Dietary Guidelines for Americans, 2010: Revised at the Family Dinner Table- Aya Obara
The Dietary Guidelines for Americans, 2010, was released by the U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) on January 31, 2011 (1). As the 7th edition of Dietary Guidelines for Americans, this year’s document puts more emphasis on lowering calorie intake and increasing physical activity. The Dietary Guidelines for Americans has been published every five years since 1980 by HHS’s Office of Disease Prevention and Health Promotion and USDA’s Center for Nutrition Policy and Promotion and Agricultural Research Service (2). This document was created by the federal government as evidence-based, nutritional guidance to reduce the risk of chronic diseases in people two years and older. It is an important document for governing policy and a public health intervention on the quality and access to better diets and lifestyles, and to reduce the rate of overweight and obesity nationally through betterment of nutritional health and physical activity (3).
Poor diet and physical inactivity are the most important factors contributing to obesity in the country; 72 percent of men and 64 percent of women are overweight or obese, with about one-third of adults being obese (4). Poor diet and physical inactivity are associated with causes of morbidity and mortality even in the absence of obesity. Health effects include cardiovascular disease, hypertension, type 2 diabetes, and osteoporosis (3). Racial and ethnic groups can also be disproportionately affected by the high rates of overweight, obesity, and associated chronic diseases, thus improved nutrition and physical activity choices provide significant opportunities to reduce health disparities through dietary and fitness changes (3). Furthermore, nearly 15% of American households have been unable to acquire adequate food to meet their needs because of insufficient money or other resources for food (5). Americans can also therefore use aid in knowing how to maximize the nutritional content of their meals within their resource constraints (3).
As reduction of calorie intake was one of the foundational ideas listed in the Guidelines, in April 2011, the Obama administration proposed rules that vendors with 20 outlets or more must comply with a new law to post calorie counts of foods and drinks on menu boards, expected to take effect in 2012 (6). In helping policymakers design and implement nutrition-related programs, the Guidelines are used by the Federal Government to develop nutrition assistance programs such as school meals programs and Meals on Wheels programs for seniors, as well as nutrition education programs (3). The Guidelines also provide the foundation for the Healthy People national health promotion and disease prevention objectives related to nutrition, as well as dietary advice provided by professionals (1).
Major actors in the development of this year’s Guidelines include Agriculture Secretary Tom Vilsack and HHS Security Kathleen Sebelius (1). Sebelius attests that, “The new Dietary Guidelines provide concrete action steps to help people live healthier, more physically active and longer lives” (1). Vilsack stated in the press release of the Guidelines that, “one in three children [are] overweight or obese and this is a crisis that we can no longer ignore… The bottom line is that most Americans need to trim our waistlines to reduce the risk of developing diet-related chronic disease” (1). Though, in taking the Guidelines as a public health intervention, it serves more as an educational resource for policymakers and nutritionally literate consumers, rather than a social intervention. In its lack of explicitness in certain areas, it likely feeds into the optimistic bias of the consumer, and uses knowledge as a jumping board for reasoned action. For these reasons, a more personalized and family-centered approach can motivate action for better dietary patterns, therefore reducing risk of chronic dietary-related disease. In effectively utilizing advertising and branding theory for family health and well-being, as well as addressing consumption of fresh produce and its cost-effectiveness as a family need, the necessary push for action to reduce disparities of access to quality food can grow from communities. Thereby affecting policy and inspiring change in the community, Americans need a deeper motivation, in addition to education, to consume better diets for better futures.
Lack of Explicitness and Mixed Messages According to Advertising Theory
It is arguable that the Guidelines offer “concrete action steps,” as the document states slightly vague resolutions for American citizens to consider. The inherent vagueness stems from the conflict of interests involved with the Guidelines, embedded in the USDA having two conflicting goals: one to guide the public in making good dietary choices and one to promote the nation’s consumption of manufactured food (7). An editorial in the New York Times points out that the USDA succeeds to fulfill both goals by convincing the public that eating manufactured food lower in solid fats and sugar is “healthy,” while also endorsing manufactured products with added fiber and reduced fats, in order to appease the nation’s industry of food processing (8). Thus, the basic messages that the Dietary Guidelines 2010 offered were predictable and very general. Eating less food and sodium, controlling calorie intake, discontinuing soda consumption and increasing water consumption, and eating more vegetables were the key elements of the document (3).
The generalization factor of the Guidelines is also attributed to addressing nutrients that should be reduced, rather than examples of whole foods. Instead of its emphasis on reducing “solid fats,” the Guidelines should more explicitly emphasize to reduce red meat and dairy products (9). The Huffington Post also points out that classifying foods as “healthful” or “unhealthful” on the basis of specific nutrients such as certain vitamins and fat, may lead to dietary choices that stray away from the basis of the “eat more vegetables” part of the Guidelines. For example, some low-fat processed foods are high in refined sugar, but to fulfill school nutrition guidelines that specify a minimum number of total calories but a maximum proportion of fat calories, gelatin desserts and sugar-sweetened milk are used to achieve this (7). While the appendix of the Guidelines does list more specific groups of foods overly consumed by the general public, such as pizza, grain-based desserts, and sodas, which could aid in the creation of consumer education materials, its chapter on which foods to reduce is by far its greatest downfall. This vagueness and lack of explicitness also contributes to resistance of the public as described by Advertising Theory, as put by “Confessions of an Advertising Man,” by David Ogilvy. The Guidelines must give enough factual information to “sell” the notion that reducing foods containing exuberant amounts of sodium and hydrogenated oils will make them healthier (10). As Confessions acknowledges, most responses are awarded to campaigns that create a “coherent image,” and the “stability to stick with it over a long period;” the Guidelines misses this issue by trying to sell two things at once: the American food economy and healthy choices.
The USDA is not recognized as an independent, scientific research group, but a federal entity that is tied to economic and food industry-related interests. It is argued by Harvard School of Public Health nutrition scientists that the current document continued to fail to highlight the need to cut back on red meat and dairy products, suggesting that beef and dairy industries retain their strong influence within the USDA; the Grocery Manufacturers Association, the Sugar Association, the National Milk Producers Federation, and the National Cattleman’s Beef Association were all listed as organizations, along with the general public, who commented on drafts of the document during the two-year process of gathering data for the final Guidelines (9). For instance, the Guidelines continue to generalize red meat together with fish, poultry, eggs, nuts, soy, seed, and bean in one “protein foods” group, and there is no mention of scientific evidence that reducing red meat consumption could help prevent cardiovascular disease and the risk of diabetes (9). Also, the Guidelines continue to recommend increasing intake of low-fat milk and dairy products to satisfy a high intake of calcium, though research shows that milk and dairy should not be heavily relied upon as the only source of calcium, nor primary preventative measures against osteoporosis or fractures (vitamin D-rich foods must also be stressed) (9). If people are misled by outside industries influencing the source of intervention in nutritional guidance, it is unlikely that people will be receptive to the intervention.
Unrealistic Optimism of General Consumer
Additionally, the intervention does not take into account Optimistic Bias Theory of the general consumer (11). It would be relatively easy for readers of this document to rationalize that they are already eating well, and do not need to adhere to the Guidelines because they are feeling healthy and do not want to change eating habits. People believe that negative events are less likely to happen to them than to others, and only when the perceived probability of an event is great, the tendency for people to believe that their own chances becomes stronger (11). For instance, the Dietary Guidelines focus on sodium as key to lowering blood pressure in a majority of the population, and calls for 2300 mg a day of sodium for the general public and 1500 mg a day for sodium for high risk populations (elderly, diabetic, existing kidney problems) (3). The Guidelines do point out that most of the sodium in the population’s diet stems from processed foods, which is the most explicit statement veering encouragement away from consuming manufactured foods (3). By simply proclaiming the amounts of sodium that are suggested for consumption, along with risks of cardiovascular disease and high blood pressure, people may be likely to pay attention to nutrition labels on processed foods, but are not likely to think about these facts when casually adding salt to their food from a shaker without seeing how much in milligrams they are adding. The perceived risk of too much salt intake is not explicit in the document when thinking about unconscious salt intake (I.e. from salt shakers) and people are likely to be more unrealistically optimistic about their risks to these diseases given their salt intake.
The report also recommends lowering the consumption of soda, adding that it is a major source of refined sugars and calorie intake, which was also a less conservative piece of advice from the Guidelines, given reaction from the Sugar Association (3). Again, the Guidelines do not address the Optimistic Bias Theory, in that people who do not eat a lot of calories from nutrient-rich whole foods may rationalize their continuing consumption of soda to their already “calorie conscious diet.” People can be unrealistically optimistic to their intake of refined sugars because they may work out and exercise excessively or regularly, and can wave away the notion that they could develop diabetes later on in life because of their exercise regime. Additionally, the main basis of lowering caloric intake to lose weight is a short-sighted piece of advice, as clinical research has shown that high carb high sugar diets produce metabolic reactions that make it difficult for weight loss because it contributes to cravings and blood-sugar fluctuations (7). This kind of information should also be added to their recommendation to cut soda drinking for the optimistic majority to consider.
Need to Motivate Communities to Address Access to Healthier Choices
Given the two flaws listed above, the Dietary Guidelines of 2010 assumes that consumers who read the document will change their behaviors based on the fact that there is no “American” eating pattern, but proclaiming that Americans eat too many calories, too much solid fat, added sugars, refined grains, and sodium (3). Reiteration of foods and nutrients that Americans should be eating in more than one chapter of the document, the Guidelines assume that the reader’s intentions in terms of knowledge will be the immediate precursor and best determinant of behavior, according to the Theory of Reasoned Action (12). The Guidelines do accurately assess and give data on health problems and growing rates of obesity among American families around the nation, and calls for a healthy eating pattern to be established for individuals. In theory, the principles it offers to achieve this are simple and realistic: focus on nutrient dense foods, remembering that beverages count for calorie intake, handling food in a sanitary manner, and to consider the role of supplements and fortified foods (3).
This eating pattern is partially based on research on Mediterranean-style eating patterns, because diets in this region emphasize vegetables, fruits, nuts, olive oil, and whole grains, with small amounts of meats and dairy products included. (3) For instance, traditional eating patterns in the Crete region were associated with a low risk of cardiovascular disease, and as over time, a higher intake of saturated fatty acids and cholesterol developed, the Crete population experienced a steady rise in risk of heart disease (3). While the Guidelines address that healthy eating patterns around the world are diverse, the common threads that exist within all of them include abundance in vegetables and fruits, and moderate amounts of varieties of foods high in protein.
While the recommendations are logical and attractive to good dietary intentions, the Guidelines fail to acknowledge the “access” piece that it talked about in its Executive Summary for families, and instead focuses solely on nutrition education. Without ease of access to vegetables, fruits, and healthy sources of protein, fulfilling this kind of dietary pattern would be difficult. For instance, in speaking of health disparities in which different ethnicities and cultures experience higher rates of obesity, this could be attributed to neighborhoods within an area that characteristically have a lower socioeconomic status. Commonly termed as “food deserts,” these neighborhoods have a disproportionately low number of grocery stores that have fresh produce in the area, and are usually characterized by less healthy, convenient fast food-type options (13). Even with the intention of developing a healthier eating pattern, the Guidelines should recognize that people must self-adjust their diets according to their means, in that the actual choices for meal preparation is not the same as those of Mediterranean populations. Furthermore, there needs to be a deeper call to action for policymakers and general consumers alike, to demand for better access to achieve the goals that the Guidelines articulates.
Importance of “Family Meals” Approach
The Guidelines end with a great chapter entitled “Helping Americans Make Healthy Choices,” calling for action among policymakers to consider focusing on the community and environmental setting of the consumer, rather than just the individual’s behavior; this was by far the most compelling argument of the Guidelines. Emphasis on empowering individuals and families with improved nutrition literacy, gardening, and cooking skills were listed as a key strategy, as well as initiating partnerships with food producers/suppliers to promote smaller, more affordable portions (3).
Building upon the positive aspects of the Guidelines, it can be argued that though its last chapter emphasized environmental factors, outside of an individual’s control, that affect rising rates of obesity and chronic dietary disease in the nation, there is no proposal of changes that could arise from the immediate environment of individuals, which for most people consist of their families or roommates. If the USDA and HHS are concerned about Americans eating patterns, the logical source would be to look at what is on family dining tables.
In a recent study based on a nationally representative sample, the presence of at least one parent during the evening meal was associated with a lowered odds of poor consumption of fruits, vegetables, and dairy foods and a lowered odds of skipping breakfast among adolescents (14). Of adolescents who ate three or fewer family meals per week, three-fourths reported poor consumption of vegetables, compared with two-thirds of adolescents who ate six or seven family meals per week (14). It is recommended that particular attention should be paid to the challenges families with older children face in participating in regular mealtimes. Furthermore, encouraging parents of adolescents to emphasize the importance of breakfast and provide guidelines for their children represents a promising intervention for not only improving adolescence nutrition but also adult nutrition; parents who eat evening meals with children may be more likely to eat breakfast with their children (14). The findings are consistent with previous research using a younger sample (children age 9 to 14 years), that showed positive parental influence on children’s eating patterns (15).
Minority groups were at higher risk of cancers, diabetes, and hypertension and were found to be at greater risk for poor consumption of vegetables and dairy foods, thus improving dietary habits of minority youth is critical in reducing racial health disparities later in life (14). Additionally, findings from the 1999 National Health and Nutrition Examination Survey indicated that 14% of adolescents age 12-19 were overweight, when more than double of the percentage (31.8%) perceived themselves to be overweight (16). This large gap between the percentage of adolescents who are actually overweight and those who perceive themselves to be overweight highlights the importance for adolescents to be educated about healthy body image and healthy weight (14).
Healthy body image and minority children disparities in eating patterns could both be aided by more public awareness that mealtimes should be shared with families and friends. As the above studies show, family-oriented mealtimes correlate with health benefits for both the children as well as the adults. Emphasis on family-oriented mealtimes is not a new idea, but a traditional approach to eating that seems to be an after-thought in the present world; with more career-oriented parents, busy after-school schedules to gear children towards a brighter future, and the plethora of take-out and convenience style food available through online ordering, convenience and efficiency can take precedence. This approach of anti-solitary mealtimes not only targets families and children, but can also translate universally to people of all cultural backgrounds, ages, demographics, and living situations.
Because it would be strange and probably subject to mockery to have a public service announcement about “eating as a family,” this approach could primarily be translated via commercials to advertise restaurants, grocers, and farmer’s markets acknowledging how cost-efficient it is to eat as a family as well as include more vegetables in the meal. Cost-effectiveness should be stressed, as well as the great ease and savings in time that cooking a meal with the family and eating with the family can ensure. For instance, a commercial starts off with a family of four shopping at a farmer’s market on a weekend, then fast forwards to the kitchen where the family is making a stew, and each vegetable used is highlighted , along with its total price for the meal for four people. All the while, the commercial also shows the kids helping to wash the produce and/or interacting with the parents in the kitchen. The final product is showcased, with the family sitting down at the table, enjoying the meal and chatting, and then a slogan appears, such as “Shop at your local farmer’s market: Save money, eat as a family, and live healthier.” Depending on the region, a quick schedule of farmer’s markets in the area can be shown at the end. A nationwide farmer’s market organization such LocalHarvest could partner with USDA and HHS to gain funding for such media advertisement for farmer’s markets.
A great example of a similar media campaign geared towards family eating that was well received by the public was Stouffer’s “Let’s Fix Dinner” campaign released in 2010 (16). Stouffer’s teamed up with the family dinner advocates at the Center for Alcohol and Substance Abuse at Columbia University, to acknowledge that meals prepared at home as a family and eating together as a family is not as hard as one would think. The product of their coalition was a reality TV-like YouTube channel in which six families were followed in their commitment to eat more meals together to see the benefits of their efforts, (18) and a TV commercial (19) that emphasized family teamwork and ease in preparing meals as a family, and how cost effective eating together can be. As Stouffer’s is a frozen dinner product company that was able to use corporate money to support promoting family dinner and value, clearly other grocers, restaurants with healthy choices, and farmer’s markets especially, could be advertised in this same extent.
Addressing a Family Values Through Advertising Theory
Using the family-centered approach in this commercial, there is no mistaking the action steps required to achieve a healthy lifestyle that is recommended: use farmer’s markets, shop together, make meals together, eat together, save money, and be healthy. As Ogilvy points out in successful advertising campaigns, “large promise is the soul of an advertisement” (10). This approach of eating as a family correlating to healthier eating patterns is a coherent image, that connotes consistency in a promise that is supported by what Americans know already, that eating more vegetables is a good thing for their diet. There is no indication that Big Meat and Big Dairy could influence this campaign, and thus the only message delivered is clear and unobstructed by fancy processed foods with nutrient emphasis. The nutrients factor is embedded in the push for consumption of fresh, local produce. The campaign also connects healthy eating patterns with a cohesive family ritual of cooking and eating as a unit, which is an indirect way to guide a behavior, as a promise, without authoritatively dictating that families must behave in this way to have nutritional benefits. The support of eating as a family and shopping at the local farmer’s market is shown in the final product, with a healthy and hearty meal that is cost-efficient, easy, and fun when prepared together. In using the self-referencing factor mentioned in class, the commercial makes viewers picture themselves in the lifestyle that is portrayed in the campaign. Lastly, both promise and support are surrounded by core values, which touch on a sense of belonging as an integral part of a family, and a healthy lifestyle.
Also, in picking out core success tactics from the “Truth” tobacco campaign, specifically the tone and branding strategies of this campaign, one can also see how this commercial further steers the message of this campaign as a belief that the public would respect and acknowledge (20). Once again, people generally know that eating vegetables is necessary for a healthy diet, and making the central anecdote of the commercial to be a typical weekend afternoon shopping at the farmer’s market, the tone is relaxed and realistic. Most families would not be able to go shopping as a family during a weekday, more so during the day, due to work and school. The vegetables are highlighted, the cost is shown to make an entire meal, and the family as a unit is shown to work together and enjoy the final product of their meal. Farmer’s markets in the local area are shown at the end, thus it is up to the viewer to take this information and use it, according to their means. Because the public knows the general dietary significance of eating produce, farmer’s markets are an obvious source where they can shop to gain this benefit. The commercial thus “brands” the act of shopping at farmer’s markets as identifying with core values that families and the general population would like to achieve, in living a healthy lifestyle while enjoying the company of others. It is implied that the act of going to a farmer’s market and making use of produce is also a great way to improve social conditions of the home life, as well as a great way to save money and encourages acts to reduce obesity and other chronic dietary-related diseases.
Optimism Counteracted with Hierarchy of Needs
It may be simple for individuals to see the commercial described above and rationalize that either a) they already live a healthy and cost effective lifestyle without going to the farmer’s market and/or b) that their family unites and spends time together in more efficient ways than simply centered around eating at the dining table, when compared to the rest of their peers or the public. This notion of optimistic bias is attributed to comparing themselves to a stereotype of a person or family who does nothing to improve his or her chances of achieving a healthy eating pattern or lifestyle (11). Another aspect is that people could rationalize that there are more cost-effective and/or time-effective ways to achieve similar benefits promised by the campaign. Though, when taking into account Maslow’s Hierarchy of Needs, this optimistic bias is counteracted through theories of positive human motivation (21). The campaign addresses eating as a family as an easy and sequentially realistic end product of healthy eating behaviors. The need for fresh produce in the diet is automatically connected with family-centered meals, and the benefits that are reaped from the sequence that is sourced from farmer’s markets is magnified with the social aspect of cooking and eating together; there is a complete picture of a lifestyle that could be achieved. As Maslow points out, human needs arrange themselves in hierarchies of prepotency, and every drive is related to the state or satisfaction of other drives (21). The five basic needs are physiological, safety, love, esteem, and self-actualization, and these goals are arranged in a hierarchy and people are motivated to achieve or maintain various conditions upon which these basic satisfactions rest (21). The need for satisfying intake of vegetables and thus eating for better health benefits physiologically is strongly correlated with the love, esteem, and bond that social eating offers in the family-style setting, in the commercial. No matter which basic need is prioritized first in an individual’s life, the satisfaction factor is visually and emotionally magnified (by the commercial) if these two needs are met together. By emphasizing that eating vegetables and having healthier eating patterns (therefore reducing risk of dietary related disease) while spending time with the family is a need, rather than an ideal or two separate entities to satisfy two different goals, this campaign guides the viewer and general public to want to achieve such a lifestyle.
“Branding” Farmer’s Markets for Community Push for Access
Instead of empowering families and consumers with knowledge and nutrition facts, the campaign aims to empower them through the value of family playing a central role in healthy eating patterns and life styles. With families being more aware of their responsibilities and needs as a family to eat healthy together, there is an incentive to seek outlets for healthy options with heightened community awareness of the question of whether or not they have easy access to eating healthy. Are there farmer’s markets near my neighborhood? The campaign personalizes this sentiment, and creates community awareness in a way that is not explicitly marketed in the campaign, but rather an after effect of watching and being exposed to the kind of lifestyle where healthy eating patterns come easily. The behavior is not a result of intentions based on knowledge, similar to the argument made about the Guidelines following the Theory of Reasoned Behavior, but through social motivation and awareness that they too deserve this option for a healthy eating pattern.
Therefore, once again by ‘branding’ the act of shopping at a farmer’s market as a way to promote healthy eating patterns, people are positively motivated to demand for access to this ‘brand’ of behavior. The development of the consumer-brand relationship and the development of the equity (or value) of farmer’s markets is derived directly from the engagement in the target behavior of attaining healthier eating patterns (22). Demand increases for the farmer’s markets, therefore the motivation to mobilize communities to speak up for access to engage in shopping at farmer’s markets grows. In striking a chord in the inherent core value of family, healthy dietary lifestyles and therefore reduction of chronic disease can be achieved in personalizing dietary betterment from the home perspective.
References:
1. Press Release. 31 January 2011. Accessed 27 March 2011.
2. “Dietary Guidelines for Americans.” http://www.health.gov/dietaryguidelines/history.htm. Accessed 27 March 2011.
3. USDA, US Dept. HHS. December 2010. Dietary Guidelines for Americans, 2010. Accessed 27 March 2011.
4. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among U.S. adults, 1999-2008. JAMA. 2010;303(3):235-241.
5. Nord M, Coleman-Jensen A, Andrews M, Carlson S. Household food security in the United States, 2009. Washington (DC): U.S. Department of Agriculture, Economic Research Service. 2010 Nov. Economic Research Report No. ERR-108. Available from http://www.ers.usda.gov/publications/err108.
6. “Obama to Set New Calorie Count Rules.” http://online.wsj.com/article/SB10001424052748704530204576237203366549010.html?mod=googlenews_wsj. 2 April 2011. Accessed 26 April 2011.
7. “Dr. Jonny Bowden: Dietary Guidelines 2010: Not Much to Write Home About.” http://www.huffingtonpost.com/dr-jonny-bowden/dietary-guidelines-2010-_b_819953.html 9 February 2011. Accessed 21 April 2011.
8. “Is ‘Eat Real Food’ Unthinkable?” http://opinionator.blogs.nytimes.com/2011/02/08/is-eat-real-food-unthinkable/ 8 February 2011. Accessed 26 April 2011.
9. “New U.S. Dietary Guidelines: Progress, Not Perfection.” http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/dietary-guidelines-2010/index.html Accessed 21 April 2011.
10. Ogilvy D. Chapter 5: How to Build Great Campaigns.” Confessions of an Advertising Man, New York: Atheneum, 1964. Pp 89-103.
11. Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology. 1980; 39(5): 806-820.
12. Cameron KA. A practitioners guide to persuasion: an overview of 15 selected persuasion theories, models and frameworks. Patient Education and Counseling. 2009; 74: 309-317.
13. Gordon C, Purciel-Hill M, Ghai NR, Kaufman L, Graham R, Van Wye G. Measuring food deserts in New York City’s low income neighborhoods. Health Place. 2011; 17(2):696-700.
14. Videon TM, Manning CK. Influences on adolescent eating patterns: the importance of family meals. 2003; 32(5): 365-373.
15. Gillman M, Rifas-Shiman S, Frazier A et al. Family dinner and diet quality among older children and adolescents. Arch Family Med. 2000; 9:235-240.
16. National Center for Health Statistics. Health and stats. Prevalence of overweight among children and adolescents, United States 1999 (2001) Accessed 29 April 2011.
17. “SocialResponsibility Stouffer’s Style.” http://www.eatdinner.org/2010/04/social-responsibility-stouffers-style.html Accessed 29 April 2011.
18. “Let’s Fix Dinner Channel.” YouTube. http://www.youtube.com/user/letsfixdinner
Accessed 29 April 2011.
19. “Stouffers TV Commercial.” YouTube. http://www.youtube.com/watch?v=gE79cJmA0-Q&feature=player_embedded Accessed 29 April 2011.
20. Hicks JJ. The strategy behind Florida’s “Truth” campaign. Tobacco Control. 2001; 10: 3-5.
21. Maslow AH. A theory of human motivation. Psychological Review. 1943; 376-396.
22. Blistein JL et al. “Chapter 2: What is a Public Health Brand?” Public Health Branding: Applying Marketing for Social Change, Oxford: Oxford University Press, 2008, Pp. 25-41.
Poor diet and physical inactivity are the most important factors contributing to obesity in the country; 72 percent of men and 64 percent of women are overweight or obese, with about one-third of adults being obese (4). Poor diet and physical inactivity are associated with causes of morbidity and mortality even in the absence of obesity. Health effects include cardiovascular disease, hypertension, type 2 diabetes, and osteoporosis (3). Racial and ethnic groups can also be disproportionately affected by the high rates of overweight, obesity, and associated chronic diseases, thus improved nutrition and physical activity choices provide significant opportunities to reduce health disparities through dietary and fitness changes (3). Furthermore, nearly 15% of American households have been unable to acquire adequate food to meet their needs because of insufficient money or other resources for food (5). Americans can also therefore use aid in knowing how to maximize the nutritional content of their meals within their resource constraints (3).
As reduction of calorie intake was one of the foundational ideas listed in the Guidelines, in April 2011, the Obama administration proposed rules that vendors with 20 outlets or more must comply with a new law to post calorie counts of foods and drinks on menu boards, expected to take effect in 2012 (6). In helping policymakers design and implement nutrition-related programs, the Guidelines are used by the Federal Government to develop nutrition assistance programs such as school meals programs and Meals on Wheels programs for seniors, as well as nutrition education programs (3). The Guidelines also provide the foundation for the Healthy People national health promotion and disease prevention objectives related to nutrition, as well as dietary advice provided by professionals (1).
Major actors in the development of this year’s Guidelines include Agriculture Secretary Tom Vilsack and HHS Security Kathleen Sebelius (1). Sebelius attests that, “The new Dietary Guidelines provide concrete action steps to help people live healthier, more physically active and longer lives” (1). Vilsack stated in the press release of the Guidelines that, “one in three children [are] overweight or obese and this is a crisis that we can no longer ignore… The bottom line is that most Americans need to trim our waistlines to reduce the risk of developing diet-related chronic disease” (1). Though, in taking the Guidelines as a public health intervention, it serves more as an educational resource for policymakers and nutritionally literate consumers, rather than a social intervention. In its lack of explicitness in certain areas, it likely feeds into the optimistic bias of the consumer, and uses knowledge as a jumping board for reasoned action. For these reasons, a more personalized and family-centered approach can motivate action for better dietary patterns, therefore reducing risk of chronic dietary-related disease. In effectively utilizing advertising and branding theory for family health and well-being, as well as addressing consumption of fresh produce and its cost-effectiveness as a family need, the necessary push for action to reduce disparities of access to quality food can grow from communities. Thereby affecting policy and inspiring change in the community, Americans need a deeper motivation, in addition to education, to consume better diets for better futures.
Lack of Explicitness and Mixed Messages According to Advertising Theory
It is arguable that the Guidelines offer “concrete action steps,” as the document states slightly vague resolutions for American citizens to consider. The inherent vagueness stems from the conflict of interests involved with the Guidelines, embedded in the USDA having two conflicting goals: one to guide the public in making good dietary choices and one to promote the nation’s consumption of manufactured food (7). An editorial in the New York Times points out that the USDA succeeds to fulfill both goals by convincing the public that eating manufactured food lower in solid fats and sugar is “healthy,” while also endorsing manufactured products with added fiber and reduced fats, in order to appease the nation’s industry of food processing (8). Thus, the basic messages that the Dietary Guidelines 2010 offered were predictable and very general. Eating less food and sodium, controlling calorie intake, discontinuing soda consumption and increasing water consumption, and eating more vegetables were the key elements of the document (3).
The generalization factor of the Guidelines is also attributed to addressing nutrients that should be reduced, rather than examples of whole foods. Instead of its emphasis on reducing “solid fats,” the Guidelines should more explicitly emphasize to reduce red meat and dairy products (9). The Huffington Post also points out that classifying foods as “healthful” or “unhealthful” on the basis of specific nutrients such as certain vitamins and fat, may lead to dietary choices that stray away from the basis of the “eat more vegetables” part of the Guidelines. For example, some low-fat processed foods are high in refined sugar, but to fulfill school nutrition guidelines that specify a minimum number of total calories but a maximum proportion of fat calories, gelatin desserts and sugar-sweetened milk are used to achieve this (7). While the appendix of the Guidelines does list more specific groups of foods overly consumed by the general public, such as pizza, grain-based desserts, and sodas, which could aid in the creation of consumer education materials, its chapter on which foods to reduce is by far its greatest downfall. This vagueness and lack of explicitness also contributes to resistance of the public as described by Advertising Theory, as put by “Confessions of an Advertising Man,” by David Ogilvy. The Guidelines must give enough factual information to “sell” the notion that reducing foods containing exuberant amounts of sodium and hydrogenated oils will make them healthier (10). As Confessions acknowledges, most responses are awarded to campaigns that create a “coherent image,” and the “stability to stick with it over a long period;” the Guidelines misses this issue by trying to sell two things at once: the American food economy and healthy choices.
The USDA is not recognized as an independent, scientific research group, but a federal entity that is tied to economic and food industry-related interests. It is argued by Harvard School of Public Health nutrition scientists that the current document continued to fail to highlight the need to cut back on red meat and dairy products, suggesting that beef and dairy industries retain their strong influence within the USDA; the Grocery Manufacturers Association, the Sugar Association, the National Milk Producers Federation, and the National Cattleman’s Beef Association were all listed as organizations, along with the general public, who commented on drafts of the document during the two-year process of gathering data for the final Guidelines (9). For instance, the Guidelines continue to generalize red meat together with fish, poultry, eggs, nuts, soy, seed, and bean in one “protein foods” group, and there is no mention of scientific evidence that reducing red meat consumption could help prevent cardiovascular disease and the risk of diabetes (9). Also, the Guidelines continue to recommend increasing intake of low-fat milk and dairy products to satisfy a high intake of calcium, though research shows that milk and dairy should not be heavily relied upon as the only source of calcium, nor primary preventative measures against osteoporosis or fractures (vitamin D-rich foods must also be stressed) (9). If people are misled by outside industries influencing the source of intervention in nutritional guidance, it is unlikely that people will be receptive to the intervention.
Unrealistic Optimism of General Consumer
Additionally, the intervention does not take into account Optimistic Bias Theory of the general consumer (11). It would be relatively easy for readers of this document to rationalize that they are already eating well, and do not need to adhere to the Guidelines because they are feeling healthy and do not want to change eating habits. People believe that negative events are less likely to happen to them than to others, and only when the perceived probability of an event is great, the tendency for people to believe that their own chances becomes stronger (11). For instance, the Dietary Guidelines focus on sodium as key to lowering blood pressure in a majority of the population, and calls for 2300 mg a day of sodium for the general public and 1500 mg a day for sodium for high risk populations (elderly, diabetic, existing kidney problems) (3). The Guidelines do point out that most of the sodium in the population’s diet stems from processed foods, which is the most explicit statement veering encouragement away from consuming manufactured foods (3). By simply proclaiming the amounts of sodium that are suggested for consumption, along with risks of cardiovascular disease and high blood pressure, people may be likely to pay attention to nutrition labels on processed foods, but are not likely to think about these facts when casually adding salt to their food from a shaker without seeing how much in milligrams they are adding. The perceived risk of too much salt intake is not explicit in the document when thinking about unconscious salt intake (I.e. from salt shakers) and people are likely to be more unrealistically optimistic about their risks to these diseases given their salt intake.
The report also recommends lowering the consumption of soda, adding that it is a major source of refined sugars and calorie intake, which was also a less conservative piece of advice from the Guidelines, given reaction from the Sugar Association (3). Again, the Guidelines do not address the Optimistic Bias Theory, in that people who do not eat a lot of calories from nutrient-rich whole foods may rationalize their continuing consumption of soda to their already “calorie conscious diet.” People can be unrealistically optimistic to their intake of refined sugars because they may work out and exercise excessively or regularly, and can wave away the notion that they could develop diabetes later on in life because of their exercise regime. Additionally, the main basis of lowering caloric intake to lose weight is a short-sighted piece of advice, as clinical research has shown that high carb high sugar diets produce metabolic reactions that make it difficult for weight loss because it contributes to cravings and blood-sugar fluctuations (7). This kind of information should also be added to their recommendation to cut soda drinking for the optimistic majority to consider.
Need to Motivate Communities to Address Access to Healthier Choices
Given the two flaws listed above, the Dietary Guidelines of 2010 assumes that consumers who read the document will change their behaviors based on the fact that there is no “American” eating pattern, but proclaiming that Americans eat too many calories, too much solid fat, added sugars, refined grains, and sodium (3). Reiteration of foods and nutrients that Americans should be eating in more than one chapter of the document, the Guidelines assume that the reader’s intentions in terms of knowledge will be the immediate precursor and best determinant of behavior, according to the Theory of Reasoned Action (12). The Guidelines do accurately assess and give data on health problems and growing rates of obesity among American families around the nation, and calls for a healthy eating pattern to be established for individuals. In theory, the principles it offers to achieve this are simple and realistic: focus on nutrient dense foods, remembering that beverages count for calorie intake, handling food in a sanitary manner, and to consider the role of supplements and fortified foods (3).
This eating pattern is partially based on research on Mediterranean-style eating patterns, because diets in this region emphasize vegetables, fruits, nuts, olive oil, and whole grains, with small amounts of meats and dairy products included. (3) For instance, traditional eating patterns in the Crete region were associated with a low risk of cardiovascular disease, and as over time, a higher intake of saturated fatty acids and cholesterol developed, the Crete population experienced a steady rise in risk of heart disease (3). While the Guidelines address that healthy eating patterns around the world are diverse, the common threads that exist within all of them include abundance in vegetables and fruits, and moderate amounts of varieties of foods high in protein.
While the recommendations are logical and attractive to good dietary intentions, the Guidelines fail to acknowledge the “access” piece that it talked about in its Executive Summary for families, and instead focuses solely on nutrition education. Without ease of access to vegetables, fruits, and healthy sources of protein, fulfilling this kind of dietary pattern would be difficult. For instance, in speaking of health disparities in which different ethnicities and cultures experience higher rates of obesity, this could be attributed to neighborhoods within an area that characteristically have a lower socioeconomic status. Commonly termed as “food deserts,” these neighborhoods have a disproportionately low number of grocery stores that have fresh produce in the area, and are usually characterized by less healthy, convenient fast food-type options (13). Even with the intention of developing a healthier eating pattern, the Guidelines should recognize that people must self-adjust their diets according to their means, in that the actual choices for meal preparation is not the same as those of Mediterranean populations. Furthermore, there needs to be a deeper call to action for policymakers and general consumers alike, to demand for better access to achieve the goals that the Guidelines articulates.
Importance of “Family Meals” Approach
The Guidelines end with a great chapter entitled “Helping Americans Make Healthy Choices,” calling for action among policymakers to consider focusing on the community and environmental setting of the consumer, rather than just the individual’s behavior; this was by far the most compelling argument of the Guidelines. Emphasis on empowering individuals and families with improved nutrition literacy, gardening, and cooking skills were listed as a key strategy, as well as initiating partnerships with food producers/suppliers to promote smaller, more affordable portions (3).
Building upon the positive aspects of the Guidelines, it can be argued that though its last chapter emphasized environmental factors, outside of an individual’s control, that affect rising rates of obesity and chronic dietary disease in the nation, there is no proposal of changes that could arise from the immediate environment of individuals, which for most people consist of their families or roommates. If the USDA and HHS are concerned about Americans eating patterns, the logical source would be to look at what is on family dining tables.
In a recent study based on a nationally representative sample, the presence of at least one parent during the evening meal was associated with a lowered odds of poor consumption of fruits, vegetables, and dairy foods and a lowered odds of skipping breakfast among adolescents (14). Of adolescents who ate three or fewer family meals per week, three-fourths reported poor consumption of vegetables, compared with two-thirds of adolescents who ate six or seven family meals per week (14). It is recommended that particular attention should be paid to the challenges families with older children face in participating in regular mealtimes. Furthermore, encouraging parents of adolescents to emphasize the importance of breakfast and provide guidelines for their children represents a promising intervention for not only improving adolescence nutrition but also adult nutrition; parents who eat evening meals with children may be more likely to eat breakfast with their children (14). The findings are consistent with previous research using a younger sample (children age 9 to 14 years), that showed positive parental influence on children’s eating patterns (15).
Minority groups were at higher risk of cancers, diabetes, and hypertension and were found to be at greater risk for poor consumption of vegetables and dairy foods, thus improving dietary habits of minority youth is critical in reducing racial health disparities later in life (14). Additionally, findings from the 1999 National Health and Nutrition Examination Survey indicated that 14% of adolescents age 12-19 were overweight, when more than double of the percentage (31.8%) perceived themselves to be overweight (16). This large gap between the percentage of adolescents who are actually overweight and those who perceive themselves to be overweight highlights the importance for adolescents to be educated about healthy body image and healthy weight (14).
Healthy body image and minority children disparities in eating patterns could both be aided by more public awareness that mealtimes should be shared with families and friends. As the above studies show, family-oriented mealtimes correlate with health benefits for both the children as well as the adults. Emphasis on family-oriented mealtimes is not a new idea, but a traditional approach to eating that seems to be an after-thought in the present world; with more career-oriented parents, busy after-school schedules to gear children towards a brighter future, and the plethora of take-out and convenience style food available through online ordering, convenience and efficiency can take precedence. This approach of anti-solitary mealtimes not only targets families and children, but can also translate universally to people of all cultural backgrounds, ages, demographics, and living situations.
Because it would be strange and probably subject to mockery to have a public service announcement about “eating as a family,” this approach could primarily be translated via commercials to advertise restaurants, grocers, and farmer’s markets acknowledging how cost-efficient it is to eat as a family as well as include more vegetables in the meal. Cost-effectiveness should be stressed, as well as the great ease and savings in time that cooking a meal with the family and eating with the family can ensure. For instance, a commercial starts off with a family of four shopping at a farmer’s market on a weekend, then fast forwards to the kitchen where the family is making a stew, and each vegetable used is highlighted , along with its total price for the meal for four people. All the while, the commercial also shows the kids helping to wash the produce and/or interacting with the parents in the kitchen. The final product is showcased, with the family sitting down at the table, enjoying the meal and chatting, and then a slogan appears, such as “Shop at your local farmer’s market: Save money, eat as a family, and live healthier.” Depending on the region, a quick schedule of farmer’s markets in the area can be shown at the end. A nationwide farmer’s market organization such LocalHarvest could partner with USDA and HHS to gain funding for such media advertisement for farmer’s markets.
A great example of a similar media campaign geared towards family eating that was well received by the public was Stouffer’s “Let’s Fix Dinner” campaign released in 2010 (16). Stouffer’s teamed up with the family dinner advocates at the Center for Alcohol and Substance Abuse at Columbia University, to acknowledge that meals prepared at home as a family and eating together as a family is not as hard as one would think. The product of their coalition was a reality TV-like YouTube channel in which six families were followed in their commitment to eat more meals together to see the benefits of their efforts, (18) and a TV commercial (19) that emphasized family teamwork and ease in preparing meals as a family, and how cost effective eating together can be. As Stouffer’s is a frozen dinner product company that was able to use corporate money to support promoting family dinner and value, clearly other grocers, restaurants with healthy choices, and farmer’s markets especially, could be advertised in this same extent.
Addressing a Family Values Through Advertising Theory
Using the family-centered approach in this commercial, there is no mistaking the action steps required to achieve a healthy lifestyle that is recommended: use farmer’s markets, shop together, make meals together, eat together, save money, and be healthy. As Ogilvy points out in successful advertising campaigns, “large promise is the soul of an advertisement” (10). This approach of eating as a family correlating to healthier eating patterns is a coherent image, that connotes consistency in a promise that is supported by what Americans know already, that eating more vegetables is a good thing for their diet. There is no indication that Big Meat and Big Dairy could influence this campaign, and thus the only message delivered is clear and unobstructed by fancy processed foods with nutrient emphasis. The nutrients factor is embedded in the push for consumption of fresh, local produce. The campaign also connects healthy eating patterns with a cohesive family ritual of cooking and eating as a unit, which is an indirect way to guide a behavior, as a promise, without authoritatively dictating that families must behave in this way to have nutritional benefits. The support of eating as a family and shopping at the local farmer’s market is shown in the final product, with a healthy and hearty meal that is cost-efficient, easy, and fun when prepared together. In using the self-referencing factor mentioned in class, the commercial makes viewers picture themselves in the lifestyle that is portrayed in the campaign. Lastly, both promise and support are surrounded by core values, which touch on a sense of belonging as an integral part of a family, and a healthy lifestyle.
Also, in picking out core success tactics from the “Truth” tobacco campaign, specifically the tone and branding strategies of this campaign, one can also see how this commercial further steers the message of this campaign as a belief that the public would respect and acknowledge (20). Once again, people generally know that eating vegetables is necessary for a healthy diet, and making the central anecdote of the commercial to be a typical weekend afternoon shopping at the farmer’s market, the tone is relaxed and realistic. Most families would not be able to go shopping as a family during a weekday, more so during the day, due to work and school. The vegetables are highlighted, the cost is shown to make an entire meal, and the family as a unit is shown to work together and enjoy the final product of their meal. Farmer’s markets in the local area are shown at the end, thus it is up to the viewer to take this information and use it, according to their means. Because the public knows the general dietary significance of eating produce, farmer’s markets are an obvious source where they can shop to gain this benefit. The commercial thus “brands” the act of shopping at farmer’s markets as identifying with core values that families and the general population would like to achieve, in living a healthy lifestyle while enjoying the company of others. It is implied that the act of going to a farmer’s market and making use of produce is also a great way to improve social conditions of the home life, as well as a great way to save money and encourages acts to reduce obesity and other chronic dietary-related diseases.
Optimism Counteracted with Hierarchy of Needs
It may be simple for individuals to see the commercial described above and rationalize that either a) they already live a healthy and cost effective lifestyle without going to the farmer’s market and/or b) that their family unites and spends time together in more efficient ways than simply centered around eating at the dining table, when compared to the rest of their peers or the public. This notion of optimistic bias is attributed to comparing themselves to a stereotype of a person or family who does nothing to improve his or her chances of achieving a healthy eating pattern or lifestyle (11). Another aspect is that people could rationalize that there are more cost-effective and/or time-effective ways to achieve similar benefits promised by the campaign. Though, when taking into account Maslow’s Hierarchy of Needs, this optimistic bias is counteracted through theories of positive human motivation (21). The campaign addresses eating as a family as an easy and sequentially realistic end product of healthy eating behaviors. The need for fresh produce in the diet is automatically connected with family-centered meals, and the benefits that are reaped from the sequence that is sourced from farmer’s markets is magnified with the social aspect of cooking and eating together; there is a complete picture of a lifestyle that could be achieved. As Maslow points out, human needs arrange themselves in hierarchies of prepotency, and every drive is related to the state or satisfaction of other drives (21). The five basic needs are physiological, safety, love, esteem, and self-actualization, and these goals are arranged in a hierarchy and people are motivated to achieve or maintain various conditions upon which these basic satisfactions rest (21). The need for satisfying intake of vegetables and thus eating for better health benefits physiologically is strongly correlated with the love, esteem, and bond that social eating offers in the family-style setting, in the commercial. No matter which basic need is prioritized first in an individual’s life, the satisfaction factor is visually and emotionally magnified (by the commercial) if these two needs are met together. By emphasizing that eating vegetables and having healthier eating patterns (therefore reducing risk of dietary related disease) while spending time with the family is a need, rather than an ideal or two separate entities to satisfy two different goals, this campaign guides the viewer and general public to want to achieve such a lifestyle.
“Branding” Farmer’s Markets for Community Push for Access
Instead of empowering families and consumers with knowledge and nutrition facts, the campaign aims to empower them through the value of family playing a central role in healthy eating patterns and life styles. With families being more aware of their responsibilities and needs as a family to eat healthy together, there is an incentive to seek outlets for healthy options with heightened community awareness of the question of whether or not they have easy access to eating healthy. Are there farmer’s markets near my neighborhood? The campaign personalizes this sentiment, and creates community awareness in a way that is not explicitly marketed in the campaign, but rather an after effect of watching and being exposed to the kind of lifestyle where healthy eating patterns come easily. The behavior is not a result of intentions based on knowledge, similar to the argument made about the Guidelines following the Theory of Reasoned Behavior, but through social motivation and awareness that they too deserve this option for a healthy eating pattern.
Therefore, once again by ‘branding’ the act of shopping at a farmer’s market as a way to promote healthy eating patterns, people are positively motivated to demand for access to this ‘brand’ of behavior. The development of the consumer-brand relationship and the development of the equity (or value) of farmer’s markets is derived directly from the engagement in the target behavior of attaining healthier eating patterns (22). Demand increases for the farmer’s markets, therefore the motivation to mobilize communities to speak up for access to engage in shopping at farmer’s markets grows. In striking a chord in the inherent core value of family, healthy dietary lifestyles and therefore reduction of chronic disease can be achieved in personalizing dietary betterment from the home perspective.
References:
1. Press Release. 31 January 2011. Accessed 27 March 2011.
2. “Dietary Guidelines for Americans.” http://www.health.gov/dietaryguidelines/history.htm. Accessed 27 March 2011.
3. USDA, US Dept. HHS. December 2010. Dietary Guidelines for Americans, 2010. Accessed 27 March 2011.
4. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among U.S. adults, 1999-2008. JAMA. 2010;303(3):235-241.
5. Nord M, Coleman-Jensen A, Andrews M, Carlson S. Household food security in the United States, 2009. Washington (DC): U.S. Department of Agriculture, Economic Research Service. 2010 Nov. Economic Research Report No. ERR-108. Available from http://www.ers.usda.gov/publications/err108.
6. “Obama to Set New Calorie Count Rules.” http://online.wsj.com/article/SB10001424052748704530204576237203366549010.html?mod=googlenews_wsj. 2 April 2011. Accessed 26 April 2011.
7. “Dr. Jonny Bowden: Dietary Guidelines 2010: Not Much to Write Home About.” http://www.huffingtonpost.com/dr-jonny-bowden/dietary-guidelines-2010-_b_819953.html 9 February 2011. Accessed 21 April 2011.
8. “Is ‘Eat Real Food’ Unthinkable?” http://opinionator.blogs.nytimes.com/2011/02/08/is-eat-real-food-unthinkable/ 8 February 2011. Accessed 26 April 2011.
9. “New U.S. Dietary Guidelines: Progress, Not Perfection.” http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/dietary-guidelines-2010/index.html Accessed 21 April 2011.
10. Ogilvy D. Chapter 5: How to Build Great Campaigns.” Confessions of an Advertising Man, New York: Atheneum, 1964. Pp 89-103.
11. Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology. 1980; 39(5): 806-820.
12. Cameron KA. A practitioners guide to persuasion: an overview of 15 selected persuasion theories, models and frameworks. Patient Education and Counseling. 2009; 74: 309-317.
13. Gordon C, Purciel-Hill M, Ghai NR, Kaufman L, Graham R, Van Wye G. Measuring food deserts in New York City’s low income neighborhoods. Health Place. 2011; 17(2):696-700.
14. Videon TM, Manning CK. Influences on adolescent eating patterns: the importance of family meals. 2003; 32(5): 365-373.
15. Gillman M, Rifas-Shiman S, Frazier A et al. Family dinner and diet quality among older children and adolescents. Arch Family Med. 2000; 9:235-240.
16. National Center for Health Statistics. Health and stats. Prevalence of overweight among children and adolescents, United States 1999 (2001) Accessed 29 April 2011.
17. “SocialResponsibility Stouffer’s Style.” http://www.eatdinner.org/2010/04/social-responsibility-stouffers-style.html Accessed 29 April 2011.
18. “Let’s Fix Dinner Channel.” YouTube. http://www.youtube.com/user/letsfixdinner
Accessed 29 April 2011.
19. “Stouffers TV Commercial.” YouTube. http://www.youtube.com/watch?v=gE79cJmA0-Q&feature=player_embedded Accessed 29 April 2011.
20. Hicks JJ. The strategy behind Florida’s “Truth” campaign. Tobacco Control. 2001; 10: 3-5.
21. Maslow AH. A theory of human motivation. Psychological Review. 1943; 376-396.
22. Blistein JL et al. “Chapter 2: What is a Public Health Brand?” Public Health Branding: Applying Marketing for Social Change, Oxford: Oxford University Press, 2008, Pp. 25-41.
posted by Melanie Pennison @ 9:43 AM
0 Comments:
Post a Comment
Subscribe to Post Comments [Atom]
<< Home