Communicating science-based nutrition information can be challenging in today’s environment where consumers are constantly bombarded with a multitude of conflicting health messages. To help consumers make healthful food choices, it is important to develop dietary guidance tools that are not only consistent with the latest scientific research but are also understood by and applicable to consumers.
Dietary guidance tools include advisory statements or “dietary guidelines” and symbols called “food guides,” which visually translate the guidelines into simple food intake patterns. The U.S. currently uses the 2005 Dietary Guidelines for Americans and MyPyramid. The process of designing the image, slogan, and messages of MyPyramid involved a series of focus groups, Web testing, and one-on-one interviews with consumers.
The U.S. is not alone in developing dietary recommendations with input from consumer research. The joint Food and Agriculture Organization (FAO) /World Health Organization (WHO) Consultation on the Preparation and Use of Food-based Dietary Guidelines recommends consumer testing to ensure the appropriateness and cultural acceptability of these tools.
What have other countries done to find out whether their own set of dietary guidelines and food guides resonated with consumers? Food Insight looks into the methods that Mexico, Thailand, and South Africa used to test their nutrition education tools and summarizes the key findings resulting from that process.
Mexico: Baja California’s Apple of Health
The “Pyramid of Health” was Mexico’s food guide until 1998. When it was still in use, the Nutrition Institute of the state of Baja California developed a regional food guide called the “Apple of Health.” The Apple was based on the current nutrition research of that time and the typical eating patterns of the Baja California population, whose food supply is influenced by the U.S. (located immediately north of the state). To compare the two food guides, researchers conducted focus group discussions and a “diet design” exercise.
Focus group participants were women from two different education levels. They evaluated the graphic impact, recognition of food groups, recommended servings, meal distribution, and usability of each guide. In the diet design exercise, other sets of participants were randomly assigned to either the Pyramid or Apple—without explanations or accompanying text—and were asked to design a 1-day menu plan. This was done to assess consumers’ level of comprehension when a specific food guide alone was used.
These tests showed that Mexican consumers, in general, favored the Apple over the Pyramid. A majority of the participants found that the Apple was more visually appealing and provided clearer information about foods (i.e., food identity and the number of suggested servings from each food group and each meal). The mean diet design percentage scores of participants—based on the food groups included in each meal and the correct number of portions—were higher for those who were assigned to the Apple. Although information on portion size was felt to be missing, most participants agreed that the Apple of Health was the better educational tool for families.
Thailand: The Nutrition Flag
The Thai Nutrition Flag looks like an inverted version of the former USDA Food Guide Pyramid, with the broadest section representing the “rice-starchy food” group on top and the apex, comprised of the “oil, sugar, and salt” group, at the bottom. It specifies a range of recommended servings from each food group. The exact number of servings depended upon three reference energy levels (1600, 2000, and 2400 calories).
Before the Nutrition Flag became the official food guide for the Thai population, it was consumer-tested with another symbol, the Fan, using the central location testing (CLT) method. The CLT is a survey technique in which researchers station themselves in locations that would most likely be frequented by the target groups of the study. The researchers approach people and, if they are willing to participate and fit the study criteria, the survey is administered. The goals of the CLT were to test the cultural appropriateness of the proposed food guides; assess consumers’ understanding of the key concepts (variety, portion, and quantity); and determine consumers’ preference between the two symbols.
The five “CLT sites” were located in Bangkok and its suburbs: 1) universities; 2) factories; 3) department stores; 4) fresh food markets, and 5) bus stations. The rationale for selecting these sites was that researchers would be able to recruit participants whose energy needs correspond to the standard levels—the general population, including students and older adults—with further opportunities to sub-sample by age, gender, and settlement (urban and rural). For instance, participants recruited at the bus stations were considered as the rural subgroup because these travelers came from provinces outside of the capital city. Guided by a four-page questionnaire, the researchers screened and interviewed eligible participants, who were shown posters of the food guides.
The CLT showed that consumers were confused with the wording of “portions” in the fruit recommendation, because fruits cannot be measured using household utensils. About 60 percent of the participants did not understand that the range of servings from each food group should still be adjusted for individual energy needs. For example, consumers thought that they can eat all “8 to 12 rice-serving spoons” in a day when the lower limit, 8 rice-serving spoons, actually fits within a 1600 calorie diet and the upper limit, 12 rice-serving spoons, corresponds to a 2400 calorie diet. Consumers preferred the flag over the fan because it was easier to understand and helped them quantify the recommended amounts from each food group.
South Africa: “Stand-Alone” Dietary Guidelines
Historically, dietary guidelines in South Africa have been nutrient-based and targeted at a population eating a typical Western diet. The Three- and Five Food Group Guides—systems “imported” from the U.S. and the U.K.—were commonly used for nutrition education.
When South Africa began developing its own set of “food-based” dietary guidelines (FBDG) to address the unique nutrition challenges and food patterns of the culturally diverse population, the FBDG Work Group overseeing this task had two main objectives for the consumer testing phase: 1) To assess consumers’ comprehension of and ability to apply the FBDG and 2) To assess the compatibility of the food categorization proposed by the FBDG with that of the food guides commonly used in South Africa. These objectives were met using focus groups and semi-structured individual interviews—both of which were subjected to participant observation. This inclusion of a third data collection method, called “triangulation,” enhanced the validity of the research by providing a greater understanding of how consumers applied their knowledge of the dietary guidelines.
The focus groups—comprised of a representative sample of women from South Africa’s major ethnic groups and rural/urban settlements—were conducted in four out of nine South Africa provinces. Results from these discussions showed that consumers:
- Considered fruit an expensive commodity compared to vegetables
- Were familiar with the term “legumes” but regarded it as uncommon
- Understood the word “fat” to include cooking fats, but not fatty foods and spreads
- Were confused by the guideline “Eat healthier snacks”
Based on these findings, changes were proposed to specific dietary guidelines, namely:
- “Vegetables” should be listed before “fruits” because the former is cheaper and more available
- Actual examples of legumes (e.g. dry beans, peas, lentils) should replace the general term, “legumes”
- Rephrase the guideline, “use fat” to “eat fats” sparingly
- Omit the “eat healthier snacks” guideline but include information on sensible snacking in the explanatory text
The individual interviews included an interactive component in which participants were instructed to demonstrate how they would organize into “piles” colored photographs of foods they personally considered to be similar. This unprompted food categorization exercise yielded remarkable results:
- The common number of piles (n=11) into which participants categorized common foods and beverages as well as the names given to these piles matched all but two of the ten proposed FBDG categories, the exceptions being, “foods from animals” and “legumes.”
- The 3- and 5-Food Group Guides were incompatible with the proposed FBDG because the number of food groups, terminologies, and advice implied in these guides did not match the FBDG food categories. Furthermore, the food examples depicted in these guides are not commonly eaten by South African consumers.
These findings suggest that the South Africa FBDG were well understood by consumers and a food guide to complement the FBDG may not be necessary because consumers’ personal categorization of foods closely resembles that of the dietary guidelines themselves.
The lessons learned from these international experiences highlight the value of consumer testing. It is worth investing time and resources in this process because it provides insights into consumers’ needs, resources, and potential barriers to behavior change. It validates theoretical assumptions with practical experience. Finally, consumer testing enhances the credibility and efficacy of dietary guidance tools.
Resources:
- Food and Agriculture Organization of the United Nations (FAO) Web site
- Institute of Nutrition, Mahidol University, Thailand
- International Journal of Food Sciences and Nutrition (2002) 53, 163-169.
- South African Food-Based Dietary Guidelines Country Report 2004.
Culture-Based Food Guides
Food guides come in a variety of shapes and colors—sometimes reflecting nationalistic themes in their design. Here are some examples:
Japan's Spinning Top
Guatamalan Food Jug
Chinese Pagoda
