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The public arena for diet-related health information struggles for the increasingly fragmented "scarce resource" of public attention.62 This trend is influenced by three factors: (1) the expansion and diversification of the Nation's communications infrastructure, (2) the ubiquity of food and nutrition advertising, and (3) news media reporting and advocacy group activity regarding food and nutrition issues.
Expansion of the Communications Infrastructure
Profound changes in the Nation's communications infrastructure have been occurring since the 1980s. The availability of consumer satellite television receivers, consumer videocassette recorders (VCRs), and cable television systems increased dramatically during the period after 1980. For example, cable television increased from about 4,000 systems in 1980 to more than 12,000 systems nationwide in 1996.63 Although cable systems originated in the 1950s to rebroadcast local television signals to hard-to-reach areas, in the 1980s they expanded across the country to carry dozens of channels to more than 6 out of 10 U.S. households. The expansion of this capacity coincided with the proliferation of new channels of entertainment and news. Digital Broadcast Satellites first came online in 1993, with a typical system providing more than 300 different channels. In 1999, the National Association of Broadcasters estimated that, of the Nation's 100 million households, about 98 percent had at least one television, 74 percent had two or more televisions, and 66 percent received an average of 45 channels. With the advent of Digital and HDTV, systems of 1,000-1,500 channels are projected in the near future.64 Television is switched on in the average American household for a little more than 7 hours per day, although actual viewing is about 4 hours. Television consumes about 40 percent of American leisure time, and about 70 percent of Americans report television as their main source of news.
The World Wide Web (WWW), also developed in the 1990s as a new interactive multimedia format using the Internet, was first established in 1969. The growth of the WWW has been extremely rapid over a relatively short period. It is estimated that registered domain names of Web sites now number more than 12 million worldwide.65 Health and medicine in 1998 were estimated to be the principal emphasis of more than 15,000 U.S. Web sites.66
From 1994 to 1998, the number of American homes with a personal computer almost doubled, from 24.1 percent to 42.1 percent.67 By February 2000, more than one-half of U.S. households were online and, of these, 90 percent used the Internet.68 More recent survey data show that nearly two-thirds of Americans over age 12 have access to the Internet, and one-half go online every day.69 The use of computers and the Internet is even higher when worksite access is factored in, and is projected to increase further with the emergence of high-speed cable and digital service telephone lines delivered to homes.67 Although all income groups have demonstrated remarkable increases in computer ownership and Internet use, higher income groups report both greater computer ownership and greater Internet use. For example, 80 percent of households earning $75,000 or more per year reported owning a computer; 44 percent reported Internet use. This has led to concerns about a "digital divide" between the rich and the poor, with particular concern that fewer health-related benefits will accrue to the disadvantaged poor.70
Although the development of new media has driven the proliferation of channels, traditional media have grown as well. For example, although the number of nondaily newspapers has remained static since the 1970s, there has been a steady, significant increase in circulation.71 In the past 10 years, the number of published magazines has increased 37 percent, to about 18,500 titles.72 The number of U.S. radio stations is about 11,000, with 96 percent of Americans 12 years old and above reporting daily listening.
One benefit of this growth in communications infrastructure is that even relatively small communities receive virtually the same media programming as do large metropolitan areas. However, this growth also is having profound effects on traditional media-use patterns. Current evidence indicates that new media use has fragmented the use of more traditional media. This is a double-edged sword for commercial and noncommercial media campaign planners alike. The emergence of new communication channels (e.g., the Internet, World Wide Web, Digital Satellite Television) offers more opportunity for communication overall, and the possibility of more tailored communication to specific groups. However, the fragmentation of the communications system makes it more difficult to reach the majority of Americans consistently and inexpensively.
Food and Nutrition Advertising
The 5 A Day Program also occurs in a communications environment that is dense and multi-layered with commercial messages about food and nutrition. Overall, various categories of food and beverage advertising in the United States typically rank among the highest categories of expenditures.73 In 1999, U.S. advertising expenditures totaled some $215 billion across all communications media.74 This was about a 7 percent increase over 1998. Advertising for food and food products ranked 6th of all product categories in 1998 at about $3.3 billion. Fast-food advertising (which is not included in advertising for food and food products) ranked 8th at about $3.1 billion. Non-alcoholic beverage advertising ranked 16th at $1.3 billion, and candy and snack advertising ranked 19th at about $1.1 billion. Beer and wine advertising ranked 23rd at $896 million, with liquor advertising 36th at $292 million. In addition, advertising for fitness and diet programs and health spas ranked 41st at $149 million.
Fast-food corporations, in particular, rank among the most prolific brand-name advertisers. For example, McDonald's Corporation, which is ranked first among fast-food burger restaurants, alone controls about 43 percent of that market. It has the highest advertising expenditures in that category, ranks 14th among the leading U.S. national advertisers at about $1.03 billion in advertising expenditures, and generates about $5 in sales for every advertising dollar spent.74
During the first 10 years of the 5 A Day Program, the NCI directly spent about $1 million annually on media and communications in support of the Program. Contributed resources leveraged through the 5 A Day public/private partnership added an estimated $35 million annually (these in-kind funds were spent by industry to include the 5 A Day logo and message in supermarket ads and industry marketing). As impressive as these figures may be, they are dwarfed by commercial advertising for food and beverages. Expenditures for the marketing of food, fast food, and alcoholic and nonalcoholic beverages totaled about $10 billion in 1999 alone. The difference in magnitude is instructive and speaks in support of what the 5 A Day Program has managed to accomplish with modest means. However, it also speaks to the magnitude of the behavior-change problem in the United States of continued overconsumption of total calories and less healthful eating.
Reporting of Nutrition, Food, and Diet-Related News
News about science and health ranks high as a content choice among media consumers. Recognizing this, newspapers, in the 1980s, began to develop special sections for reporting health, medicine, and science.75 Television and radio outlets have occasionally hired physicians and scientists with communications skills to report health and medical stories. Personal health and fitness also ranks high among magazine titles. For these, a recent survey of Internet users found that health as a general subject ranked among the top five uses of the World Wide Web, with 30.8 million people (46% of Internet users) reporting use of the Web to search for information about a medical, health, or personal problem.
The scientific enterprise in the United States indirectly generates a considerable amount of this information about diet-related health. Studies appearing weekly, monthly, or quarterly in refereed scientific journals often find their way into the popular media. Because scientists and journalists work differently and are guided by different values, the public is frequently ill-served in developing a comprehensive understanding of diet-related health issues.76 Scientists work in an empirical framework in which each study is, at best, an incremental advance over previous work. A single study is seldom decisive, and scientists are trained to qualify their results, to tolerate ambiguity, and to consider a single study in a larger research context. Journalists, on the other hand, apply news values to their work and therefore seek to emphasize the new, the unusual, the contradictory, the "breakthrough," and other information they judge to be of interest to their audience. Although science and health stories usually are reported accurately from a factual standpoint, they often lack a larger context for interpretation. In addition, journalists have a low tolerance for qualification and ambiguity, having been trained to seek clarity or contrast in the interests of their audience. This, and the scientific community's penchant for reporting positive results, often concludes in an "overdose of optimism" in the reporting of health research.77
Entertainment media, especially television, also are a source of diet-related health information, albeit indirectly through modeling healthy or unhealthy eating patterns. Past content analyses of entertainment programming have noted the frequently unhealthy nature of depicted eating and drinking patterns, seldom linking them to unhealthy outcomes, and even framing them as "normal" and "legitimate."78
It is clear that a great deal of promotional activity—including 5 A Day—drove diet and nutrition-related messages in the media during the 1990s. Major media report diet and nutrition messages in a variety of contexts. In addition to scientists, food, health, and science-advocacy groups have generated a great deal of news coverage about diet and nutrition issues. Industry commodity groups frequently promote the results of studies that favor the positive effects of the products they promote. Public-interest advocacy groups frequently target specific foods as unhealthy to counter food-industry influence and advertising. Such activity seeks to influence both the agenda and the setting or context of media reporting on health and diet-related issues.79
Effects on the 5 A Day Message Environment
The volume, inconsistency, and often contradictory nature of information in the marketplace in combination with the other factors described above have created less than ideal conditions for healthful behavior change. The effect of these factors is that the public frequently is overwhelmed by the sheer volume of information and left confused by the pastiche of entertainment, news stories, advertising, and other sources of health information about food, diet, and nutrition. A recent national survey sponsored by Cornell University's National Nutrition Information Center reported that 64 percent of respondents said that they often "change their minds" about nutrition when "the study of the week" contradicts previous work or traditional dietary advice.80 Although 59 percent admitted that conflicting nutrition information had caused them to change their eating patterns in the past 2 years, about 20 percent said they had ceased to pay attention to nutrition studies altogether because of the confusion they often engendered.
In the context of this environment, there is a need for reliable and credible sources of dietary information to prevent the further growth of "dietary helplessness," to help the public differentiate good from poor information, to provide a larger context for personal dietary decisions, and to help clarify the confusion engendered in the message environment. The 5 A Day Program, as a public/private partnership, is in an excellent position to further these efforts with perhaps an increased emphasis on influencing media news reporting and the "framing" of health-related dietary issues.79 The Program will never have the resources equivalent to the private sector, yet there is good evidence that local health promotion activity can have a beneficial effect on changing dietary patterns even in the context of a message-dense, fragmented, and competitive environment.
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