Food Selection

Our food preferences, food choice, and food liking affect the foods we select to eat. Although these terms reflect similar food-related behaviors, they are different.² Food preferences are those foods we choose to eat when all foods are available at the same time and in the same quantity. Factors affecting preferences include genetic determinants and environmental effects. Genetic factors include inborn desires for sweet and salty flavors. One study of taste receptors notes that because of genetic taste markers, some people experience the taste of vegetables such as broccoli and Brussels sprouts as bitter and therefore avoid such foods, whereas other people find this flavor enjoyable.³ Consumption of cruciferous vegetables, such as broccoli and Brussels sprouts, may be associated with a decreased risk of developing certain cancers.³ If some people avoid them because of perceived bitter taste, will they be more at risk for cancers?

Environmental effects are learned preferences that are the result of cultural and socioeconomic influences. We often adjust our choices to match those around us. Because we are around our families the most, their influence is the most significant factor in the choices we make; therefore, the dietary patterns we experience as children affect us throughout our lives⁴ (see the Cultural Considerations box, Ethnic Food Preferences and Foodborne Illness). In fact, even the food a mother eats prenatally affects the preferences of her child in the future.⁵

An indirect influence on food preferences is the media. Television advertising in particular is a potent force that influences the foods we prefer and buy. Programs spread messages about the food and lifestyle preferences of different socioeconomic groups. A TV show about a working-class family presents images of food intake associated with those of a lower socioeconomic status; dinner might be hot dogs and beans. In another TV show, an upper socioeconomic family might sit down to a meal of baked salmon and salad. Each unintentionally sends messages about appropriate food intake for individuals belonging to each socioeconomic group.

Health promotion issues are tied to food preferences. If recommendations call for changes in foods for which preference is rooted in genetic determinants, the motivation for change needs to be different from when the food preference is environmentally learned. New preferences can be learned; genetic preferences are more difficult to change.

Food choice concerns the specific foods that are convenient to choose when we are actually ready to eat; rarely are all our preferred foods available at the same time to satisfy our preferences. Food choices are restricted by convenience. As a result of our hectic lifestyles, we tend to avoid foods that take long to prepare. Instead, we often repeatedly choose foods that are easy to prepare and eat, regardless of their nutritional value. Cost is also a factor. We sometimes weigh cost benefits against time benefits. If a food costs more but saves time, we may choose it. We may decide that a food item, even if nutrient dense, costs too much money for the benefits received. Again, nutritional value may not be a prime concern that affects food choice.

Food liking considers which foods we really like to eat. We may want to eat foods that enhance our health, but we like to eat chocolate cake, for example. We constantly weigh all the factors of preference, choice, and liking when we select the foods we eat. Ultimately, these three types of food behaviors greatly affect individual nutritional status.²

These three food behaviors may be covertly manipulated when the food industry develops and markets foods that appeal to our possible genetic preferences of sweet and/or salty.³ These preferences are reinforced by repeated consumption and through advertising promoting the taste and “having fun” when consuming these products.⁶ Marketing promotions and product availability may influence selection by consumers because of convenience, including accessibility, cost, or time saving, often with no consideration of nutritional value. Food liking evolves from, and may be the result of, repeated exposures. While some are able to moderate their consumption of less-nutrient-dense food products, others cannot, thereby impacting their nutritional status and health determinants.⁶

It is the small steps we take that eventually lead to cumulative change. As we study different aspects of food and nutrition, we will present suggestions that move us and our clients toward significant change. These suggestions will lead to the formation of new personal food habits.

Dietary Guidelines for Americans

In response to the dietary recommendations, the U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) developed in 1977 the Dietary Guidelines for Americans. These guidelines are updated every 5 years and are intended for healthy Americans older than 2 years of age. The Dietary Guidelines for Americans are based on the latest scientific knowledge about diet, physical activity, and other health issues. This knowledge is used to formulate lifestyle and dietary pattern recommendations that will contain adequate nutrients, promote health, maintain active lifestyles, and decrease the risk of chronic diseases. As such, the Dietary Guidelines serve as the foundation of federal nutrition policy and education.⁸

The American public consumes insufficient amounts of certain nutrients such as vitamin D, calcium, potassium, and dietary fiber, even though excessive energy intake has led to a majority of Americans being overweight or obese. The current, Dietary Guidelines for Americans 2010 (hereafter referred to simply as Dietary Guidelines), focuses on the goals of “good health and optimal functionality across the life span” with consideration of the malnutrition (deficiency of nutrient intake) and weight issues of the population-at-large.⁸ Consequently, to attain these goals a lifestyle (behavioral) approach is suggested. This approach centers on a total diet concept. To implement a total diet concept that is balanced in energy and nutrient content, dietary patterns would emphasize portion size and consumption of plant foods such as vegetables, beans, fruits, whole grains, nuts and seeds, and increased intake of low-fat dairy products and moderate amounts of poultry, lean meats, and eggs.⁸ In addition, lower intake of foods with added sugars and solid fats supports energy balance goals.

To sustain this endeavor, community support will be critical so that on a population level, individuals and families can adopt these guidelines whether eating at home, at school or work, or in restaurants. Local food availability is a concern to assure that more nutrient dense foods are affordable and accessible in all settings from the neighborhood supermarket to fast food restaurants. The techniques to prepare simple home cooked meals and strategies of food safety are prerequisites for achieving the goals of the Dietary Guidelines. These techniques and strategies can be taught in informal and formal educational settings including health care clinics, public health departments, faith-based organization, and print and electronic media.

Listed in Box 2-1 are the four major actions that if implemented would assist everyone to practice health-promoting nutrient consumption and be physically active.

Additional details of the Dietary Guidelines are available at www.dietaryguidelines.gov.

As nurses work within communities and/or hospital settings, the Dietary Guidelines provide nutrient and physical health recommendations on which community programming and patient education can be based.

MyPlate Food Guidance System

How do we and our clients implement the recommendations of the Dietary Guidelines on an everyday basis? In the past, the Food Guide Pyramid filled this purpose, but it has been replaced by the MyPlate Food Guidance System designed to guide us through our food selections to meet the goals of the Dietary Guidelines.⁹ The creation of MyPlate took into account the present patterns of consumption of Americans plus the recommendations of the Dietary Guidelines and the Dietary Reference Intakes (DRIs). The result is a total diet that meets the nutrient needs from foods while limiting dietary components that are often eaten in excess. A tool to use in conjunction with MyPlate is the Nutrition Facts labels on food products.

MyPlate is an Internet-based interactive tool providing recommendations based on a person’s age, sex, and activity level. Individuals can go directly to the website (www.MyPlate.gov) and enter their own data to receive personalized guides to the food group servings to meet their needs. The food groups include grains, vegetables, fruits, milk and dairy products, and meat and beans (Figure 2-1). MyPlate is intended for adults; a MyPlate for Preschoolers (ages 2 to 5), MyPlate for Kids (ages 6 to 11), and MyPlate for Moms (pregnancy and lactating) are also available (available at http://www.choosemyplate.gov). For individuals who do not have a computer or access to one, or don’t have computer skills, hard-copy print materials are available.

By following the interrelated recommendations of MyPlate, the following results can be expected:⁹

The recommendations represent the following four themes:

The simple MyPlate symbol reminds us and our clients to make healthy food group choices. The significant concepts of the symbol are highlighted in Figure 2-1.

Other Food Guides

Not all health professionals view the recommendations of MyPlateas the most sound to improve and maintain health. Some cite the increasing incidence of diet-related disorders as evidence that MyPlate recommendations do not meet our health goals. These disorders include type 2 diabetes, obesity, and syndrome X. Syndrome X, or metabolic syndrome, is a group of heart disease risk factors including abdominal obesity, glucose intolerance, high blood pressure, and abnormal blood lipid levels. Perhaps the pyramid is not being followed correctly, resulting in continuing diet-related disorders. Research supports that the dietary intake of most Americans is unbalanced when compared with the recommendations of MyPlate. Intake of meats and grains is higher than recommendations, while consumption of dairy, fruits, and vegetables is lower (Figure 2-2).¹⁰ If it is being followed, then the emphasis on complex carbohydrates from grains and the use of animal-derived foods (dairy and protein sources) as the foundation of our dietary intake do not provide the expected health benefits.

One of the first alternative pyramids to address these concerns was developed by Dr. Walter Willett, chairperson of the Department of Nutrition at the Harvard School of Public Health. Based on accumulated scientific research, this pyramid—the Healthy Eating Pyramid—changes the focus of food selection and distinguishes between whole and refined grain foods as well as highlights plant sources of protein, such as nuts and legumes, which contain healthful plant oils (Figure 2-3). Animal-derived foods are pushed high up on the Healthy Eating Pyramid to reflect that they are foods to be consumed occasionally. For example, red meat is to be used sparingly or infrequently. Fish, poultry, and eggs are to be consumed zero to two times a day. This is different from the traditional pyramid, which groups animal and plant sources of protein together (meat, poultry, fish, dry beans, eggs, and nuts) with suggested servings of two or three times a day without distinguishing between the nutrient content of these foods. In addition, the Healthy Eating Pyramid includes recommendations for daily exercise and weight control (Figure 2-3).¹¹

Alternative (Figure 2-4) and ethnic food pyramids are also available, providing specific food selections conforming to the general pyramid categories. These recognize that traditional dietary patterns of other cultures also offer opportunities to decrease the risk of diet-related disorders. The Asian, Mediterranean, and Latin American Diet Pyramids are accessible from the Oldways Preservation & Exchange Trust website (www.oldwayspt.org). These pyramids differ from MyPyramid in the number of servings of animal foods, legumes, nuts, and seeds recommended.¹² Vegetarian and soul food pyramids have been created as well. Other countries and commonwealths have food guides reflecting their national food supply, food consumption patterns, and nutritional status. Examples of the food guides for Mexico, and Puerto Rico are shown in Figure 2-4. Although the shapes of the guides may differ from MyPyramid of the United States, all recommend similar distributions of food category servings.¹³ Ethnic food guides may be useful when caring for clients from other countries.

Exchange Lists

The food guides refer to eating a number of servings of specific foods daily. But what is a “serving”? A resource for serving sizes is the Exchange Lists for Meal Planning, published jointly by the American Dietetic Association (ADA) and the American Diabetes Association¹⁵ (see Appendix A). Serving sizes may differ by weight or volume from the portion sizes we receive in restaurants or serve ourselves at home.

Foods are divided into different groups or lists: carbohydrates, meat and meat substitutes, and fats. Each list or exchange contains sizes of servings for foods of that category, and each serving size provides a similar amount of carbohydrate, protein, fat, and kcal. The carbohydrate group is subdivided into lists of starch, fruit, milk, other carbohydrates, and vegetables. The meat and meat substitute group is sorted by fat content (Table 2-1).

The exchange lists were first developed for use by people with diabetes. A dietitian can create an appropriate dietary program that prescribes the number of kcal and units of each exchange category to be consumed daily, as well as a plan for when foods should be eaten. By using the exchange lists for carbohydrate counting, an individual can choose favorite foods from each list while controlling the amount and kind of carbohydrates consumed throughout the day.

Guidelines for individuals with diabetes, published by the ADA, deemphasize prescribed calculated kcaloric diets only using the exchange lists.¹⁶ The focus is now on adapting dietary intake to meet individual metabolic nutrition and lifestyle requirements (see Chapter 19).

The exchange lists encourage variety and help to control kcal and grams of carbohydrates, protein, and fats. As a tool for dietary instruction, these lists have been adapted to meet the needs of weight reduction programs and nutrition therapy planning. MyPyramid also uses the concept of units of servings by recommending a range of servings for each food category. A difference is that MyPyramid categorizes groups of foods based on the nutrients they contain, whereas the exchange lists categorize groups by proportion of carbohydrate, protein, and fat.

Criteria for Future Recommendations

Although the current recommendations are expected to provide sound advice for a while, other organizations may issue their own guidelines in the future. Which guidelines should we follow? Should we change our eating habits and revise client dietary recommendations for each new study? Or, to avoid confusion, should new recommendations just be ignored?

Following are criteria used to evaluate future dietary guidelines and recommendations:

Food Selection Patterns

Food selection patterns may be estimated from assessing government data gathered through national surveys and programs. One approach is to evaluate information gathered from the online MyPyramid Tracker. Developed as part of the MyPyramid food guidance system, the MyPyramid Tracker measures the dietary quality of an individual’s food intake and physical activity based on the extent to which the intake follows the Dietary Guidelines and the DRI recommendations.¹⁷

According to research, those with more healthful dietary intakes have higher levels of nutrition knowledge and advanced education levels. Consequently, the data reveal that higher socioeconomic characteristics are related to a greater understanding of nutrition and the effects of healthy diets in reducing the risks of diet-related disorders.¹⁸ This difference may reflect access to resources (e.g., time and financial means) supporting preparation and consumption of foods that follow the dietary guidelines.

As a nation we need to improve our nutrient intake. An aspect of doing so must take into account our beliefs and attitudes toward our dietary intake. A study using national data reveals that only 23% of the surveyed population is interested in improving their intake, whereas 37% are not interested in doing so, and 40% believe their intake does not need to change. Most view healthy eating as too complicated. In addition, the majority views snacking as an unhealthy practice, and as a result, the majority chooses snacks that are also unhealthy.¹⁹

Application to nursing: When working with clients, we can be aware of their attitudes toward nutrition and dietary change. Although changing dietary intake is a prime strategy to reduce the risk of diet-related chronic disorders, many Americans are not interested in changing their eating behaviors. In addition, the belief that snacking is unhealthy is unfortunate. Snacks do not have to be high fat, high sodium, or calorie laden. Consuming additional fruits, vegetables, and whole grain foods is often best accomplished through wisely selected additional “mini meals” or snacks. We may need to educate or remind clients about the nutritional benefits of dietary change as a disease-prevention strategy, and we should definitely emphasize the positive value of snacking on wholesome foods. Providing clients with simple techniques for changing food selection habits is crucial.

Food Consumption Trends

Food consumption trends reflect the food decisions Americans made in the past. Tracking these trends is the responsibility of the USDA. Following changes in consumption trends across the years for specific foods reveals information about food substitutions, including food prices or technologic changes that bring new types of food products to the marketplace. Food consumption trends now show that generally Americans eat more food in larger portions with additional snacks, which results in a greater caloric intake than in the past.²⁰

Implications of food consumption trends

Food consumption trends affect the nutritional status of the U.S. population. Consumption of fruits and vegetables keeps increasing but still does not meet recommended intakes. This is a concern because fruit and vegetable consumption is ideal to reduce risk factors associated with diet-related chronic diseases.²¹ Underconsumption may be related to cost. Income differences may account for the difference in consumption because low-income households consume fewer fruits and vegetables than other households. Generally, however, many of us need to learn how to prepare the wider variety of vegetables available in the supermarkets so they taste and look good and are safe to eat. Teaching how to prepare foods is an adjunct goal of nutrition education. Programs such as Fruits & Veggies—More Matters that provide point-of-purchase preparation techniques and recipes should prove effective. Additionally, the popularity of TV cooking shows, such as those broadcast on the Food Network, increase our knowledge base. Some shows such as Iron Chef America, Top Chef, and Throwdown with Bobby Flay—through the use of themes and competitions are popular with viewers, including some men who previously had no interest in food preparation.

Although consumption of cereals and grains is increasing, dietary guideline recommendations are to increase the intake of whole grains rather than continue to increase refined grains. A way to accomplish this is to learn new ways to prepare different kinds and forms of grains, such as wheat, rice, buckwheat, and corn, in the forms of pastas, couscous, and tortillas to meet the dietary recommendations of 6 to 11 servings a day. For the best nutrient value, grains and cereals should be consumed as whole grains, not refined, for at least half of the daily servings. Breakfast cereals can be a way to become accustomed to whole grains. These products have qualities in demand by today’s consumers; they are convenient, may contain fiber, are good sources of nutrients, and are low in calories.

Animal sources of protein (total meat)—meat, poultry, fish, and shellfish—are increasing.²² In recent years, within this category, beef consumption decreased while poultry and fish consumption increased. More fish is being consumed because of increased availability of fresh and frozen fish since the development of refrigerated and frozen storage techniques.

The way meat, poultry, and fish are cooked determines the final dietary fat content. The message to reduce dietary fat and cholesterol intake affects how we consume and prepare animal protein. Health benefits are greatest when we choose low-fat cooking methods. Some popular ethnic cuisines extend meat, poultry, or fish by combining protein sources with cereals, grains, vegetables, and sauces.

Dairy product trends reflect dietary recommendations to consume products that are lower in fat. The consumption of whole milk with high amounts of fat is decreasing, while the consumption of low-fat and nonfat milk and other dairy products is increasing because of the wide array of new products in the marketplace. Consumption of yogurt and other fermented dairy products with live cultures continues to increase because of their health benefits. Of concern are the continuing trends that as children and adolescents grow older, consumption of milk and juice declines, while soft drink intake increases.²³ Soft drinks are drunk in larger quantities per serving than either milk or juice products, so they provide more total calories. Such sweetened beverages may be a factor in the increasing obesity rates of American youth.

Caloric sweetener consumption continues to increase.²² Consumption of cane and beet sugars has decreased, but corn and noncaloric sweetener consumption has increased. These changes occurred because the technologies associated with producing corn sweeteners from cornstarch and manufacturing noncaloric sweeteners reduced their costs, allowing them to compete economically with cane and beet sugars. Sweetener and beverage consumption trends affect the nutritional status, depending on whether the type of sweetener or beverage chosen increases or decreases the intake of energy and other nutrients. Other issues of sweeteners are discussed in Chapter 4.

Although these trends reflect per capita consumption patterns based on the total population, it is our individual food choices that have the greatest influence on our personal level of wellness.

 Personal Perspectives

The LocalHarvest Blog: Local and Organic for $37/week February 24, 2009

LocalHarvest.org, a unique website, is a dynamic public nationwide directory of small farms, farmers markets, and other local food sources. The site search engine connects consumers with sources of local sustainably grown food and family farms. Products from small farms are accessible through an online store. This entry of the LocalHarvest Blog written by Erin Barnett, director of LocalHarvest.org, gives a perspective of the “home economics” of eating locally.

Last week I was part of a panel at local farm conference, where my assignment was to talk about the “home economics” of eating locally. I spoke about what my family eats and why, and the time and money our diet requires.

I was especially curious about the money part. It should be said that my husband and I put a high value on eating well. We also grow a lot of our own food. It’s our sustenance, both physical and spiritual. Turns out, the garden saves us a lot of money, too.

I went through a year’s worth of credit card statements, the check book register, and my memory of how much cash I spent at the farmers market and found that on average, our family spent $412 a month on food last year. This is for two adults and one voracious toddler—a 2.5 eater household. Do the math, and it comes out to $37/person per week. If you’re broke, or have a big family, $37/person per week is a lot. But if you’re lucky enough to have a good job, it might seem like a reasonable number. Did I mention this includes our eating-out budget? It does. We live in a small town with not too many restaurant choices, so that keeps the eating-out impulse in check. So does liking to cook.

After figuring the cash, I made a list of what we’re getting for that much money. By intent, and by dint of the bounty of rural Minnesota, all our meat, milk, cheese, and eggs are local and organic. We eat a moderate amount of meat (1-2 chickens a month and a pound or two of beef), but go through a fair amount of eggs and dairy products.

Most of the rest of the food, besides the produce, is not local. Grains, beans, tofu, corn chips, condiments, chocolate—not local, but often organic.

In the summer and fall, 100% of our veggies and fruits are either grown in our gardens or bought at the farmers market. In the winter and spring, about 2/3 of our fruit and 3/4 of our veggies are local because we freeze and can so much food in the summer. Here’s a list of the garden produce we are eating this winter.

• Frozen: kale, chard, sweet corn, pesto, red bell peppers, tomato sauce, winter squash, strawberries, plums

• Fresh food, stored in the basement: potatoes, onions, garlic, sweet potatoes, parsnips (also had beets, but they are gone)

• Canned: various tomato products, pickles, salsa, jam, applesauce.

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