Review of Consumer Awareness Understanding and Use of Foodbased Dietary Guidelines

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British Journal of Nutrition (2011), 106, 15–26 doi:10.1017/S0007114511000250
q The Authors 2011
Review Article
A review of consumer awareness, understanding and use of food-based

dietary guidelines
Kerry A. Brown1, Lada Timotijevic1, Julie Barnett2, Richard Shepherd1, Liisa Lähteenmäki3
and Monique M. Raats1*
1
Psychology Department, Food Consumer Behaviour and Health Research Centre, Faculty of Arts and Human Sciences,
University of Surrey, Guildford, Surrey GU2 7XH, UK
2
Department of Information Systems and Skills, Brunel University, Kingston Lane, Uxbridge UB8 3PH, UK
3
MAPP Institute of Marketing and Statistics, Århus School of Business, Århus University, Haslegaardsvei 10,
8210 Århus V, Denmark
British Journal of Nutrition
(Received 22 April 2010 – Revised 1 December 2010 – Accepted 10 January 2011 – First published online 9 March 2011)
Abstract
Food-based dietary guidelines (FBDG) have primarily been designed for the consumer to encourage healthy, habitual food choices,
decrease chronic disease risk and improve public health. However, minimal research has been conducted to evaluate whether FBDG
are utilised by the public. The present review used a framework of three concepts, awareness, understanding and use, to summarise con-
sumer evidence related to national FBDG and food guides. Searches of nine electronic databases, reference lists and Internet grey literature
elicited 939 articles. Predetermined exclusion criteria selected twenty-eight studies for review. These consisted of qualitative, quantitative
and mixed study designs, non-clinical participants, related to official FBDG for the general public, and involved measures of consumer
awareness, understanding or use of FBDG. The three concepts of awareness, understanding and use were often discussed interchangeably.
Nevertheless, a greater amount of evidence for consumer awareness and understanding was reported than consumer use of FBDG. The
twenty-eight studies varied in terms of aim, design and method. Study quality also varied with raw qualitative data, and quantitative
method details were often omitted. Thus, the reliability and validity of these review findings may be limited. Further research is
required to evaluate the efficacy of FBDG as a public health promotion tool. If the purpose of FBDG is to evoke consumer behaviour
change, then the framework of consumer awareness, understanding and use of FBDG may be useful to categorise consumer behaviour
studies and complement the dietary survey and health outcome data in the process of FBDG evaluation and revision.
Key words: Food-based dietary guidelines: Consumers: Awareness of dietary guidelines: Understanding of dietary guidelines:
Use of dietary guidelines
Food-based dietary guidelines (FBDG) have been described as align health policies and nutrition programmes (e.g. food
‘consistent and easily understandable translations of popu- stamps, school meal composition and food labelling)(4 – 6).
lation nutrient goals to encourage healthy habitual food The development and implementation of national/regional
choices and improve public health’(1). They consist of written FBDG has the potential to bring substantial health and econ-
messages (e.g. UK 8 tips for eating well(2)), which are com- omic benefits. FBDG were originally developed to combat
monly depicted in the form of visual food guides (e.g. nutrient-deficiency disease, but they may play an important
German 3-D food pyramid(3)). The purpose of these messages role in discouraging/encouraging the adoption of certain diet-
and food guides appears to be various in terms of the audi- ary patterns, which have been associated with preventing
ence, application and aim. FBDG have been used to provide chronic non-communicable diseases (CNCD; e.g. CVD, certain
information to the consumer, monitor population dietary cancers). Modifiable risk factors such as diet and physical
patterns, check compliance of food industry as well as to activity have been suggested to account for up to 30 % of
Abbreviations: CNCD, chronic non-communicable diseases; DGA, Dietary Guidelines for Americans; FBDG, food-based dietary guidelines; FGP, Food
Guide Pyramid.
* Corresponding author: Dr M. M. Raats, fax þ44 1483 682913, email [email protected]

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16 K. A. Brown et al.
morbidity and mortality in the USA(4), and ill health from poor disadvantages to the choice of different study methods (e.g.
diet has been estimated to cost the UK National Health Service qualitative interviews susceptible to interviewer and interpret-
billions of Great British Pounds each year(7). ation bias, but allow depth to answers and idiosyncratic data v.
The FAO and the WHO have actively promoted FBDG with questionnaire forced choices but population-level findings),
the International Conference on Nutrition(8), the expert con- with each employed depending on the study rationale.
sultation meeting(9) and the Countrywide Integrated Noncom- The variety of study rationales and designs of consumer
municable Diseases Intervention programme(10), all pivotal in studies to evaluate or revise FBDG limits the possibility of con-
encouraging the development of FBDG in countries across the ducting a meta-analysis review. The present study sought to
world(4). Despite the promotion of FBDG, there has been little provide a narrative review of this research by categorising
evaluation of their effectiveness or monitoring of their impact studies using the three concepts of awareness (conscious
on population health(11). Attention has arguably been directed perception), understanding (subjective and objective) and
away from evaluation and focused on the development of use (single use, extended, indirect and direct) in an adapted
FBDG, such as translating nutrient reference values into theoretical framework developed by Grunert & Wills(16). The
FBDG or investigating the mechanisms behind dietary pattern/ framework is based upon classic consumer decision-making
nutrient compound effects on certain health outcomes(11). research on how information provision (e.g. FBDG) deter-
For example, the USA have a long history and commitment mines choice when there are multiple options available, as
to government-led consumer dietary guidance, where the well as upon attitude and change research on whether consu-
Dietary Guidelines for Americans (DGA) have been released mers process information, conduct cost– benefit analysis and
every 5 years since 1980, with a legal obligation for their find meaning, which is a prerequisite for information to
release written into the congressional mandate since affect behaviour (for further details, see Grunert & Wills(16)).
1990(11,12). Yet, there remains no obligation to evaluate the The categorisation and interpretation of consumer behaviour
DGA(6). studies may provide valuable information on how, if at all,
Limited evaluation of FBDG has led to an uncertainty in the FBDG influence consumer dietary choices and the employ-
efficacy of FBDG and the role that they may play in (1) chan- ment of FBDG, and thus complement the dietary survey and
ging consumer health behaviours, (2) improving population health outcome data in the process of FBDG revision and
nutrient/dietary intake/status or (3) decreasing negative the evaluation of FBDG efficacy.
health outcomes such as CNCD(4,13). The design of public
health initiatives such as FBDG may ultimately contribute
Methods
towards the achievement of (3) decrease in CNCD. However,
measuring CNCD incidence (or intermediary health markers of A total of nine electronic databases were searched (PubMed,
CNCD) before and after FBDG implementation is insufficient Web of Science, EconLit, IPSA (International Political Science
to evaluate the impact of FBDG on CNCD. Chronic diseases Abstracts), PsychInfo, EMBASE (Excerpta Medica Database),
by their nature involve small changes over time. Therefore, Cochrane, IBSS (International Bibliography of the Social
a plethora of multidimensional factors may have influenced Sciences) and CINAHL (Cumulative Index to Nursing and
a particular CNCD aetiology and pathogenesis. Repeated Allied Health Literature)), together with manual searches of
national dietary surveys provide data a step between FBDG reference lists and Internet searches of grey literature.
implementation and CNCD incidence, which yields valuable
information on FBDG compliance and monitoring of dietary
Search terms
patterns. However, aside from the practical problems inherent
in collecting dietary intake data (e.g. energy levels(14)), these The search strategy consisted of an unlimited date range until
sets of data can be similarly influenced by many factors. August 2009, any language and the following search terms
Thus, a certain dietary intake pattern may have changed (used in PubMed and modified slightly in other databases):
irrespective of FBDG implementation(15). (food based dietary guidelines) or (food-based dietary guide-
An additional dataset, which can provide evaluative infor- lines).
mation a step closer to the implementation of FBDG, can All references were entered into an endnote library. The
come from consumer dietary behaviour studies. These may initial search in PubMed was entered first, and all additional
provide additional information by either directly asking consu- searches were added to the library only after comparison
mers about the influence of FBDG on their dietary beha- for duplicates with the PubMed search. The final library
viours/dietary choices and their subjective understanding contained 939 articles before exclusion (Table 1).
and use of FBDG or using tasks to test consumer objective
understanding and use of FBDG. The majority of this research
Exclusion –inclusion criteria
is likely to be conducted during FBDG development or
following short-term interventions of FBDG implementation. References were excluded using predefined exclusion criteria
These studies consist of qualitative study designs such as devised by the research team (Table 1). The majority of studies
interviews and focus groups or quantitative designs such as were excluded, because they were conducted in a clinical set-
questionnaire surveys. Furthermore, they may take the form ting and involved dietary guidelines for the maintenance of
of mixed designs, e.g. a questionnaire survey with a number participants who had underlying health problems or diseases
of open-ended questions. There are inherent advantages and (e.g. CVD, alcoholism and HIV). These participants were
Food-based dietary guidelines and consumers 17
excluded from the review, because they may have different guidelines for assessing methodological quality of published
motivations and health needs to the general public(6,13). In papers by Greenhalgh(17). This involved judging the details
addition, a large number of quantitative studies were available on the study aim, purpose, method, design, theoreti-
excluded, which analysed food-frequency data and retrospec- cal framework, analysis, findings, discussion, presentation
tive compliance with FBDG or used FBDG as a benchmark to and references.
measure ‘healthiness’ of diet.
Initially, papers were excluded or included on the basis of
Results and discussion
their abstracts. Where clarification was needed, full-text
papers were obtained and excluded using a data coding A total of twenty-eight studies were reviewed, which
form (Table 2 is a condensed version of this form). Strenuous employed both qualitative methods such as interview and
efforts were made to find the original sources of studies by focus groups and quantitative methods such as questionnaire
searching online, emailing authors and translating papers surveys. Of the twenty-eight studies, sixteen referred exclu-
into English. When it was not possible to find the original sively to the US DGA, Food Guide Pyramid (FGP(18)) or
sources of data, primarily due to unpublished, inaccessible MyPyramid(19). The quality of the twenty-eight studies varied
or untranslatable data, citations were included in the review. with definition of terms (awareness, knowledge, preference,
This has limited the available details, thus judgement of quality understanding and use), often unclear and used interchange-
for certain studies. ably, as well as with study design or method details at times
incompletely reported (especially as expected in the cited
findings). Analysing and comparing the results from the
Framework twenty-eight studies was difficult due to the different ratio-

The three concepts of awareness (conscious perception), nales and study designs employed. However, we sought to
understanding (subjective and objective) and use (one time, provide an overview of the findings from the studies
extended, direct and indirect) taken from the theoretical reviewed. Findings have been reported in relation to the
framework developed by Grunert & Wills(16) were used to three concepts of awareness, understanding and use, and
categorise study findings. Categorisation was decided using organised by study design (qualitative, quantitative and
the study-reported terminology (i.e. what was described as mixed).
awareness, understanding or use) as well as interpretation
by one research member. The validity of grouping was re- Awareness
viewed and confirmed by the study authors. Only the study
details relevant to consumer awareness, understanding or use The FGP has been used throughout the US education system,
of FBDG were reviewed and reported in the present review. and focus groups with American elementary schoolchildren
reported that the majority had seen the FGP and they were
aware of the key elements of the DGA (1990)(20). Similarly,
Quality and risk of bias in Chile, more recent focus group data indicated that Chilean
schoolchildren were aware of the Chilean food guide (Chile
No studies were excluded on the basis of quality or research
FGP; S Olivares, unpublished results, cited in Albert(21)).
design, but the quality of the studies (qualitative, quantitative
In contrast, focus groups with US adults in the 1990s reported
and mixed designs) and risk of bias were judged using the
that some had awareness of a few DGA, but that the majority
were unfamiliar with the DGA (1995)(22). Likewise, in New
Table 1. Literature review excluded and included papers
Zealand, focus groups and key informant interviews in 1998
Reason for exclusion/inclusion References indicated that older people, parents and children – adolescents
had limited awareness of the FBDG, and few participants
Excluded
Duplicate missed; non-European 16
appeared to have seen the official FBDG-related education
language; unpublished data booklets(22 – 24). More recent focus groups with US adults indi-
or unavailable paper cated that many consumers were aware of the DGA (2000)(25).
Clinical/dental participants or 348
This was also observed with focus groups of women in Baja
animal studies (animal nutrition
or related to animal nutrition) California who showed some awareness of two food guides,
Unofficial FBDG or non-general 192 the Pyramid of Health and the Apple of Health, with the
public FBDG (children, elderly and sports) Pyramid believed to be more familiar than the Apple(26 – 28).
Supplements/fortification; CAM; 105
labelling/health claims or toxicology/food safety
Reported quantitative data indicated that awareness in the
Food-frequency data or nutrition 250 USA may have increased over time. American surveys in
intake/status measures to check 1994 (n 1945) and 1995 (n 1001) reported that one-third of
compliance with FBDG those sampled were aware of the DGA (1990). With respect
Included
Search terms: (food based dietary guidelines) 28 to the FGP, awareness was also one-third (33 %) in 1994 but
or (food-based dietary guidelines) significantly increased to 43 % in 1995(29). In a different
Total 939 survey, two-thirds of the Americans appeared to recognise
FBDG, food-based dietary guidelines; CAM, complementary and alternative or be aware of the FGP by 1997(30,31). More recent surveys
medicine. with grocery shoppers in 2000 showed that 75 % were
Table 2. Papers and studies reviewed
18
First author and year Country – FBDG Aim Design and measures Sample Analysis Results
van Dillen (2003)(15) The Netherlands – FBDG Nutrition awareness Mixed study. Qualitative n 30 Three mixed Coding framework Consumers believed that
and food conversation focus groups FBDG sex groups: and themes they ate healthily –
topics relevant Focus (1) 18– 30 years; categorised using possibly lacked nutrition
groups – card sort task (2) 31– 50 years; NUD*IST (QSR awareness (defined as
to pick five food topics (3) 51– 80 years Melbourne, Australia) realisation of one’s
and ranked importance software personal risk behaviour
regarding nutrition)
Lytle (1997)(20) USA – FGP (1992) Child understanding and Qualitative. Focus groups Convenient sample Video data transcribed Differences observed across
and DGA (1990) interpretation of DGA and interviews with a recruited from after verbatim. Coding age groups with a
(1990) and FGP (1992) food identification task school daycare. n 141, templates identified younger/pre-operational/
(name three foods with 54 % girls, two school concepts, which concrete stage of
high/low fat, high sugar/low districts near Minneapolis were sorted, summarised – cognitive development.
sugar, fruit, vegetables and St Paul Minnesota. independently reviewed. Difficulties interpreting
or grains). Questions based K– 4th and 5 –6th grade. FIT – two reviewers abstract ideas of
on Piaget’s stages of Primarily white, middle SES evaluated and scored variety/healthy weight
cognitive development/social response (inter-rater and identifying foods high
cognitive theory. Pilot feedback reliability 98 %) No in salt/sugar/grains.
resulted in DGA ‘moderate’ test of prior nutrition Difficulties observed in
phrasing to ‘a little’ knowledge interpreting serving size
from the FGP. Vast
majority had seen the
FGP but unable to
articulate learning
Olivares (unpublished Chile – FBDG and Evaluation of FBDG and (1) Qualitative study in schools and Asked about FBDG and (1) Schoolchildren had
results, cited pyramid food guide (2) quantitative Internet pyramid, then received seen pyramid but did
in Albert(21)) quasi-experimental survey information and awareness not understand portions.
K. A. Brown et al.
and willingness to change 30 % knew FBDG and
diet were measured 60 % knew the pyramid.
(2) Information provision
increased awareness
and willingness to
change diet to 80 %
Geiger (2001)(22) USA – DGA 1995 Revision of DGA Qualitative. Market research n 40 Six single sex (three men Somewhat familiar with
company. Focus groups have and three women) groups with FGP. Most unfamiliar
shown different DGA formats: eight persons per group. with DGA but had heard
(1) seven DGA; (2) seven Recruited by telephone and some messages.
DGA in two tiers; paid for participation Confused by ‘maintain
(3) four top tier DGA 25 –45 years or improve your weight’,
‘balance the food you eat
with physical activity’
and ‘balance’. Preferred
version (3)
Cameron (1998)(23) New Zealand – FBDG Evaluation of written health Qualitative focus groups. Children, adolescents, Few older people, parents,
education materials Key informant interviews parents and older persons children or adolescents
had seen the booklets.
Materials were found
unappealing/outdated
by adolescents,
complicated by
parents and informative
by older people
Trustin (1998)(24) New Zealand – FBDG
IFIC (2005)(25) USA – DGA (2000) Perspectives of DGA Qualitative. Market research Four groups, seven to ten people Consumers know what to do
company. Focus groups each, two US cities. BMI but do not always do it.
22 –30 kg/m2, age 25 –55 years. Many were aware of
One session to split into four DGA. Many were
groups: (1) nutrition savvy confused, can name
women; (2) common sense nutrients but do not
women; (3) dieters/restricting understand them.
food/food groups; Distinguish between
(4) diet opposed eating for health and
eating for weight loss.
Quotes provided
Table 2. Continued
Barcadi-Gascon Baja California – Apple Compare and evaluate the Qualitative focus groups with Women of 7 or 15 years Diet mean plan scores
(2002)(26) of Health two guides for message a diet plan task to measure of schooling insignificantly different
(1996) and Mexico understanding and ability objective understanding (Apple 76·7 %, Pyramid
Pyramid of Health (1998) to apply messages 64·1 %). Preference
for Apple as more
attractive, colourful,
clearer to identify food
groups and servings
Levy (1995)(29) USA – FGP (1992) Paper prepared for Dietary Quantitative. Survey Significant increase in
and DGA (1990) Guideline Advisory Committee FGP awareness
(1994–5) 33– 43 %.
In FGP (1995)
recognised .DGA
or 5/d. In FGP (1994)
and (1995), one-third
were aware of DGA
ADA (1997)(30) USA – FGP (1992) Quantitative. Survey 67 % Americans were aware
Kennedy (1998)(31) USA – FGP (1992) Quantitative. Survey More than two-thirds of
Food-based dietary guidelines and consumers

Americans sampled
recognised FGP
Wheat Foods USA – FGP (1992) Quantitative. Gallup survey (1994), Primary grocery shoppers In the 2000 survey, 75 %
Council (2001)(32) (1996) and (2000) were somewhat or very
familiar with FGP (60 %
in the 1994 and 1996
surveys)
Olivares (2004)(33) Chile – FBDG and INTA formal evaluation of FBDG Quantitative. Survey Nutritionists of provisional Educational sessions
pyramid dissemination health services (n 36 120). 500 000
leaflets, posters and
flyers distributed
Keenan (2002)(34) USA – DGA (1995) Knowledge and understanding Mixed. Telephone open-ended Next-birthday method of Tallied number of DGA Qualitative: fat guideline
of DGA, sources of health survey questions. Number random respondent recalled. Stepwise knowledge poor. Quantitative:
information of DGA recalled (maximum selection from 1000 multiple regression to .50 % unaware of nutrition
possible thirteen versions telephone numbers explain variance in federal policy/DGA document.
of seven guidelines) in three zip codes knowledge scores Few named FGP (n 38) or
(1 £ high- and 2 £ DGA (n 1). Average DGA
low-median income). recalled 2·5/13. Diet high in
Response rate: 400/976 vegetables, fruit and low in fat
contacted. 56 % women were the most commonly
of 18 – 49 years. 4·3 % recalled (n 208, 191 and 188,
did not graduate from respectively). Higher number
high school. Twin cities of media sources predicted
area, Minnesota higher recall (r 2 0.08, P, 0·001)
Hunt (1995)(37) UK – BOGH (1994) Testing ten versions of the food Qualitative interviews and tasks. n 2074 SES groups C Nutritional awareness Sex, age and SES effects
guide for effectiveness in conveying Awareness measure ‘In your (59 %) and D (41 %) scored using a seen on the performance
nutrition concepts to consumers; opinion what are the main Recruited from town predefined list of five of different tasks. Nutrition
consumer preferences for guide things you need to do to centres using a quota statements (e.g. eat knowledge effect on all
format; preference effects on eat healthily?’. Task – random system to ensure more fruit/vegetables). four tasks – higher level
understanding and recall of food allocation to three groups: representative in The scores are as follows: of nutritional awareness
guide messages (also carried out a (1) control, no guide (n 298); sex and age of the 3/5, high awareness (9 %); performed better than
questionnaire survey asking health (2) one out of ten guides seen general public. 53 % 1 or 2/5, medium (71 %); lower. COM and SOR
professionals’ views on the guide, briefly (n 883); (3) one out female. 14 %, 11– 18 years; none, low awareness (20 %). task performance better
but those results have of ten guides seen throughout 30 %, 19 –30 years; 32 %, One-way ANOVA, t tests with a guide seen
not been included) (n 893). Four tasks: SUB; 31 –45 years; 24 %, 46 þ years and x 2 test. Only significant throughout than the
COM; SOR; DISH. Asked results have been reported control group.
preference for guide name, here – see paper for statistics Prior exposure affected
most- and least-appealing guide most- and least-preferred
choices with those who
had previously seen a
guide more likely to say
they preferred it v.
control group
19
20
Table 2. Continued
(38)
Achterberg (1989) USA – DGA (1985) Four studies which evaluated DGA Qualitative. Design common Women (n 72), 30– 40 years, All four studies had difficulties
(1985) brochures and bulletins to four studies: (1) pre-interview; high school diploma or in interpreting DGA,
(2) intervention of reading higher, median income especially the abstract ideas
brochures/bulletins; ‘desirable weight’, ‘healthy
(3) post-interview. Random weight’ and ‘too much’.
allocation to the Misunderstood brochures
treatment/control group and DGA. Most groups
learned a significant amount
but relatively small amounts
compared with what they
could have learnt.
Those who learned the
most consistently had
fewer misconceptions.
No sex difference once
prior knowledge/
misconceptions controlled
Achterberg (1990)(39) USA – DGA (1985) Women (n 60), 30– 45 years
and 60 þ years, high school
diploma or higher,
median income
Achterberg (1991)(40) USA – DGA (1985) Men (n 45), 30– 45 years,
high school diploma or
higher, median income
Auld (1991)(41) USA – DGA (1985) Men (n 40), 30– 50 years,
high school diploma or
K. A. Brown et al.
higher, median income
Holm (1991)(42) Denmark – FBDG Interviews at the end of a Men and women in their 20’s Surprised diet consisted of
different 8-month study familiar foods, large
that served Danish volumes of vegetables,
recommendation diets potatoes and bread, and
was palatable
Duenas (unpublished Pre-Thailand – FBDG and Tested the food guide Qualitative. Interviews Public from department Developed rice serving
results, cited Nutrition Flag (1998) and messages about understanding stores, food markets, spoon the as household
in Albert (21)) of portion size and factories, universities unit for measuring foods
quantities using the flag and bus stations
Britten (2006)(43) USA – FGP (1992) Consumer understanding Qualitative. Market (1) Weighted by marital Transcribed and verified. (1) FGP familiar. Recognised
and use of FGP messages research company. status, age, education, Systematic content some messages but
and possible revisions in terms Twenty-six focus groups, race/ethnicity, employment analysis. Systematic misinterpreted food
of understandable terminology, three US cities in two status and household. Equal content analysis, organised group placement and
educational messages and phases: (1) 2002, eighteen number of male and female by group type and location. quantities. Task .80 %
actionable messages groups (eight to twelve single sex groups (n 178). Themes identified, common put one food group in the
people). Individual task Eighteen groups: 6 £ recurring themes wrong tier. No problems
for objective understanding/ general adults, 4 £ 60 þ years, selected and draft with composite task.
knowledge and discussed by 4 £ food stamp recipients, report produced. Understood select more
the group. Place food groups 4 £ overweight (2) n 75. Draft reviewed by foods from the bottom,
and on blank FGP and place Eight groups (4 £ 25 –49 years, staff who had observed but not the ‘sprinkled’
composite meals on FGP. 4 £ 50—79 years) focus groups to validate graphic. (2) Lifestyle
(2) 2004, eight groups analysis obstacles to FGP use.
(eight to eleven people) Limited understanding
of whole grains, fat,
vegetable subgroups
and physical activity
Albert (2007)(44) Grenada, Dominica, Process of developing FBDG Qualitative. Field tests: Field tests: heads of households Field tests: many barriers
St Lucia and in four countries (1) pre-interview; from various parts of the country. to FBDG. Focus groups:
St Vincent, and the (2) follow a DG 1 week; Focus groups: women and corrections and
Grenadines – FBDG (3) post-interview. Diet variety men from rural and urban adjustments made
knowledge ¼ grouping of food parts of the country to messages and
items. Focus groups shown: graphics based on results
(1) FBDG;
(2) food guide;
(3) both together
Table 2. Continued
(46)
Campbell (1996) USA – FGP (1992) Quantitative. Survey 58 % Americans heard of FGP
and 13 % say they understand
(47)
Zhao (2001) China – FBDG and Food Trial of effectiveness of the Quantitative. Soon after n 5145 from five cities with FBDG meaning increased
Guide Pagoda (1997) guidelines as a mass the publication of FBDG. different geographic and 12– 93 % in 1 year, more
education tool Understanding and nutrition economic conditions so with children and elderly.
knowledge pre- and post-repeated Nutrition knowledge
promotions of FBDG and pagoda increased from 48– 59 to
68– 91 %. Schoolchildren
balanced breakfast increased
26– 52·5 %
Kennedy (1996)(48) USA – DGA (1995) Consumer perceptions of DGA Qualitative. Market research Twelve focus groups in three Four themes: (1) difference
concepts and perceived company. Focus groups US cities; all single sex. between recommendations
barriers to following DGA Four groups, cross section; and what is already known
eight groups, target groups as well as what needs to
of African-Americans, elderly, be known to use; (2)
overweight, food stamp recipients most consumers were
not motivated by health
consequences underpinning
DGA; (3) perception of DGA
Food-based dietary guidelines and consumers

do not explain ‘how to do it’;
(4) would like DGA in
straightforward language –
no time, energy or
inclination to learn
nutritional science
Love (2001)(49) South Africa – FBDG Assess comprehension, interpretation Qualitative. Focus groups. Five magistrate districts in KZN Transcribed and coded, Fruit/vegetables and fat
and implementation of preliminary Aided with colour photos and the WC. Random selection analysed to identify guidelines familiar to all
South African FBDG as a nutrition of different foods (non-branded, dependent on settlement type common themes groups. FBDG well
education tool for women in uncooked) discussed previous (non-urban, urban in/formal), understood. Confused
KZN and the WC exposure to FBDG, interpretation ethnicity (black, mixed, Indian with the terms ‘legumes’,
of FBDG, constraints to and white). Only women who ‘animal foods’ and
implementation and ability to made purchased food and food ‘healthier snacks’.
plan a day’s meals using the preparation decisions. Barriers to FBDG
FBDG 137 women, 19 –63 years implementation cost
availability, taste
preferences, purchase
habits, traditional food
preparation/cooking,
time, accessibility and
attitudes to health. Many
felt already implemented
several FBDG, and all
were able to construct a
day’s meals using FBDG
FMI (1997)(50) USA – FGP (1992) Quantitative. Survey Shoppers 27 % changed purchases
FBDG, food-based dietary guidelines; FGP, food guide pyramid; DGA, Dietary Guidelines for Americans; SES, socio-economic status; FIT, food identification task; IFIC, International Food Information Council; ADA, American Dietetic Associ-
ation; INTA, International Institute on Food Technology and Nutrition; BOGH, Balance of Good Health; SUB, substitution; COM, comparison; SOR, sorting; DISH, composite dish; DG, dietary guideline; KZN, KwaZulu-Natal; WC, Western
Cape; FMI, Food Marketing Institute.
21
‘somewhat/very familiar’ with the FGP(32). All of the aforemen- awareness over time. However, the measurement and defi-
tioned studies refer to evaluating the outcome of FBDG nition of the concept awareness was not always clear, and
implementation. During the review of FBDG in Chile, they the terms of familiarity, awareness and knowledge were
evaluated the output of FBDG implementation. A survey by used both interchangeably and differentially across studies.
the International Institute on Food Technology and Nutrition Clarifying what is meant by awareness and how this is
reported that .36 000 people had participated in FBDG nutri- measured would be crucial when comparing data across
tion education programmes and .50 000 leaflets, posters and studies to evaluate FBDG and when trying to study the com-
flyers had been distributed. This provides information on the plicated relationship between awareness, understanding and
dissemination of FBDG-related material reported in terms of use of FBDG.
FBDG evaluation, but it does not provide a measure of out-
come in terms of awareness(33).
The definition of awareness differs slightly throughout the
Understanding
studies reviewed but predominantly relates to familiarity or
knowledge of a FBDG or food guide. A mixed methods Awareness of FBDG or food guides does not appear to auto-
study in The Netherlands defined awareness slightly differ- matically translate into understanding of FBDG. Focus groups
ently. A high amount of ‘knowledge’ was reported in response and interviews with US schoolchildren suggested that they
to the question ‘what dietary guidelines do you know?’. were comfortable using the terms ‘low fat’ and ‘low sugar’,
However, the researchers suggested that participants may but they had difficulties when asked to display objective
have lacked nutrition awareness in terms of ‘realisation of understanding of these terms by naming three foods in
one’s own personal risk behaviour regarding nutrition’, because either of these categories, particularly with the younger chil-
the focus group participants may have mistakenly believed dren(20). Similarly in Chile, schoolchildren, although aware
that they ate healthily or followed the FBDG/food guide(15). of the FGP, did not understand the portion information por-
An American telephone interview study supported the trayed within the pyramid (S Olivares, unpublished results,
1990s US focus group data indicating that there was some cited in Albert(21)).
but not widespread awareness of the DGA. Participants Studies that have looked at subjective understanding in
reported an average recall of less than 2·5 DGA (1995) out terms of asking participants what they understood indicated
of a possible 13, and only one out of 400 responders correctly that misunderstandings were common with abstract ideas.
identified the DGA as the US nutrition policy document(34). This was observed particularly in relation to weight, physical
It is difficult to assess the effect of awareness from the activity, health, variety or balance, where focus group partici-
studies reviewed. Awareness has been suggested as a prere- pants stated confusion with guidelines that included ‘desirable
quisite to behaviour change(35), and this was indicated by weight’, ‘healthy weight’, ‘maintain or improve your weight’,
the reporting of a Chilean Internet study intervention, which ‘balance the food you eat with physical activity’ and ‘healthy
implied that the provision of information improved awareness snacks’(20,22,38 – 41).
both of the 1997 Chile FBDG/food guide and willingness to Consumer understanding of food quantities such as portion
change diet (S Olivares, unpublished results, cited in and serving sizes was often confused. In Denmark, partici-
Albert(21)). However, the reality of the relationship between pants were surprised that a Danish nutrient recommen-
awareness and behaviour change is complicated by many dation-compliant diet that they had followed could consist
other factors such as liking and preference, which can be dif- of such large volumes of food, especially vegetables, bread
ferentially affected by awareness. For example, the previously and potatoes(42). Researchers in Thailand and America found
mentioned Baja Californian focus group study reported that that specific examples rather than volumes and weights
participants consciously stated that they were more familiar were useful to explain quantities to consumers. The ‘rice ser-
with the Pyramid food guide, yet they preferred the Apple ving spoon’ was developed as a household measure after con-
food guide, stating that it was more attractive, colourful and sumer testing of the Thai Nutrition Flag (G Duenas,
clearer to identify foods and food group servings(28). In con- unpublished results, cited in Albert(21)). American focus
trast, a UK study compared ten food guide versions during groups reported a preference for quantity size guidance to
the development of the UK Balance of Good Health plate be depicted in cups for food and minutes for physical activity,
(1994)(36) and found that those who had previously seen a rather than ounces or terms such as sedentary. However, con-
guide (higher awareness, unconscious/conscious) were more fusion remained with fruits and vegetables, where quantities
likely to display a preference for the shape they were exposed or portion sizes were still considered confusing and difficult
to compared with the control group who had not seen any to measure even with household units such as cups(43).
guides. It was hypothesised that preference, or familiarity, A number of studies selected in the present review reported
for a guide may affect an individual’s ability to extract the consumer understanding of guidelines but omitted raw data or
guide’s key information either by being more likely to notice referred to unpublished results(44). This has been observed in
and recall information or by familiarity, leading to loss of previous FBDG reviews(45). For example, an interesting paper
attention to the information(37). The aforementioned studies depicted FBDG development in four Eastern Caribbean
indicated that there was a degree of awareness of FBDG countries, which involved focus groups, interviews and field
and food guides, an apparent greater awareness of food tests, where participants were asked to employ one FBDG
guides compared with FBDG and a possible trend of increased for a week. However, within the space constraints of the
article, no specific understanding measurement methods or included the consumer behaviours such as remove chicken
results were reported. skin rather than eat less fat(48) and visual examples (solid fat
The quantitative results suggested an inconsistent relation- v. oils) rather than technical terminology (saturated v. unsatu-
ship between increased awareness and increased understand- rated fat)(43). It was stressed that these should be from the
ing. In an American survey, 58 % of those sampled said they consumer’s point of view rather than the scientific standpoint
had heard of the FGP, but only 13 % said they understood and must not require consumers to become nutritional
it(46). In contrast, a review paper reported a study with a scientists(20,38 – 41,43,48,49).
sample of more than 5000 participants, where understanding A quantitative Food Marketing Institute trends data survey
of the Chinese 1997 FBDG grew on average from 12 to 93 % reported that 27 % of US shoppers said they used FGP
within a year following repeated promotions of the guidelines information to make changes in their food purchases(50),
and Food Guide Pagoda. The largest effect was observed with and another survey reported that only 13 % of those sampled
schoolchildren and the elderly(47). The UK Balance of Good said they used the DGA(46). One quantitative study in China
Health study demonstrated that food guides may improve did include behavioural measures following the promotion
objective understanding of a healthy diet and food groups, of the 1997 ‘Guidelines for Chinese residents’ and Food
yet also highlighted the complicated nature of the relationship Guide Pagoda. They indicated that the percentage of school-
between awareness (or exposure) and understanding. Those children who had a healthy breakfast increased from 26 to
who had been shown one of the ten Balance of Good 52 % following the intervention(47). It is not clear whether
Health food guide versions performed significantly better the children (or parents) consciously employed the promoted
than the control group on comparison and sorting tasks. guideline, if these effects were sustained or if these changes
However, understanding was dependent on sex, age, socio- may be explained by other factors, but it is a rare example
economic status and nutrition awareness(37). of a concrete behavioural outcome measured as an indicator
A mixed design study with US focus groups suggested that of FBDG success. From the limited information available in
equal awareness of FBDG may not lead to equal understand- the papers reviewed in this section, it appears that FBDG
ing, and results demonstrated consumer misinterpretation of and food guides are minimally used by consumers.
guidelines. The ‘eat a diet low in sugar’ guideline was con-
sidered to be ambiguous and difficult to quantify, whereas
Conclusion
the dietary fat guideline produced the most confusion with a
particular lack of understanding relating to the saturated fat The present review has presented a wide variety of study
recommendation and those that involved percentages. For approaches and applied methods and the possible limitations
example, when participants were told about the DGA of of these needs to be addressed. External validity may have
, 30 % total fat and then asked to quantify the amount of satu- been limited by unrepresentative samples due to the small
rated fat that was recommended, answers ranged from 0 to sample sizes and the qualitative nature of the focus groups/
50 %. This study suggested that the new DGA (2000) that interviews, as well as the convenient samples used in a
incorporated behavioural messages would be better under- number of the quantitative surveys. In addition, there was a
stood than the DGA (1995)(34). possibility of bias during qualitative data analysis interpret-
The studies reviewed in this section appeared to show ation and a lack of controlled confounding variables
mixed results for consumer understanding. Some studies or over-interpretation during quantitative data analysis.
showed a general understanding of the key concrete concepts Furthermore, the present review may not have sourced all of
of FBDG and food guides, but some difficulties were observed the studies relating to FBDG evaluation. For example, studies
with understanding abstract concepts and specific ideas such that used alternative terminology for FBDG, investigated
as portion sizes and quantities. There is a need for further pro- unofficial FBDG, focused on one guideline rather than
spective studies to investigate the long-term effect of FBDG FBDG in their entirety, or measured concepts other than
information provision on different aspects of FBDG under- consumer awareness, understanding or use of FBDG. Never-
standing (subjective and objective) and how this might affect theless, we believe that the present review is replicable and
dietary behaviour change or the use of FBDG. exhaustive in terms of the research question, and it has
highlighted several issues to consider in future public health
initiatives and research surrounding FBDG.
Use
First, a degree of consumer awareness and understanding of
Few studies explicitly measured consumer-intended or actual FBDG was identified by the literature reviewed. Evidence of
use of FBDG/food guides or indicated that use of FBDG FBDG use was limited, but the researchers acknowledged
could be a measure of FBDG effectiveness. Focus group dis- the possibility that consumers may not believe that it is necess-
cussions referred to the barriers of FBDG use, considering ary to follow FBDG to eat healthily or they might use FBDG
time constraints, disinterest in shopping and preparation of without consciously realising that they are doing so, and that
food as potential barriers to one’s daily food choices(43). this would not have been apparent from the literature
A number of studies, which predominantly measured consu- reviewed.
mer understanding of FBDG and food guides, commented Second, the review indicated that the promotion of FBDG
on the need for concrete behavioural examples and messages may not have always been accompanied by evaluation of
to enable consumers to use the guidelines. Suggestions effectiveness, or that research conducted on FBDG successes
and failures has not always been widely published or made and development of the search strategy. K. A. B. carried out
available(4). This evaluation is necessary to ensure that the the search strategy, conducted the analysis and wrote the
efficacy of FBDG can be judged and that FBDG achieve the draft of the final manuscript. All authors took part in the
purpose for which they are designed. For example, there is revision of the manuscript. The authors have no conflicts of
a growing trend to move away from nutrient-based targets pri- interest to declare. Ethical approval was not required for the
marily designed to prevent nutrient-deficiency diseases and to present study.
derive FBDG from healthy food-based dietary targets, which
may be more appropriate to change lifestyle behaviours
associated with lowering chronic disease risk(51,52). Evaluation
is required to identify whether these alternatively devised References
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A review of consumer awareness, understanding and use of food-based

* Corresponding author: Dr M. M. Raats, fax þ44 1483 682913, email [email protected]

Framework twenty-eight studies was difficult due to the different ratio-

Food-based dietary guidelines and consumers

Food-based dietary guidelines and consumers

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