full) are more likely to be able to eat the people to learn to like whole grains, fruits, and vegetables in similar
appropriate amount of food than are those who are asked to focus on social contexts.
externally oriented cues such as the time of day or the amount of food Food preferences have a very direct impact on children’s intakes
remaining on the plate (Birch, McPhee, Shoba, Steinberg et al. 1987; because children tend to eat the foods they like and reject the foods
Birch 1999). Children at age 3 eat about the same amount regardless they do not like in terms of taste, smell, or texture. The relationship
of the portion size of the food offered. However, by age 5, children eat between taste preferences and food choices is more indirect in older
more when they are offered more (Rolls, Engell, & Birch 2000). children and adults because experience with food and beliefs about the
impact of food on weight, appearance, health, or other valued outcomes
Rewards can modify their propensity to act on their preferences for high-fat and
The use of rewards has complex consequences (Birch 1999; Savage, high-sugar foods. These considerations may lead individuals to eat more
Fisher, & Birch 2007; Ventura & Birch 2008). If a food is given as a re- healthful diets even if these are not the most appealing, as we discuss
ward, there is a significant increase in preference: “You did a good job in the next section.

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 Chapter 2  Overview of Determinants of Food Choice and Dietary Change: Implications for Nutrition Education 31

Intrapersonal Determinants
Experience with Food
Associative conditioning Perceptions, Beliefs, Attitudes, and Motivations
Our food choices and dietary practices are influenced by a variety of
Biologically Physiological personal factors, such as our beliefs about what we will get from these
Determined Conditioning
Behavioral choices. We want our foods to be tasty, convenient, affordable, filling,
• Familiarity:
Predispositions familiar, or comforting. Our food choices may be determined by the
learned safety
• Taste/pleasure • Conditioned food personal meanings we give to certain foods or practices, such as chicken
• Sweet, sour, salt, and bitter preferences soup when we are ill, or chocolate when we feel self-indulgent. We may
• Hunger/satiety mechanisms • Conditioned satiety also be motivated by how the food will contribute to how we look, such
• Sensory-specific satiety as whether it will be fattening or, in contrast, good for our complexion.
Social Conditioning Our food- and nutrition-related behaviors are also determined by our
• Social-affective context attitudes toward them—for example, our attitudes toward breastfeeding
• Parenting practices
or certain food safety practices. Our identity in relation to food may also
influence our behaviors. For example, some teenagers may see them-
selves as health conscious, but many others may see themselves as part
of the junk-food-eating set. We may see that there are health benefits to
Food Choice eating more healthfully but may consider the barriers, such as high cost
and Diet-Related
Preferences/dislikes: or the effort required to prepare the foods in healthful ways, just too
Sensory-affective factors Behaviors
great to take action. Or perhaps we lack confidence in preparing foods
in ways that are tasty and healthful. Or again, we may have specific
Figure 2-2  Our experiences with food that influence food choices and culturally related health beliefs that influence what we eat. For example,
dietary behaviors. although the concepts of balance and moderation are common among
many cultures, individuals may come from cultures in which foods are
88 Person-Related Determinants believed to have hot and cold qualities and must be eaten in such a way
Biology and personal experiences with food are not the only influences as to balance cold and hot body conditions. These cultural beliefs can
on individuals’ food intake. People also develop perceptions, expecta- have a major influence on food choices.
tions, and feelings about foods. These perceptions, attitudes, beliefs, We come to value some aspects of food over others. In the United
values, emotions, and personal meanings are all powerful determinants States, the major values in choosing foods are taste, convenience, and
of food choice and dietary behavior, as are people’s interactions with cost (Glanz et al. 1998). In Europe, the major values are quality/fresh-
others in their social environment. These influences or determinants ness, price, nutritional value, and family preferences, in that order
are shown in Figure 2-3. (Lennernas et al. 1997).

Person-Related
Determinants

Experience with Food

Intraperson
• Associative conditioning Factors
• Perceptions
Biologically Physiological • Attitudes
Determined Conditioning • Beliefs
Behavioral
• Familiarity: • Motivations
Predispositions
learned safety and values
• Taste/pleasure • Conditioned food • Personal
• Sweet, sour, salt, and bitter preferences meanings
• Hunger/satiety mechanisms • Conditioned satiety • Knowledge
• Sensory-specific satiety and skills
• Social norms
Social Conditioning
• Cultural
• Social-affective context norms
• Parenting practices
Interperson
Factors
• Family and social
networks

Food Choice
and Diet-Related
Sensory-affective Beliefs, attitudes, norms,
factors knowledge, and skills Behaviors

Figure 2-3  Intra- and interpersonal factors that influence food choices and dietary behaviors.

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 32 part I  Linking Research, Theory, and Practice: The Foundations

Food rejections are also highly influenced by psychological processes, and expectations to varying degrees. For example, teenagers may feel
based on both previous experience and beliefs. Rozin and Fallon (1987) pressure to eat less-nutritious fast food items in a choice situation with
place the motivations for rejecting foods into three main categories: peers (e.g., after school), or individuals may experience family members’
(1) sensory-affective beliefs (e.g., the food will smell or taste bad) that expectations that they will eat in a certain way. Whether to breast-feed
lead to distaste, (2) anticipated consequences or beliefs about the pos- may be influenced very much by the desires of a woman’s family. Our
sible harmful outcomes of eating certain foods (e.g., vomiting, disease, perceptions of our status and roles in our communities are also impor-
social disapproval), leading to danger, and (3) ideation or ideas about tant. The food choices and eating patterns of celebrities create social
the origin or nature of foods, leading to disgust. expectations for us all. What others in our community think are appro-
Knowledge regarding all these numerous person-related factors is priate foods to eat in various situations may also create social pressures.
crucial for nutrition educators so that we can better understand and Thus, our choice of foods may be heavily influenced by our perceptions
assist our audiences to eat more healthfully. of the social and cultural expectations of those around us.

The Process of Choosing Foods Interpersonal Determinants

Environmental Stimuli Within societies, we all participate in a network of social relationships,
Our thoughts and feelings interact with what we experience in the the extensiveness and density of which vary among individuals. These
environment. For example, we you may see a news story on the role of networks involve family, peers, coworkers, and those in various orga-
fruits and vegetables in reducing cancer risk, or a friend of ours develops nizations to which we belong. For example, in one study, food choices
colon cancer (external stimuli). We process such environmental stimuli were 94% similar between spouses, 76% to 87% similar between ado-
or external events both cognitively and emotionally. These stimuli are lescents and their parents, and 19% similar between adolescents and
filtered through a host of internal personal reactions of the kind listed their peers (Feunekes et al. 1998). Food choices and eating patterns
previously, such as our perceptions, beliefs, values, expectations, or are also influenced by the need to negotiate with others in the family
emotions, and together these filters determine what actions we will about what to buy or eat (Connors et al. 2001; Contento et al. 2006).
take. For example, we may process the idea of eating more fruits and Relationships with peers and those with whom we work also have an
vegetables in terms of taste, convenience, expected benefits, perceived impact on our day-to-day choices (Devine et al. 2003).
barriers, or what our friends and relatives do, in addition to our con- Indeed, eating contexts and the management of social relationships
cerns about getting cancer. Consequently, our decisions about whether in these numerous contexts play a major role in what people eat. For
to eat more fruits and vegetables to reduce cancer risk are based on our example, if a woman becomes motivated to reduce her fat intake by
beliefs and knowledge about expected consequences (of eating fruits and using nonfat milk instead of whole milk, she may find that other family
vegetables), our motivations and values about desired consequences members like whole milk and do not want to switch. She must decide
(reduced risk of cancer), and our personal meanings and values (with whether to go along with family wishes or to buy low-fat milk separately
respect to developing cancer). for herself. She also must consider whether she has the space in the
refrigerator to keep both types of milk, which then becomes a barrier
Trade-Offs to change.
In the food choice process, most times we will also need to make trade-
offs among various criteria or reasons for food choice, such as among
88 Social and Environmental Determinants
health considerations, taste, and cultural expectations. People may also
trade off between items within a meal or between meals. For example, Social and environmental factors are powerful influences on food choice
individuals may choose an item for its fillingness (e.g., a donut) but and nutrition-related behaviors and must be considered by nutrition
then balance it with something perceived as more healthful (e.g., or- educators in planning programs.
ange juice). Or individuals may choose a “healthy” dinner to balance
what they consider to have been a less than healthful lunch (Contento Physical/Built Environment
et al. 2006). The built environment includes all aspects of the environment that
are modified by humans, including food outlets (e.g., grocery stores),
Knowledge and Skills homes, schools, workplaces, parks, industrial areas, and highways.
People’s food-related knowledge and skills also influence what they There is a growing body of evidence that the built environments in
eat. In particular, their misconceptions may play an important role. For relation to food and physical activity have important impacts on health
example, a national survey found that about one third of individuals (Sallis & Glanz 2009).
thought that the recommended number of servings of fruit and veg-
etables per day was one, and another third thought it was two; only Food Availability and Accessibility
8% thought it was five (Krebs-Smith et al. 1995). Many consumers In developed countries and increasingly in less developed countries, food
have major misconceptions about the amounts of fat and energy in and processed food products are available in an ever-widening array of
many common foods and in their own diets (Mertz et al. 1991; Mela choices. More than 50,000 food items are available in U.S. supermar-
1993; Brug, Glanz, & Kok 1997). Lack of skills in preparing foods also kets, and about 9,000 new brand-name processed food products are
influences what individuals eat. introduced each year (Gallo 1998; Lipton, Edmondson, & Manchester
1998). The typical shopper averages 2.2 trips to the supermarket each
Social and Cultural Norms week (Food Marketing Institute 2005). Overall availability may be de-
Humans are social creatures. We all live in a social and cultural context scribed as the array of food options that are present in the food system
and experience social norms and cultural expectations, which can be that are acceptable and affordable. Accessibility may be thought of as
extraordinarily powerful. We feel compelled to subscribe to these norms “immediate” availability, referring to the readiness and convenience of

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 Chapter 2  Overview of Determinants of Food Choice and Dietary Change: Implications for Nutrition Education 33

a food—whether the food requires little or no cooking, is packaged in a physical activity or obesity of residents in those neighborhoods (Ferreira
convenient way so that it can be eaten anywhere, or whether it can be et al. 2007; Wendel-Vos et al. 2007).
stored for some time without spoilage.
Social Structures and Cultural Environment
Markets Social environments and cultural contexts are no less important than
Studies have shown that the availability of more healthful options in the physical environment. Social influences and cultural practices all
neighborhood grocery stores, such as fruits and vegetables or low-fat influence food choice and dietary behavior (Rozin 1996).
milk, is correlated with these foods being more available in the homes,
which in turn is related to a higher quality of food choices and intakes Social Relations
(Cheadle et al. 1991; Morland, Wing, & Diez Roux 2002). Thus, what is Society has been described as a group of people interacting in a common
available in the community influences what is purchased and consumed. territory who have shared institutions, characteristic relationships, and
The availability and accessibility of fruits and vegetables at home and a common culture. Most eating occurs in the presence of other people.
school enable their consumption by children (Hearn et al. 1998). A The effect can be positive or negative in terms of healthful eating, in part
study of data from 28,050 zip codes and the 2000 census found that because family and friends serve as models as well as sources of peer
low-income neighborhoods had only 75% as many chain supermarkets pressure. For example, there is evidence that eating with others can lead
as middle-class neighborhoods and that African American neighbor- to eating more food compared with eating alone, especially when the
hoods had only 52% and Hispanic neighborhoods 32% as many chain others are familiar people (de Castro 1995, 2000). Spending more time
supermarkets as in white neighborhoods (Powell et al. 2007). There is at a meal eating with others also increases intake. Eating with others
now discussion of “food deserts” in neighborhoods. can result in pressure to eat higher-fat foods. On the other hand, eating
Accessibility also is dependent on where sources of food are physi- with others can also result in pressure to try new foods that are healthy
cally located. Supermarkets, where a wide range of foods is available, (MacIntosh 1996). Parents’ own eating patterns likely influence that of
may require transportation to reach, limiting the accessibility of food for their children (Fisher et al. 2002; Contento et al. 2005), and it has been
many people, such as older people who are no longer able to drive or shown that children and adolescents who eat with their families most
lower-income people without cars. The types of foods that are readily days each week have better-quality diets than those who eat with their
available in the local grocery stores, small corner stores, and restaurants families less frequently (Gillman et al. 2000).
within a given community depend on potential profits, consumer de-
mand, and adequate storage and refrigeration facilities. The foods served Cultural Practices and Family of Origin
or products stocked in them thus tend to be those that sell well, which Culture has been described as the knowledge, traditions, beliefs, values,
are not always the most nutritious. Farmers’ markets provide fresh, and behavioral patterns that are developed, learned, shared, and trans-
local foods but may require transportation to reach and are often only mitted by members of a group. It is a worldview that a group shares,
seasonal. Hence, some foods that are very important for health, such and hence it influences perceptions about food and health. Cultural
as fruits and vegetables, may not be readily accessible or are available practices and family of origin have an important impact on food choices
only at a higher cost. and eating practices even in modern, multiethnic societies where many
different types of cuisine are available. Those from different regions of
Workplaces, Schools, and Homes the country may have different practices. For example, for those from
Foods available at or near workplaces also tend to be those that are the American South a home-style meal is chicken-fried steak, mashed
convenient, low in cost, and that sell well. In most schools, food is avail- potatoes, corn bread, and bacon- and onion-laden green beans, with pie
able and accessible. The National School Lunch Program provides meals for dessert, whereas those who live in Texas may expect to eat barbecue
that conform to federal guidelines that specify nutritional standards to
be met. Increasingly, however, à la carte offerings, vending machines,
and school stores compete for student participation; the foods available
from these sources are not subject to these guidelines. Participation in
the School Lunch Program declines with age so that by high school two
thirds of students are obtaining their lunch from other sources. The
majority of competitive foods in these other venues have been found to
be high-fat and high-sugar items, including snack chips, candy, and soft
drinks. It has been shown that what is available in school environments
affects the dietary behaviors of children (Briefel et al. 2009). Within
the home, accessibility means that a vegetable is not just available in
the refrigerator but is already cut up and ready to eat, or fruit has been
washed and is sitting on the counter ready to eat. The limited accessi-
bility of healthful, convenient foods in many settings may narrow good
choices and make it difficult to eat healthfully.

Built Environment and Physical Activity

The role of environmental determinants of physical activity has also
been studied. The walk-ability of neighborhoods as well as the avail-
ability and accessibility of neighborhood safe parks, green spaces, and
physical activity facilities have been shown to have some impact on Families who eat together generally have better-quality diets.

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 34 part I  Linking Research, Theory, and Practice: The Foundations

or Tex-Mex foods that are hot and spicy. Those who have immigrated
from different countries from around the world maintain some of their
cultural practices in varying degrees, and these traditions influence
eating patterns.
Cultural rules often specify which foods are considered acceptable
and preferable, and the amount and combination of various categories
of foods that are appropriate for various occasions. The cultural practices
of family and friends, especially at times of special celebrations and holi-
days, provide occasions to eat culturally or ethnically determined foods
and reinforce the importance of these foods. If dietary recommendations
based on health considerations conflict with family and cultural tradi-
tions, individuals wanting to make dietary changes may find themselves
having to think about and integrate their cultural expectations with This child was asked to draw a picture of her family eating their favorite meal
their concern about their personal health. All of these considerations together.
influence individuals’ willingness and ability to make changes in their
diets. These beliefs and practices must be carefully understood so that
nutrition educators can become culturally competent and can design
culturally sensitive nutrition education programs. Income
People in the United States spend only about 10% of their disposable
Social Structures and Policy income on food prepared and consumed at home, compared with 15%
The organizations to which we belong can have a profound effect on in Europe and Japan, 35% in middle-income countries, and 53% in low-
our eating patterns. Some are voluntary organizations, such as religious, income countries (Seale, Regmi, & Bernstein 2003). However, this is an
social, or community organizations; others include schools, our places average. The amount of money spent on food depends on income level.
of work, and professional associations to which we must belong. The Upper-income individuals in the United States spend more money on
influence of these organizations comes from their social norms as well food, but it is a smaller proportion of their income—about 8%. Lower-
as their policies and practices. Local, state, and national government income households economize by buying more discounted items and
policy can govern and determine the availability and accessibility of generic brands and thus spend less on food; despite this, food accounts
opportunities for healthy eating and active living. for 20% to 35% of their income (Putnam & Allhouse 1999). Compared
with other economic variables, income has the strongest marginal im-
pact (i.e., additional effect) on diet behavior: those with higher incomes
88 Economic Determinants eat a higher-quality diet (Macino, Lin, & Ballenger 2004).
Many factors in the economic environment influence food choices and In this context, statistics show that about 11% to 12% of American
dietary practices, among them price of food, income, time, and formal households are food insecure, meaning that they do not have access,
education. Nutrition educators must consider these factors when design- at all times, to enough food for an active, healthy life for all household
ing nutrition education programs. members. The prevalence of food insecurity with hunger is about 3%
to 4%, hunger being defined as the uneasy or painful sensation caused
Price by lack of food (Food Research and Action Council 2005).
Economic theory assumes that relative differences in prices can partially
explain differences among individuals in terms of their food choices and Time Use and Household Structure
dietary behaviors. The price of food as purchased is usually per item, Surveys and time use diaries show that the amount of time people spend
by unit weight, or by volume. However, price can also be considered in on food-related activity in the home depends on many factors, including
terms of the amount of food energy obtained per dollar. Processed foods whether men or women are employed outside the home and whether
with added fats and sugar are cheaper to manufacture, transport, and they have children (Robinson & Godbey 1999; National Pork Producers
store than are perishable meats, dairy products, and fresh produce. This Council 2002; Cutler & Glaeser 2003).
is partly because sugar and fat on their own are both very inexpensive, Time is scarce for all households, regardless of income. Many people
resulting in part from government agricultural policies. A diet made up with whom nutrition educators work today say they are too busy to
of refined grains and processed foods with added sugar and fats can prepare healthful foods or to cook at all. This is particularly true of
be quite inexpensive (a day’s worth of calories for one to two dollars). low-income families who often work long hours. For some households,
Beans cost about the same, but animal protein sources may cost 5 to 10 time constraints may limit personal investments in healthier behaviors.
times more per calorie, and fruits and vegetables (except potatoes and For example, it has been found that men and women who are married
bananas) can cost some 50 to 100 times more per calorie than high-fat, with children have a higher-quality diet than single parents, probably
high-sugar, mass-produced food products (Drewnowski & Barrett-Fornell because they are better able to attend to their own health (Macino et
2004). When freely chosen diets were studied, it was found that adding al. 2004). Nutrition educators need to consider these time constraints
fats and sweets was associated with a 5% to 40% decrease in overall in the development of nutrition education interventions.
food costs, whereas adding fruits and vegetables was associated with
a 20% to 30% increase in overall food costs (Drewnowski, Darmon, & Education
Briend 2004). Not surprisingly, low-income individuals eat fewer fruits In general, more highly educated individuals eat a higher-quality diet
and vegetables. These disparities in cost may also contribute to the and are less sedentary partly because of watching less TV (Macino et
higher prevalence of obesity in those of lower socioeconomic status. al. 2004). People with more education may be better able to obtain,

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 Chapter 2  Overview of Determinants of Food Choice and Dietary Change: Implications for Nutrition Education 35

these various media is high: children ages 2 to 4 years are exposed to

about 4 hours a day of various media. This increases to 8 hours a day
in middle school, in consideration of the fact that adolescents often
use several media simultaneously. Television viewing is dominant and
increases to 25 hours per week through childhood, and then declines
somewhat in adolescence to 19 hours a week as music becomes more
important. Adults spend about 15 to 17 hours a week on television
viewing. The media are the main source of information about food and
nutrition for many people, making them collectively a major source of
informal nutrition education. Information about food and nutrition is
now widely covered in newspaper articles, magazines, and television
programs. Many magazines are devoted to health and nutrition, and
entire channels on TV are devoted to food-related shows. As Nutrition
Education in Action 2-1 shows, media and other influences also affect the
decisions mothers make with regard to their children.

Advertising
The media have demonstrated a powerful capacity to persuade and
the U.S. food system is the economy’s largest advertiser (Gallo 1995).
The food industry spends about $26 billion per year on marketing and
advertising (Elitzak 2001), with $15 billion aimed at children. Most of
this is spent by companies that produce high-fat and/or high-sugar
products that are highly processed and packaged; examples include $150
million for candy bars, $580 million for soft drinks, and more than $1.5
billion for fast foods (Center for Science in the Public Interest 2003).
Information on the impact of marketing on sales of food products is
not easily available because it is considered proprietary information.
However, there is evidence that these marketing activities influence food
choices (Taras et al. 2000; Borzekowski & Robinson 2001; Story & French
Consumers are inundated with food choices at the supermarket. 2004; Institutes of Medicine 2006). In addition, federally sponsored
promotions of commodities such as milk, cheese, grapefruit juice, and
orange juice resulted in greater sales (Gallo 1996). Just for comparison,
process, interpret, and apply information that can make them more able the National Cancer Institute’s budget for its program to promote fruit
to eat healthfully. They also may be more forward looking and optimistic and vegetable intake is about $4 million. The ubiquity of advertising,
about their future and thus willing to seek health information and make together with the amount of time people spend watching television
greater investments in their health (Macino et al. 2004). and are exposed to marketing, makes these influences considerable.
The environmental influences on food choice and dietary behavior are
Grocery Shopping Trends summarized in Figure 2-4.
The influences described earlier affect how people shop for food. Sur-
veys of grocery shoppers have found that about one third of shoppers
are economizers, who are budget conscious and usually come from
88 Implications for Nutrition Education
lower-income households. They plan weekly menus, check for sales, In Figure 2-4, a series of concentric circles schematically represents the
and use coupons. Another third are carefree spenders, who are the least ways in which biological, experiential, personal, social, and environ-
price conscious and least likely to compare prices and use coupons. mental determinants influence food choice and diet-related practices.
The final third are time-challenged shoppers who are obsessed with No factor is independent of any other, but they are all related, each
convenience because of their hectic, multitasking lifestyles. They have larger circle encompassing the influences of the smaller circles. These
the largest households and are most likely to have preteen children (Food concentric circles reflect levels of influence or overlapping spheres of
Marketing Institute 2002). influence.

Addressing Food-Related Determinants

88 Information Environment Addressing food-related determinants is very important in nutrition
Knowing the information context of the audience is important for nutri- education. Food is a powerful primary reinforcer that produces instant
tion educators to design messages and programs that are appropriate. gratification in taste and a sense of satisfaction and fullness. Because
taste or preference is also shaped by repeated experience with foods
Media and eating, nutrition educators working with any age group need to
The current media-saturated environment has undergone revolutionary create opportunities to offer nutritious and healthy foods such as fruits
changes in the past two decades, resulting in the availability to individu- and vegetables frequently in a positive social-affective context so that
als and households of numerous television channels, radio stations, individuals will come to like nutritious foods. Similarly, interventions
websites, and other emerging communication routes. Time spent on to decrease the intake of food components such as fat or salt should

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 36 part I  Linking Research, Theory, and Practice: The Foundations

help people adopt eating plans that include foods naturally low in these

2-1
components for a long enough time that people can become used to
Nutrition Education in Action them and come to like them. Indeed, in a long-term nutrition education
intervention with women, those who were able to stay with a low-fat
Multiple Influences on Breastfeeding: diet for 2 years or more were those who came to dislike the taste of fat
A Study of Low-Income Mothers (Bowen et al. 1994).
The use of foods in positive contexts as rewards or treats enhances
Media influences: TV shows and print media foster the perception liking for those foods, whereas having people eat a food to obtain a
that formula feeding is the norm whereas breastfeeding is not. reward likely produces a decline in liking for that food. Because foods
Instead, women’s breasts are used to advertise lingerie, perfume, high in fat, sugar, and salt are widely available, particularly in posi-
or alcohol: these images influence personal beliefs. tive social-affective contexts such as celebrations, nutrition educators
Policy influences: There is legislation that supports breastfeeding in need to help people recognize the impact of such social environmental
the work setting. Legislation also requires low-income mothers to forces on their eating patterns and acquire the competencies to address
work, thus making breastfeeding difficult. them.
Although these mechanisms influence eating behaviors directly, they
Community and organizational factors: Workplaces can be supportive also exert their influence through psychological processes that can be
or not. Baby-friendly hospitals can encourage breastfeeding, whereas perhaps even more powerful. Individuals develop attitudes toward foods,
free infant formula packages on discharge do not. Returning to values, beliefs, and personal meanings, and these intra- and interper-
work predicts quitting breastfeeding after having initiated it in the sonal determinants also influence food choices and eating patterns.
hospital.
Addressing Environmental Determinants and
Interpersonal factors: The father of the baby can be a major influence,
Personal Perception
followed by the mother’s mother. Cultural beliefs are also a factor,
such as the belief that women may not have enough milk, particularly Nutrition education needs to address environmental factors by pro-
when babies are “greedy.” moting the increased availability and accessibility of wholesome and
healthful foods and active living options and by taking into account
Personal factors: Beliefs, knowledge, and skills. The study found that the resources people have, their social networks and relationships, and
cultural beliefs positive to breastfeeding were often outweighed the influence of media and advertising. Nutrition education must also
by personal beliefs or anticipation that breastfeeding would be address social structures and policy. However, these environmental de-
painful. There also were concerns about the appropriateness of terminants are also filtered by people’s attitudes, beliefs, and values,
feeding in public settings because of sexual images in the media which in turn influence food choices and dietary behavior.
or the disapproval of the baby’s father.
Availability: Reality and Perception
Media Availability, for example, means different things to different people.
Recent immigrants may consider familiar food products “available” even
if a long car or subway ride is needed to get to stores where the food
Policy is stocked. For others, a food is not available if it cannot be cooked in
the microwave and ready to eat in 5 minutes. Such differences in the
interpretation of availability influence individuals’ food choices.

Community/organizational Economic Environment: Reality and Perception

Likewise, the economic environment is based on the analyses, values,
and interpretations of individuals, all of which have an impact on dietary
Interpersonal choices. Economics is a behavioral science based on the fundamental
notion that human wants are infinitely expansible, whereas the means
to satisfy them are finite. Human wants always exceed the means to
satisfy them, and there is, therefore, scarcity. (This has been simplified
to the statement that human greed is infinite whereas the means to sat-
Personal
isfy that greed is finite.) Economics is the study of people’s reaction to
the fact of scarcity—how people make choices when they must choose
among alternatives to satisfy their wants. Economics is concerned with
desired scarce goods, not free goods, such as air in natural settings,
Media Media
because free goods do not present a problem of choice. Cost can be
seen as the sacrifice, or what needs to be exchanged, to obtain what is
desired. In this context, the full price of a food or dietary practice is not
Source: Bentley, M. E., D. L. Dee, and J. L. Jensen. 2003. Breastfeeding among low-
just its monetary price but includes all the costs or sacrifices individu-
income, African-American women: Power, beliefs and decision-making. Journal
als make, such as travel costs, time, or child-care costs while shopping.
of Nutrition 133:305S–309S. Used with permission of the American Society for
For example, a person may be willing to exchange money for time by
Nutrition and the authors.
purchasing a food that is already prepared. Nutrition educators need to
learn about the sacrifices individuals are willing to make to engage in

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 Chapter 2  Overview of Determinants of Food Choice and Dietary Change: Implications for Nutrition Education 37

Social/Environmental
Determinants
Person-Related
Determinants Physical/Built
Environment
Experience with Food • Food availability
Intraperson
• Associative conditioning Factors • Built environment
• Perceptions
Biologically Physiological • Attitudes Social/Cultural
Determined Conditioning • Beliefs Environment
Behavioral
• Familiarity: • Motivations • Social relations
Predispositions
learned safety and values • Cultural practices
• Taste/pleasure • Conditioned food • Personal • Social structures
• Sweet, sour, salt, and bitter preferences meanings • Public policy
• Hunger/satiety mechanisms • Conditioned satiety • Knowledge
• Sensory-specific satiety and skills Economic
• Social norms Environment
Social Conditioning
• Cultural
• Social-affective context norms • Resources
• Parenting practices • Price
Interperson • Time
Factors
• Family and social Informational
networks Environment
• Advertising
• Media

Food Choice
and Diet-Related
Sensory-affective Beliefs, norms, attitudes, Social environmental
factors and skills influences Behaviors

Figure 2-4  Social and environmental factors that influence food choices and dietary behaviors.

a healthy behavior. How willing are they to sacrifice convenience for they make trade-offs with other family needs, and they have to develop
more healthful meals? various time management strategies to cope. Nutrition educators need
to be mindful of people’s real and perceived economic and time con-
Time: Reality and Perception straints and how they make choices in light of these constraints. Nutrition
In the same way, time is both an objective feature of life and a percep- Education in Action 2-2 showcases programs that were created to work with
tion. The time for food-related tasks such as cooking or eating can be economic and time constraints.
easily quantified in hours and minutes. However, the perception of time
and its worth to individuals for different tasks varies considerably. For The Importance of Personal Perception
example, the time required to make decisions about food has increased The point that is important for nutrition educators to understand is that
because information became more complex. There are about 50,000 although food-related factors and environmental context have significant
items in a supermarket and about 9,000 new food items introduced each independent influences on diet, they also influence the development of
year that people must learn about. No longer do people choose from beliefs, attitudes, interpretations, feelings, and meanings, which in turn
three or four types of cold breakfast cereal, but from whole supermarket influence behavior. It becomes clear, then, that perceptions, attitudes,
aisles of cereals. This takes time. beliefs, and meanings play a central role in food-related behaviors. As
In addition, people have become more avid consumers, and con- Epictetus said many hundreds of years ago, “We are troubled not so
sumption takes time: it takes time to use all the gadgets and objects much by events themselves but by the views we take of them.” This is
that people have acquired, particularly electronic devices such as cell good news for nutrition educators because these perceptions, attitudes,
phones, music players, and televisions. To overcome the scarcity of time, and beliefs are to some extent modifiable through education.
people do more than one thing at once, multitasking. Add to that the Indeed, these perceptions and attitudes form a central focus of much
economic necessity of two jobs for many and it is not surprising that the of nutrition education. Thus, nutrition education can be seen as the
perception is that there is not just scarcity of time, but a time famine. process of addressing all the major categories of determinants as shown
This has impacts that are important for nutrition educators. For example, in Figure 2-5, with personal perception interacting with all of them. How
low-wage employed parents find there is spillover from working long these determinants of food choice and dietary behaviors can be effec-
hours into family food-related tasks (Devine et al. 2006). There is stress tively addressed through nutrition education activities is described in
and fatigue; parents reduce the time and effort spent on family meals, the remaining chapters in this book.

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 38 part I  Linking Research, Theory, and Practice: The Foundations

Nutrition Education in Action 2-2

Programs to Accommodate Economic and Time Restraints

Barbershop Nutrition Education Operation Frontline

Prostate cancer is twice as high in African American men as in white Share Our Strength’s Operation Frontline is a nationwide nutrition
men. Eating fruits and vegetables may help to reduce risk. A novel site education program developed to address the root causes of hunger in
for nutrition education was the barbershop. A program was delivered to the United States. Operation Frontline enables chefs, nutritionists, and
African American men while they were waiting for service. A set of five dieticians to share their strengths by teaching interactive 6-week classes
true or false statements was developed about the rate of prostate cancer on nutrition and food budgeting to adults and children who are at risk
in men and the role of fruits and vegetables in cancer risk reduction. The of hunger. Operation Frontline classes make a concrete difference in the
men were asked to answer them, and then the nutrition educator went lives of program participants. The impact may be as basic as learning
over the answers. The men could keep the statements and the answer how to get a child to eat vegetables or how to cut up a chicken, or can
sheet. This simple intervention increased awareness of both prostate be as profound as providing a starting point for a career in the culinary
cancer and ways to reduce risk. industry. One special feature is that after each class, each participant
receives a bag of groceries containing all the ingredients needed to
People at Work: 5-a-Day Tailgate Sessions make that class’s meal at home. Class participants then report to the
instructors during the next class session on their success with making
Because many people working in factories and other similar locations do a meal at home and their families’ reactions. Since its inception in 1993,
not have time to go to a different site for nutrition education sessions, more than 31,000 people have participated in Operation Frontline
the nutrition educator can go to them. At one sawmill, the workers ate classes and an additional 89,000 have received nutrition information
their lunches from coolers in their cars. The nutrition educator therefore through nutrition fairs and events.
met them in the parking lot and provided monthly tailgate sessions
over the course of a year (including through the midwestern winter), Sources: Magnus, M. H. 2004. Barbershop nutrition education. Journal of Nutrition
providing a food each time that involved interesting ways to use fruits Education and Behavior 36:45–46; Benepe, C. 2003. People at work: 5-a-Day tailgate
and vegetables (such as baked apples, chili, or vegetable wraps). The sessions. Presentation, Annual Meeting of the Society for Nutrition Education, July 26,
focus was on how to incorporate fruits and vegetables into meals and Philadelphia, PA; and Share Our Strength. n.d. What we do. http://www.strength.org/
snacks. The results showed that the workers’ interest and motivation what/operationfrontline.
were enhanced, as were skills in incorporating more fruits and vegetables
in their diets.

88 Implications for Competencies and

Influencing Factors Skills for Nutrition Educators
(to change them)
Nutritionists and dietitians are well grounded in nutrition science and
clinical nutrition and are anxious to transmit what they know to a variety
Preferences and sensory- of audiences in exciting ways. They are less well grounded in the social
affective factors sciences, particularly the behavioral sciences and the field of commu-
nications. Yet as we have seen, food choices and dietary behaviors are
determined by a multitude of factors. Understanding behavior and its
context is crucial for effective nutrition education. One approach might
be for nutrition educators to deliver nutrition education through the use
of teams, in which nutritionists focus only on providing the nutrition
nutrition Perceptions, changes in
education attitudes, Food choices
science content and behavioral specialists actually design and deliver
programs beliefs, and the educational sessions. However, that is neither practical nor desirable.
meanings, dietary What the field needs is nutritionists who are sufficiently conversant with
social norms, practices the relevant fields of behavioral science and communications to be able
self-efficacy to design effective nutrition education programs. This book aims to help
nutritionists develop these competencies.

The Society for Nutrition Education’s Competencies

for Nutrition Education Specialists
Food availability and The Society for Nutrition Education (SNE) has adopted a list of the com-
environmental influences
petencies that nutrition education specialists should have (Society for
Nutrition Education 1987). The society believes that nutrition education
Figure 2-5  The process of nutrition education. specialists should be competent in the following five areas:

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 Chapter 2  Overview of Determinants of Food Choice and Dietary Change: Implications for Nutrition Education 39

1. Food and nutrition content: Understanding the fundamentals of 3. Nutrition: Graduates will have knowledge of health promotion and
nutrition science, food science, and clinical nutrition; having the disease prevention theories and guidelines.
ability to accurately assess nutritional status of individuals and
groups; applying appropriate dietary guidelines in making dietary 88 Summary
recommendations
People’s food choices and nutrition-related practices are determined by
2. Eating behavior: Understanding the complexities of food supply
many factors. This has consequences for nutrition education.
systems and their effects on food selection; understanding the
physiological, psychological, and environmental (social, cultural, Biology and Personal Experience with Food
and economic) determinants of eating behavior
Humans are born with biological predispositions toward liking the sweet
3. Behavioral and educational theory: Ability to apply learning theory,
and salt tastes and umami and rejecting sour and bitter tastes. Some
instructional theory, and behavior change theories in nutrition
genetic differences exist between individuals in sensitivity to tastes, and
education; in particular, use of theories and techniques from the
these may influence food choices. However, individuals’ preferences for
behavioral sciences for modifying food behavior
specific foods and food acceptance patterns are largely learned from fa-
4. Research methods and program evaluation: Ability to analyze and
miliarity with these foods. People’s liking for foods thus can be modified
evaluate both popular and scientific literature, and to use ap-
by repeated exposure to them. Sense of fullness is also learned.
propriate designs and methods to conduct research and program
evaluations in nutrition education Person-Related Determinants
5. Design and delivery of nutrition education: Designing nutrition ed­
People acquire knowledge and develop perceptions, expectations, and
uca­tion programs, curricula, and materials; delivering nutrition
feelings about foods. These perceptions, attitudes, beliefs, values, emo-
education programs, including the ability to communicate with
tions, and personal meanings are all powerful determinants of food
individuals, small groups, organizations, and mass audiences, to
choice and dietary behavior. Families and social networks also influence
write clearly, and to use supplemental materials appropriately;
food choices.
implementing and administering nutrition education programs
Social/Environmental Determinants
American Dietetic Association’s Competencies
The physical/built environment influences the foods that are available
The American Dietetic Association’s standards for the education of
and accessible as well venues for active living such as walkable streets
­entry-level dietitians (American Dietetic Association 2002) include some
and attractive parks. Cultural practices as well as social structures and
competencies that are relevant for nutrition education as well:
policy make it easier or harder to be healthy. The economic determi-
1. Communications: Graduates will have knowledge of negotiation nants of behavior include price of food, income, time, and education.
techniques, lay and technical writing, media presentations, in- The information environment, including the media, is very powerful in
terpersonal communication skills, counseling theory and meth- influencing people’s food choices.
ods, interviewing techniques, educational theory and techniques,
concepts of human and group dynamics, public speaking, and Knowledge Is Not Enough
educational materials development. Also, graduates will have Consequently, knowledge is not enough for people to eat healthfully and
demonstrated the ability to use oral and written communications live actively. Nutrition education must address all these determinants
in presenting an educational session for a group, counsel individu- of behavior if it is to be effective.
als on nutrition, document appropriately a variety of activities,
explain a public policy position regarding dietetics, use current in- Consequences for the Skills of Nutrition Educators
formation technologies, and work effectively as a team member. These considerations make it clear that nutrition educators need a set of
2. Social sciences: Graduates will have knowledge of public policy skills in addition to their knowledge of food and nutrition. We need to
development, psychology, and the health behaviors and educa- develop the skills to understand people, their behavior, and the context
tional needs of diverse populations. of their behavior.

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 40 part I  Linking Research, Theory, and Practice: The Foundations

Questions and Activities

Beauchamp, G. K., and J. A. Mennella. 2009. Early flavor learning and its impact
on later feeding behavior. Journal of Pediatric Gastroenterology and Nutrition
48(Suppl 1):S25–S30.
1. List at least five biological predispositions people are born with,
Bernstein, I. 1990. Salt preference and development. Developmental Psychology
and describe each in a sentence or so. Are they modifiable? If 2(4):552–554.
so, provide the evidence. How can the information be useful to
Birch, L. L. 1992. Children’s preferences for high-fat foods. Nutrition Reviews
nutrition educators? 50(9):249–255.
2. One often hears parents say that their child will just not eat cer-
——— . 1998. Psychological influences on the childhood diet. Journal of Nutrition
tain healthful foods, such as vegetables. They believe that such 128(2 Suppl):407S–410S.
dislikes cannot be changed. Based on the evidence, what would
——— . 1999. Development of food preferences. Annual Review of Nutrition
you say to such a parent? 19:41–62.
3. How can nutrition educators help young children learn to self-
Birch, L. L., and J. A. Fisher. 1995. Appetite and eating behavior in children.
regulate the amount of food they eat? Pediatric Clinics of North America 42(4):931–953.
4. “You can have dessert if you eat your spinach.” Is this a strategy
Birch, L. L., and J. O. Fisher. 2000. Mothers’ child-feeding practices influence
you would recommend to parents and child-care personnel to use daughters’ eating and weight. American Journal of Clinical Nutrition
to get children to like spinach? Why or why not? 71(5):1054–1061.
5. Influences on dietary behavior arising from within the person Birch, L. L., J. O. Fisher, and K. K. Davison. 2003. Learning to overeat: Maternal use
have been stated to be central to his or her food choices and di- of restrictive feeding practices promotes girls’ eating in the absence of hunger.
etary practices. Why is this so? Describe three of these influences American Journal of Clinical Nutrition 78(2):215–220.
in a sentence or two, and indicate why they are so important. Birch, L. L., and D. W. Marlin. 1982. I don’t like it; I never tried it: Effects of
How might understandings of these personal factors help people exposure on two-year-old children’s food preferences. Appetite 3(4):353–360.
make dietary changes? Birch, L. L., L. McPhee, B. C. Shoba, E. Pirok, and L. Steinberg. 1987. What kind
6. People live within social networks and may experience cultural of exposure reduces children’s food neophobia? Looking vs. tasting. Appetite
expectations about how and what they eat. Because these can’t 9(3):171–178.
be changed by nutrition education, why should nutrition edu- Birch, L. L., L. McPhee, B. C. Shoba, L. Steinberg, and R. Krehbiel. 1987. Clean up
cators be interested in such information about their intended your plate: Effects of child feeding practices on the conditioning of meal size.
audience? Learning and Motivation 18:301–317.
7. Distinguish between food availability and food accessibility. How Borzekowski, D. L., and T. N. Robinson. 2001. The 30-second effect: An experiment
can they influence food choice? How might nutrition educators revealing the impact of television commercials on food preferences of
address these issues? preschoolers. Journal of the American Dietetic Association 101(1):42–46.
8. Describe four environmental factors that influence people’s food Bowen, D. J., M. M. Henderson, D. Iverson, E. Burrows, H. Henry, and J. Foreyt.
choices and dietary practices. What can nutrition educators do 1994. Reducing dietary fat: Understanding the successes of the Women’s Health
with such information? Trial. Cancer Prevention International 1:21–30.
9. Think about the influences on your eating and physical activity Briefel, R. R., M. K. Crepinsek, C. Cabili, A. Wilson, and P. M. Gleason. 2009. School
behaviors and list them. Compare them to the categories of in- food environments and practices affect dietary behaviors of US public school
fluences described in this chapter. Into which categories do the children. Journal of the American Dietetic Association 109(2 Suppl):S91–S107.
items on your list fall? Are there some surprises? How would you Brug, J., K. Glanz, and G. Kok. 1997. The relationship between self-efficacy,
describe the motivations for your eating patterns? attitudes, intake compared to others, consumption, and stages of change related
to fruit and vegetables. American Journal of Health Promotion 12(1):25–30.
10. As stated earlier, in terms of healthy eating and active living,
“knowledge is not enough.” In your view, is that true? Why do Center for Science in the Public Interest. 2003. Pestering parents: How food
companies market obesity to children. Washington, DC: Author.
you say so? Give evidence for your view.
11. In reviewing the competencies suggested by the Society for Nutri- Chakravarthy, M. V., and F. W. Booth. 2004. Eating, exercise, and “thrifty” genotypes:
Connecting the dots toward an evolutionary understanding of modern chronic
tion Education for a nutrition educator, which competencies do
diseases. Journal of Applied Physiology 96(1):3–10.
you believe that you already possess? Which ones would you like
Cheadle, A., B. M. Psaty, S. Curry, E. Wagner, P. Diehr, T. Koepsell, and A. Kristal.
to develop further? Keep these in mind as you read the remainder
1991. Community-level comparisons between the grocery store environment and
of this book.
individual dietary practices. Preventive Medicine 20(2):250–261.
Clark, J. E. 1998. Taste and flavour: Their importance in food choice and acceptance.

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