“I think every single presentation has focused on the fact that you have to start where people are with the lived reality of their lives and then build whatever it is you want to do from there.”
—Cynthia Baur
The workshop ended with a final panel discussion among speakers from all of the sessions. This chapter summarizes that discussion. Panelists considered a range of topics, from the challenge of addressing taboo issues such as obesity to opportunities for designing whole communication environments as opposed to sending single messages.
A lively discussion was triggered by co-moderator Sarah Roller’s hypothetical case involving two consumers and her question about which of the two qualified as food literate. She asked, “What does a food literate consumer look like? That is, how do we measure ‘food literacy’? How do we determine who qualifies as ‘food literate’?” Several speakers agreed that asking whether a person is food literate without considering the specific context of his or her personal goals would not be asking the right question. For Cynthia Baur, the question illuminated what she thought was a significant take-home message from the workshop, as conveyed in the above quote.
The importance of starting with the “lived reality” of people’s lives resurfaced later during the discussion when co-moderator Kristen Harrison described the very busy lives of people and asked panelists how communicators can tell science-based truths about food such that the messages they are sending are interpreted as “gifts,” not “chores.” Again, several panelists highlighted the importance of focusing on the goals and needs of individual consumers. Carol Byrd-Bredbenner described an obesity prevention program with young adults in which she and her colleagues intended to discuss nutrition until they learned that stress, not nutrition, was the biggest problem facing these young adults. So they had to change their messaging.
She said, “I think we have to keep what is really important to the person in mind and then go from there.”
WHAT DOES FOOD LITERACY SUCCESS LOOK LIKE?
Roller opened the session by asking the panelists to consider a hypothetical case involving two consumers, consumer A and consumer B, and asking whether either of the two would qualify as “food literate.” Consumer A was a physician who did not like or eat vegetables, except for a single red delicious apple every now and then at lunchtime, but who knew the Dietary Guidelines for Americans (DGA) by heart and was able to communicate about nutrition to her patients. She did her best to compensate for her restricted diet by taking supplements containing essential vitamins, minerals, and dietary fiber. Consumer B was an 8-year-old boy who consumed his daily recommended amount of fruits and vegetables by eating mandarin orange slices and baby carrots, not because he knew about nutrition but because his grandmother had warned him that he needed to eat those foods to retain his eyesight. He had been playing the violin since the age of 3 years and was worried that unless he ate oranges and carrots every day, he would not be able to read his violin music. He grew to enjoy eating the little packs of baby carrots and cute little mandarin orange slices and even started collecting cartoon stickers from the mandarin orange food packages to trade with his friends in the school orchestra. Roller asked, “Do either or both of these consumers qualify as food literate? . . . What does a food literate consumer look like, and how do we make that determination?”
The question prompted considerable discussion. Tom Nagle questioned the very definition of food literacy. The ultimate measure of food literacy, in his opinion, is not knowledge but “reasonably better behavior than before.” The physician, he observed, clearly had tremendous knowledge. The boy, on the other hand, while he did not have that same knowledge, was “doing some reasonably good things.” He said, “The concept of food literacy should really be a result-based, behavior-based metric. I would vote for him.” When Roller asked Nagle if he was suggesting that the boy was food literate but the physician was not, Nagle reiterated that he did not care for the notion of food literacy. The goal is not for people to understand why they are behaving correctly, he argued. “We just need them to behave a little better within the framework of their own values.”
Craig Lefebvre stated that the question posed by Roller is not the right one to be asking. For him, the question is whether people around either consumer are indicating that her or his behavior is acceptable. Judging individual behavior by itself does not take into account the social context in which people are living their lives and consuming food, he explained. A
food literate future, in his opinion, is one in which people are taking care of each other with respect to food.
Sonya Grier agreed that Roller’s question is not the right one. People are not either food literate or not food literate, she explained. In the case of the physician, without knowing her goals and what she wants from her life, it is not really possible to say whether she is food literate. With the violinist, while his goal is to protect his eyes and while he is motivated to achieve that goal, he does not have full knowledge or a complete understanding of how food can help him reach his goal. Grier views food literacy as a continuum, with an objective of this workshop being to gain a better understanding of where consumers are on this continuum and how to help them move along it.
In response to Grier’s notion of food literacy as a continuum, Vivica Kraak opined that the boy appears to be on a better trajectory, early in life, toward food well-being, with his grandmother influencing that journey. He is highly motivated by his music and well connected socially. She suggested that the doctor could learn from the boy through intergenerational education.
Roller wondered whether the panelists’ responses would be different if, instead of being about whether either consumer was food literate, the question were about food literacy with respect to consumption of fruits and vegetables in particular. Roller asked whether it is possible that the physician is in fact food literate if she is satisfied and feels that she has developed a solution (dietary supplements) for a problem she has faced for a long time—that she “is not friends with the plant kingdom.”
“Again,” William Hallman said, “I think you are asking the wrong question.” It is either that, or the goal is not being properly defined. Is the goal for both consumers to be doing what “we” think they should be doing, which is consuming more fruits and vegetables? Or is the goal for them to be not just literate but also, using terminology Hallman had defined during his presentation, ecolate? That is, should they be able to adapt what knowledge they do have to new situations? Is there a way for a boy to better understand healthy eating than what his grandmother told him about mandarin oranges and carrots?
Asking whether someone is food literate or not is a “dead end,” Cynthia Baur stated, joining those expressing disapproval with the question. “I think every single presentation has focused on the fact that you have to start where people are with the lived reality of their lives and then build whatever it is you want to do from there,” she stated.
Roller was curious how success is defined in the field of health literacy. She asked Baur how she and her colleagues in the area of health literacy know when they are achieving progress. Do they count health literate people? Baur explained that some of her colleagues do count health
literate people. But they are often disappointed, she said, because there are far fewer health literate people than they want. In Baur’s experience, effectively changing health literacy requires intervening at the community level, not the individual level. She is in agreement with Craig Lefebvre in that respect. “Focusing on the individual has not proved to be very effective,” she said.
EDUCATING PHYSICIANS AND OTHER HEALTH CARE PROFESSIONALS ABOUT NUTRITION
Linda Neuhauser expressed disinterest in what Roller’s hypothetical consumer A, the physician, did personally, but found it important that the physician understood food and nutrition and was communicating with her patients in a way that helped advance their food literacy. Neuhauser noted that several workshop discussions had revolved around the lack of education in food and nutrition among physicians and other health care professionals. Given that an estimated 8 of every 10 chronic diseases are related primarily to food and nutrition (a statistic Neuhauser recalled hearing from someone at the workshop), such education should be a central part of the allied health curriculum, in her opinion. She called for “some kind of movement” among groups of professionals who organize to determine board licensure. Additionally, she noted that this has been an issue of discussion for probably 20 years or so, yet she has not seen much progress.
The Culinary Institute of America in Sonoma has been running a program for about the past 8 years that teaches physicians how to cook, Sally Squires noted. She described it as “a wonderful engagement,” but it covers only a very small group of people. She views cooking as a way to integrate nutrition more generally into science curricula, not just for physicians but for all students.
Panelists revisited the importance of intervening early in a child’s life. Based on his experience with the canned food marketing campaign, Nagle said, “Whatever is happening in the first 5 years or 10 years of a person’s life [probably] is determinative in a much broader, longer term than we think.” Neuhauser mentioned just having completed a national study of parenting of children aged 0 to 3 years. Both parents and providers reported knowing little about nutrition but wanting to know more. Many parents are “adrift,” Neuhauser said. An audience member suggested that those not adrift may actually be the more difficult problem because they likely are operating on the basis of a decades-long habit that is probably unhealthy.
Baur cautioned that experts need to be careful about the language they use, their own positions on these issues, and the approach they take. Thinking that “we are the experts” and “we know best” is a problematic stance, in her opinion. When experts are not respectful toward the people they are trying to engage, she suggested, people instantly pick up on that and will not pay attention or participate. She observed that she had heard that kind of language—the language of “barriers” and “intervention”—over the course of the workshop and cautioned workshop participants to try to avoid it.
Lefebvre agreed. He also cautioned against use of the term “behavior change.” “We are not trying to change people’s behavior,” he said. Rather, the goal is to “create opportunities for people to learn different ways of being food literate.” Lefebvre noted that 90 percent of what people learn is acquired by watching and then doing. However, he said, what experts call “interventions for behavior change” are not about watching and doing, but usually involve doing something to people, somehow forcing them to do things differently or nudging them in certain ways. He encouraged researchers to shift their language away from, “We are going to fix these people.” Instead, they should think about creating environments that allow people to see other options.
Neuhauser agreed that when one “unleash[es] people’s creativity,” one creates those environments. She noted that parents surveyed in the national study she had mentioned previously said to the surveyors, “Don’t preach to us.” They wanted their learning to be fun, emotional, and playful, Neuhauser said.
DELIVERING KNOWLEDGE TO PEOPLE WHOSE LIVES ARE TOO BUSY FOR THEM TO TAKE ON ANY MORE “CHORES”
Kristen Harrison described the busy lives of many people for whom obesity is a “distal threat”; they have other, more immediate fears. She shared a personal story about her own busy life and how she had, over the course of 2 years, stopped exercising and started eating “nothing but jelly beans.” She gained 30 pounds during that time. She kept asking herself, “What’s wrong with you? Why can’t you ‘rational choice’ your way back to good health?” But she could not change her behavior. In addition to the weight gain, she developed prediabetes and high insulin resistance. While she had always thought that insulin resistance was a result of weight gain, in her case it was the opposite: it started from stress and then, because insulin resistance creates extreme fatigue, she started eating jelly beans to “bump up the energy.” The stress, she explained, came from taking care
of her three children, one a 9-year-old daughter, the other two 6-year-old twins, both autistic. One of the twins had many health problems and was constantly on the move. The number one cause of death among children with autism, according to Harrison, is that they wander. She found herself in a situation in which the value of healthy eating and exercise was in direct conflict with the value of being alert and awake enough on a daily basis to make sure that her 6-year-old who wandered did not die. In her case, she knew everything she needed to know, and she wanted to resume her healthy eating lifestyle. But for her, during that period, obesity was a distal threat. Her more immediate concern was making sure that her child was still alive at the end of the day.
“The point of all this,” Harrison said, “is when there are these priorities bumping up against each other, what looks to be lack of knowledge, lack of commitment, lack of discipline, and so on may actually be somewhat heroic parenting, family care, or self-care among people who have so many chores in their lives at that moment that it is like a sinking ship. Things have to be thrown out.” She referred to a book, No Sweat, by Michelle Segar, which differentiates between chores and gifts. For Harrison, what used to be a gift—exercise—had become a chore. Segar recommends that one way to turn a chore into a gift is to think about what feels good. Harrison considered exercise to be an intensely sensory experience. She described putting on shorts and going running and feeling her thighs chafe together as “one of the worst sensory experiences.” Eating is an intensely sensory experience for her as well. The challenge, in her opinion, is to find ways to help people turn their chores, such as exercise and healthy eating, into activities that are pleasurable and that will sustain them throughout the day. She asked the panelists how to resolve the tension between, on the one hand, conveying the science-based “truth,” which she said can be “theoretically empowering,” and the risk of inadvertently turning could-be gifts into chores.
Nagle reiterated the importance of focusing on the goals, or reasons for change, that are important to the person making the change. He said, “That notion of finding the things that motivate people to act differently on their terms is different than making sure they have the food literacy to understand the scientific and factual reasons why they should change their behavior.” For some people, a body of knowledge about science and nutrition may be what motivates them, he explained, but others do not need to know why they feel great after having done something. “You don’t really need to know physiology and nutrition,” he said, “to say, ‘I feel really great when I finish running if I just wear long pants.’” He suggested focusing on what is important to people. It might be the sensory nature of the experience, as it is for Harrison, but it could be any number of things.
Grier added that in her community-based participatory research, she
and her colleagues do not design interventions without having included the consumer’s voice as part of the process. But they do not just conduct focus groups, she remarked. They use multiple qualitative methods, such as sending people out with cameras to gather in-depth data so as to better understand what consumers need and what will be realistic in their lives given all their competing priorities.
Kraak agreed with Harrison that eating is a highly sensory experience and suggested that communicators create messages about healthy food and beverage products that elicit the entire sensory experience (sight, touch, smell, sound, and taste) (Lee, 2013). “I don’t think we have really gone there in the design world,” she said, “and we should.”
Baur observed that Harrison’s story is a good example of a case in which equating food literacy primarily with [scientific] knowledge would be “wrong.” She suggested that many different levels must be addressed in order to effect a behavior change or, in Harrison’s case, “get [her] off the jelly beans.”
As another example of the tension between knowledge and other levels of experience, Harrison mentioned some work she had done with one of her doctoral students on patient–provider communication in a pediatric context. They found a positive correlation between parents liking their pediatrician in their child’s first year and children eating more obesogenic foods in their second year. The researchers suspected that because so many chores are associated with new parenthood, parents like pediatricians who tell them that everything is fine and they do not need to worry. Parents react to pediatricians who provide too much information by becoming overwhelmed and wanting to find a new pediatrician. This is an example of what Harrison perceives as the ongoing challenge between emotional and informational needs.
Squires suggested that best practices from people in real situations, such as Harrison’s, be shared to empower others who are encountering similar circumstances. She observed that this is what is being done with technology in some offices, with younger workers who are familiar with newer technologies but unfamiliar with office settings being paired with older workers for whom the reverse is true. It is a “win-win” situation, she said. She could imagine the same thing being done with food. This would be a way to invite people to share their solutions instead of telling them what to do, she explained.
Carol Byrd-Bredbenner echoed other calls to figure out what is important to the individual, suggesting that the question is, “How do they define what is important to them?” She described an obesity prevention program involving young adults in which she and her colleagues intended to discuss nutrition until they learned that stress, not nutrition, was the greatest problem facing these people. Thus, they had to change their mes-
saging and address stress. Likewise, in a project with mothers, the women did not want to hear about health but wanted to know “how to make their families happier.” Byrd-Bredbenner said, “I think we have to keep what is really important to the person in mind and then go from there.”
SENDING A SINGLE MESSAGE VERSUS DESIGNING A COMMUNICATIONS ENVIRONMENT
Lefebvre referred to Nagle’s finding that greater behavioral change around consumption of canned foods was related to the number of media channels through which consumers had heard the message about such foods. Lefebvre reached a similar conclusion in his own work when “5 a day” nutrition messages were being delivered to fifth graders through seven different channels, including Disney public service announcements and in-class curriculum. His research team found that behavior change was directly correlated with the number of channels through which the children remembered hearing the message. He encouraged communicators to think more about “media multiplexity” and how to vary messages and surround people with messages coming from different media.
Additionally, Lefebvre encouraged communicators to think about “layering” messages, that is, sending multiple messages, each with a different layer of information. Rather than trying to gain consensus on a single message, he suggested thinking about a more nuanced communication strategy with multiple messages. “It is not about a message anymore,” he said. “It is about a communications environment.”
THE PROFITABILITY OF MARKETING HEALTHY FOODS
There was a brief discussion about the lack of easy access to healthy foods and a question from an audience member about how to change the food environment to make healthier choices easier and more obvious. She commented on how she had taken the train into Washington, DC, to attend this workshop and wanted to purchase breakfast on the train. But the only options were sweet baked products, sodas, sweetened yogurt, and bananas. “If that is what we have available to people on an everyday basis, it is really hard to say what messages resonate and don’t resonate,” she said.
Nagle replied that the food environment is a capitalist’s construct and that capitalists sell “what people want to buy.” Regulating people’s choices, in his opinion, counters the core values of much of the U.S. population. When Byrd-Bredbenner suggested that the environment could be changed so that consumers could at least make a healthy choice, Nagle stated that the only way to change the inside of that train car would be to alter the capitalist’s construct.
Lefebvre pointed out that one way the marketplace inside a train could be changed is by consumers demanding something different. He mentioned that part of the “5 a day” campaign involved encouraging major grocery stores to put their fruit and vegetable sections up front instead of in the back of the store. There are few big supermarket chains anymore in which consumers walk in and fail to encounter fruits and vegetables pretty quickly, he said. So it is possible to make some of those changes, in his opinion, but doing so requires focus.
In Nagle’s opinion, making these changes is a matter of “quid pro quo.” With the canned food campaign, he and his team approached retailers and told them that they were running a campaign to get people to buy more canned goods. The retailers said they would display the canned goods better. Nagle described their response as, essentially, “If you create the market, we will sell whatever people want to buy.”
Roller described the “end game” as, “It has to be profitable to market healthy food.” Otherwise, in her opinion, there are too many obstacles, even if the messaging is “correct.”
Kraak suggested a systematic nudge approach. She mentioned that she had been working on a nudge study of the entire restaurant sector in the United States to evaluate how extensively restaurants have used systematic nudge strategies to promote healthier options to children and adolescents. Nudges include such strategies as changing the music, atmosphere, or lighting. Baur noted that couponing is another form of nudging. She observed that she buys a great deal of fruits and vegetables but never receives coupons for apples or avocadoes. Given people’s everyday realities, she said, perhaps nudging them with “little offers” would help to alter their behavior.
People are very uncomfortable talking about some issues, Baur observed, and their discomfort can affect approaches to dealing with these issues. Researchers have a difficult time asking questions about topics that are considered unacceptable to discuss. Baur mentioned a conversation she had had with Byrd-Bredbenner during the workshop about Byrd-Brenner’s research with mothers who do not want to talk about weight and being overweight and about the fact that weight is considered a “taboo” topic. Baur asked, “If there are some taboo areas, what are they? Are they important? Do they matter to the overall approach?” She remarked that public health has a history of dealing with difficult topics for which the social norms are such that those topics have been labeled “unapproachable.” A lesson learned from this history, she suggested, is that identifying “taboo” topics is an important first step toward talking about what approaches to take.
Byrd-Bredbenner mentioned a focus group study with families in Arizona and New Jersey and the “tremendous pushback” she and colleagues encountered when they used the word “obesity.” She said, “They just did not want to hear that word.” The researchers tried to find other words to use, such as “too much weight” and “heavy kids,” but they still received pushback. Byrd-Bredbenner said, “It is the elephant in the room. We have to figure out how we can talk about this in a way that is not offensive and keeps them listening.”
Wendy Johnson-Askew agreed that use of the word “obesity” can make parents feel like failures. She described how she and her colleagues have achieved some success in a community-based obesity intervention study. The study is being conducted in two cities: Newark, New Jersey, where the obesity rate for children aged 2–5 is 27 percent, which is eight times the national average; and Birmingham, Alabama. In both cities, the researchers have been running the program through parenting centers. Johnson-Askew described parenting centers as places where people can go to get information because they want to be better parents. The programmatic approach has been to tap into the value system around wanting to be good parents. At the time of this workshop, 165 families in Newark and another 132 in Birmingham had graduated from the program. “It is all about what is important to the persons that we reach,” Johnson-Askew said. Additionally, the parents are being provided with resources to help them be successful. Johnson-Askew said, “You cannot just give people the tools and not have an environment that is supportive of it.” She mentioned that she had entered the food industry from the field of public health because she was “tired of nudging and pushing individuals.” She said, “I wanted to change the food environment.” She suggested that “people who do public health from an industry side” might be a good topic for a future National Academies of Sciences, Engineering, and Medicinee workshop.
