An Analysis and Proposed Intervention for the USDA’s MyPlate Campaign towards Adolescents-Danny Neilson

Introduction

In modern America, approximately 65% of Americans can be classified as either overweight or obese (1). Furthermore, the incidences of diet-related health problems such as heart disease, diabetes and cancer are at an all time high. In America, it has been shown that 4 out of the 10 leading causes of death can be attributed to poor dietary behaviors (2). However, the incidence of obesity is not equally distributed among different genders and ethnic groups (1). In addition to different prevailing opinions among males, females and different ethnic demographics towards diet and nutrition, one can correctly assume that children and adolescents have their own unique approach to nutrition and its role in role in daily life. Studies of International Adolescent Nutrition reveal that there appears to be an increasing prevalence of obesity worldwide, possibly explained by increased dietary lipid intake and decreased physical activity, especially in urban settings (3).

Overwhelming evidence suggests that increased fruit and vegetable consumption leads to decreased risks of obesity, cardiovascular disease, cancer and stroke (4). Past US pubic health programs, such as Five a Day and the Food Pyramid, have aimed at increasing fruit and vegetable consumption. Like traditional public health interventions, past USDA public health interventions have relied on the Health Belief Model as the basis for behavior change. The Health Belief Model asserts that an analysis of Perceived Benefits and Perceived Costs leads to Intention, which then leads to Behavior (5). Despite the failings of USDA’s Five a Day campaign and the recently replaced Food Pyramid, the USDA’s new model for promoting healthier dietary choices, MyPlate, relies primarily on the principles of the Health Belief Model to instill behavioral changes.

The MyPlate campaign is mainly centered around the MyPlate icon and the USDA’s website choosemyplate.gov, which provides detailed nutritional information and an omnipresent MyPlate logo. On the website, the MyPlate logo is described as “a simple, yet powerful, visual cue to prompt consumers to think about their food choices across food groups and to build a healthy plate at meal times” (6). The MyPlate home page offers nutritional advice regarding what to eat, how much to eat and details regarding which foods should be limited (7). Furthermore, the home page details sample menus, recipes, daily food plans, nutrition tips and plans for eating on a budget (7). The consumer’s section of the MyPlate website offers specific nutritional advice for Dieters, Pregnant and Breastfeeding Women, Children from 6-11 years and Preschoolers of the ages 2-5. A notable emission from the consumer section of the MyPlate website is a sub-group specifically tailored to the needs and attitudes of adolescents. The website also offers a SuperTracker, to help Americans plan, track and analyze their diet and physical activity (7). A significant difference between the new MyPlate icon and the more recent MyPyramid is the elimination of the sub-group previously known as “discretionary calories”, which includes sweets, refined grains and soda. Interestingly, a 2005 study of American male and female adolescents found that discretionary calories make up approximately 46% of total caloric intake in the average adolescent diet (8). According to the FAQ section of the MyPlate website, these foods are not expected to be completely eliminated from the diet but were not included so as not to promote the consumption of unhealthy foods (7).

Despite the upgrades in the MyPlate campaign, the continuing flaws of the USDA’s nutrition education program will fail to promote lasting dietary changes, particularly for adolescent consumers. The most glaring of these flaws are a failure to account for Psychological Reactance, weak and one-dimensional marketing and advertising efforts, and the assumption that dietary choices are rational, education-based decisions that take place at the individual level. The proposed intervention will detail a plan of action that eliminates Psychological Reactance through an improved understanding of Communications Theory, bolsters marketing through a superior implementation of Advertising Theory and Marketing Theory and directly influences dietary behavior at the group, as opposed to individual, level.

Critique 1: MyPlate’s campaign generates Psychological Reactance and is not persuasive

Psychological Reactance Theory, developed by Brehm, Brehm and Wicklund, asserts that any persuasive message may arouse feelings of resistance, leading the listener to reject the desired behavior and do the opposite of what is suggested (9). From infancy, this behavior is evident. A study of psychological reactance in infants found that when presented with two objects, one behind a barrier and the other freely accessible, 2 year old boys resoundingly preferred the object behind the barrier (10). Unfortunately, the MyPlate campaign does not account for Psychological Reactance in its message. The logo of the MyPlate campaign, a circle split into four quadrants with a small circle outside the plate for the dairy group, literally confines American’s eating choices. The MyPlate logo and the nutrition information provided on the choosemyplate.gov website are threatening because they threaten one of the freedoms that Americans value most highly, the ability to choose the foods and quantities that they desire. While this is not the intention of the MyPlate campaign (7), the logo and information provided to American consumers reduces the dietary choices that consumers can make by blocking off food choices into specific categories and giving calorie boundaries. Furthermore, adolescents are proven to consume a high percentage of total calories from discretionary calories and also consume insufficient amounts of fruits and vegetables (8). In the same way that a smoker reacts adversely when threatened with the loss of ability to smoke, teens feel that their control and freedom is threatened when such a large amount of their diet is put on the chopping block.

Despite its good intentions, the MyPlate logo and corresponding nutritional advice decreases the control of adolescent consumers. Like past studies exploring potential loss of freedom, low personal control is similarly correlated with passivity and poor morale (11). The corresponding feelings of decreased control and explicit messaging resulting from the MyPlate logo and website are likely to generate high levels of Psychological Reactance.

Another factor that MyPlate does not account for is Communications Theory, which states that messages are more persuasive if the source delivering them is likeable, similar, familiar, and carries positive associations. Similarity increases liking and decreases resistance by making a message less threatening (12). This aspect of Communications Theory is not implemented well in the MyPlate campaign because the information on the site is provided by a faceless, voiceless source. According to the MyPlate website, all of the online materials provided, including the Daily Food Plan, Food Tracker and Food Planner were developed by a team of nutritionists, dietitians, economists, and policy experts at the USDA (7). As a result, teen consumers are not able to relate to the message being provided due to the disparity among the group providing the message and the one receiving. The MyPlate website does not provide a visible teen role model or spokesperson for adolescents to look up to, thereby inhibiting feelings of Similarity. Like the principle of Similarity, Communications Theory also suggests that Likeability makes a message more persuasive. Attraction to the communicator is a well-known force towards compliance (12). While the “voice” behind the MyPlate campaign is not necessarily unlikeable, there is nothing about the MyPlate logo or the information provided on the website that will arouse feelings of warmth and likeability towards the message being provided because it is delivered by anonymous nutrition professionals. Furthermore, familiar messages are viewed as more valid than unfamiliar messages (13). Depending on the upbringing and nutritional knowledge of the adolescent, the information provided on the MyPlate website may or may not be viewed as Familiar. In comparison to the tens of thousands of commercials and other messages that teens receive each year, many of which pertain to dietary choices, the MyPlate logo and the nutritional recommendations provided by the website are extremely unfamiliar. Lastly, Communications Theory asserts that messages will be more persuasive if they carry positive associations. Food chains, such as McDonald’s or Burger King, are quite aware of this and the distribution of toys to children in conjunction with unhealthy food and beverages has been implicated as a barrier to children meeting nutritional standards (14). The MyPlate message is not delivered in a state of enjoyment as toys are with fast-food meals, thereby limiting the campaign’s ability to achieve positive associations with teen consumers.

Critique 2: MyPlate fails in its Marketing and Advertising efforts

Despite the difficulty it takes to produce a successful public health social marketing campaign, past interventions have been effective in preventing and controlling tobacco use, increasing physical activity, improving nutrition and increasing condom use (15). One of these obstacles is the decreased visibility of public health messages in comparison to non health-promoting messages. Children view approximately 40,000 television commercials each year and marketers are increasingly exploring how to reach children through Ipods, gaming platforms, cell phones and other digital devices (16). Unfortunately, the minds behind the MyPlate campaign have not fully utilized the multitude of technological options available at their disposal. The USDA’s main efforts are centered on the MyPlate logo and the information on the choosemyplate.gov website.

The MyPlate website and logo do not demonstrate an understanding of Advertising Theory. Advertising Theory posits that effective advertising presents a promise, support (in the form of words, images, music, etc) and fulfills the aspirations of the targeted audience. On the MyPlate website, the “Consumers” section visible at the bottom of the home page does not contain a section dedicated specifically towards adolescents (7). There are sections available for Preschoolers (2-5 years), and Children (6-11 years) but not for individuals of 12 years or greater who are not yet adults. This omission is particularly significant given that studies indicate that attention is greater for tailored as compared to non-tailored health communications (17). While adolescents can use MyPlate’s resources to calculate their individual nutritional needs, the lack of information and catering towards the unique preferences and attitudes of adolescents means that attention will be low for adolescents viewing the MyPlate website. Furthermore, the central “promise” of the MyPlate logo and the MyPlate website is one of health, which is one of the least effective core values in teen marketing campaigns (18). Additionally, the main “support” of the MyPlate campaign is provided through written advice and images. Media researchers have hypothesized that computer-mediated messages are less effective than other forms of communication such as radio, video and interpersonal communication because they lack non-verbal cues, reducing the “richness” of the message (19). Since MyPlate’s campaign is decidedly computer-mediated, an opportunity to advertise more effectively through audio, visual and interpersonal communication is lost.

Despite the difficulty of designing a nationwide nutrition program for men and women of all ages, there is precedent showing that marketing campaigns can promote change for diversified social groups.  Research into the marketing practices of Absolut Vodka reveals that brand meanings change across social, cultural and national boundaries, a trend facilitated by successful marketers (20). On a related note, research into media messages promoting health and nutrition reveals that communication messages directed towards a particular audience have been proven to be the most effective in achieving change (21). While a logo or symbol may be an effective means of communicating nutritional advice, it must appeal to the core values and beliefs of the group of people it intends to influence. By directing its message more directly towards adolescents, MyPlate would be able to achieve much more significant changes in teenage dietary behavior.

Campaigns are most effective when companies and agencies market what people want, not what the group wants to sell. This way of thinking, known as Marketing Theory, can be immensely successful when implemented correctly, as shown by the results of Florida’s “truth” campaign. The core values of Florida’s “truth” campaign originated from the feedback of a 500 person youth summit and youth review board assembled to gain insight into the values that teens most identify with (18). By determining the values that teens most valued, in this case, rebellion, the “truth” campaign was equipped from the start to package a public health message that promotes a core value that adolescents cherish. This shift in thinking away from established social marketing practices is touted as the key step in the success of the “truth” campaign (18). Not only does the MyPlate campaign not appeal to a key core value for adolescents, the emission of a section of their website devoted specifically to teens means that they will not be motivated to change their dietary practices for the better.

Lastly, an understanding of the “authority effect” can help explain why MyPlate is likely to fail in its efforts to improve the eating habits of adolescents. The “authority effect” is a commonly used social influence principle used in advertising which asserts that information being delivered from an individual high in authority increases the likelihood of compliance for a given behavior (22). However, in a study of consumer behaviors for young adults in the US, teens had more receptive attitudes when the spokesperson for an ad was low as opposed to high in authority (22). With this knowledge, it is apparent that the “support” as explained by Advertising Theory would be most effective if delivered from a peer low in authority instead of the team of nutritional experts assembled by the USDA to give the MyPlate message.

            Critique 3: MyPlate assumes that dietary choices are made at the individual level through a rational, cost-benefit analysis

The Center for Nutrition Policy and Promotion, a sub-group of the USDA responsible for the creation of MyPlate describes its primary objectives as “advancing and promoting dietary guidance for all Americans and conducting applied research and analyses in nutrition and consumer economics” (7). As evidenced by the MyPlate logo and the nutritional advice provided on the MyPlate website, these objectives are mainly pursued through a reliance on the Health Belief Model. Despite the assumptions inherent in MyPlate’s usage of the Health Belief Model to explain behavior change, group level factors exert a tremendous amount of impact on dietary decisions, especially for US teens, individuals who are at a delicate stage of life where personal identity and the opinions of others are magnified in importance. A nationwide study for a sample of 1319 Americans examining the dietary quality and body mass of adults found that knowledge of basic nutrition facts, diet-health awareness and the ability to self-assess nutrient intake did not have a strong influence on dietary quality or body mass (23). Factors such as lifestyle characteristics, cultural habits, community infrastructure, and the politics of food production and retailing are hypothesized to outweigh nutrition knowledge when it comes to dietary quality and body mass for US adults (23). On a similar note, a study examining the eating habits of Dutch Adults found that elevated socioeconomic position is correlated with higher levels of fruit and vegetable intake (24). These group-level factors are not addressed in the MyPlate logo and are not visible in the nutritional advice provided on the website.

By failing to account for the limitations of the Health Belief model, principally the barriers that prevent intentions from becoming established behaviors, the MyPlate message has limited applicability to the decision-making process of US adolescents at meal time. In a study of Costa Rican adolescents, barriers to healthful eating were found to be lack of availability of healthful foods in the school environment, poor family diet, and the peer-group notion for both males and females that healthful eating for males is effeminate (25). Factors perceived as motivators included availability of high-quality, healthy foods, healthy family eating practices and healthy peer group eating (25). MyPlate’s campaign does not address these group-level variables, limiting its effectiveness.

Furthermore, there are environmental obstacles beyond the scope of the individual to creating healthy food environments for US adolescents. Changes can be made to garner more healthful food options in school cafeterias, but these programs cannot be sustained monetarily without a significant shift in student’s food preferences towards healthier options (26). Studies have found that “competitive”, non health promoting foods are widely available to students and have been linked to high intakes of calories, soft drinks, total fat, saturated fat and a lower intake of fruits and vegetables (26). Additionally, lack of school-wide communication between food service staff, health educators and teachers makes it difficult to implement school wide nutrition education programs (26). The MyPlate campaign demonstrates limited resources pertaining to developing more effective communication among the food service providers at US schools and does nothing to address the fact that many schools do not have the funds to implement optimal environments for making healthy food choices.

Articulation of Proposed Intervention:

The chief goals of the following proposed nutritional intervention for US adolescents are to eliminate Psychological Reactance, successfully implement the Theories of Communications, Advertising, and Marketing and to directly influence behavior beyond the individual level. This will begin with two 30 second commercials that will air during the 2013 Super Bowl. At the end of both commercials, the new slogan for the USDA’s dietary intervention program will be unveiled. Spelled out with the shapes of fruits and vegetables, this message will read, “Freedom to Achieve Your Dreams”.

Attempts to eliminate Psychological Reactance will be centered around delivering implicit messages that do not threaten freedom or control. These implicit messages will be based upon Communications Theory, which states that in order for messages to be maximally effective, they must be delivered from a source that is Similar, Familiar, Likeable and carries Positive Associations. In order to appeal equally to both male and female adolescents, two spokespeople of both genders will be chosen to represent MyPlate, Olympic gymnast Aly Raisman, 18 year old Captain and gold medal winner for the US Women’s Gymnastic Team at the 2012 Olympic Games, and Josh Hutcherson, 20 year old and one of the leading actors in the immensely popular movie, “The Hunger Games”.

Advertising and Marketing efforts will be based upon appealing to the core value of freedom, and not Health. This coincides with Marketing Theory, which shows that public health campaigns are most effective when agencies market the core value(s) that people want (18), in this case for teenagers, freedom, as opposed to what the USDA wants to sell, in this case Health. To maximize advertising efforts, both commercials will contain a Promise, Support and demonstrate that eating healthfully fulfills the aspirations of US teenagers. Unlike the MyPlate website, which does not contain a section devoted specifically to adolescents, this campaign specifically targets teens, which has been shown to increase the effectiveness of public health campaigns (21).

Lastly, this intervention will take into account the irrational behavior of US teenagers and eliminate the usage of the Health Belief Model. Instead the campaign will focus on the implementation of alternative models of behavior change. With Raisman and Hutcherson serving as role models, the commercials will promote a “tipping point” for individuals to adopt healthier eating practices, a characteristic outlined in Diffusion of Innovation Theory (27). Furthermore, since both individuals are highly popular and in the news due to their recent captivating performances, this campaign will successfully utilize the components of Agenda-Setting Theory, which essentially states that messages are more effective when their message coincides with what is being covered by the media.

Defense of Intervention Section 1:

The MyPlate campaign is built upon the presentation of explicit, rather than implicit messages. A study of anti-smoking public service announcements reveals that public health messages are most effective and generate far less Psychological Reactance when they are delivered implicitly, rather than explicitly (28). Psychological Reactance occurs for teens viewing the MyPlate logo and reading nutritional advice on the choosemyplate.gov website because the information provided details specific actions that consumers should take rather than relying on implicit messaging techniques such as metaphors.

Rather than delivering explicit nutritional advice, the two commercials will focus on decreasing reactance through implicit, non-threatening messages. First of all, this will start through the new slogan of the campaign, “Freedom to Achieve Your Dreams” spelled out with fruits and vegetables. This message will not generate Psychological Reactance because it does not pose a threat to freedom by delivering explicit advice. These commercials will contain no dialogue, instead relying on images, motivating music and story-telling to motivate teens to change their dietary behaviors. Although the specifics of the commercials will be slightly different so as to show the unique story of both teens, the message for both will be the same, eating a healthy diet provides the impetus to live freely and achieve one’s dreams. For Aly’s spot, the images depicted will show a sped-up version of her life, from birth, through childhood, adolescence and ultimately culminating with footage of her Olympic Gold medal performance. This commercial will intersperse footage of Aly in her daily life with images of her eating healthy foods, such as fruits and vegetables and overcoming the grueling demands of her training as a result. For Josh, the commercial will depict a re-enactment of critical scenes from “The Hunger Games” interspersed with images of him eating nutritious foods which gave him energy, allowing him to display his tremendous strength to the sponsors of the competition. The commercial will also depict scenes in which his character, Peeta, was able to stave off death through the nourishment of the healthy foods he ate leading up to and during the competition.

These two spokespeople will allow for a great display of Communications Theory when executed to the fullest. Since both characters are adolescents, they will invoke feelings of Similarity from the audience, as opposed to the faceless, nameless creators of the MyPlate campaign. Furthermore, to capitalize on the need for Likeability as explained by Communications Theory, both characters are attractive and athletic, two characteristics which serve as strong motivators for teens when it comes to nutrition (3). Next, both individuals are familiar to American teens, as they have appeared in the Olympic Games and a block-buster movie, respectively. These two will have success in serving as public advocates because familiarity increases the chances of proposed behaviors being adopted (13). Like fast-food chains which capitalize on the fact that children are in a state of enjoyment when eating at their restaurants by handing out toys, these commercials will be especially effective because they will be viewed during a time in which enjoyment is high. The Super Bowl is one of the most widely watched programs during the year and it is usually watched in the company of family and friends where ample amounts of food are present. These factors all add up to the teenage consumers being in a high state of enjoyment when the ad is played, leading them to adopt positive feelings towards the message.

Defense of Intervention Section 2:

The commercials outlined above will be much more successful than the MyPlate campaign because of a superior usage of Advertising Theory and Marketing Theory. Additionally, the commercials will be very influential because they will utilize a captivating form of media. Research shows that messages are more effective when they come from a non-computer source, a fact possibly explained by non-verbal cues which contribute to the “richness” of the message (19). The promise inherent in the MyPlate message, in accordance with Advertising Theory, will be that eating healthful foods gives teenagers the freedom to pursue and fulfill their dreams. In the same way that Aly Raisman went from unknown to international gymnastics star and Peeta Mallark, Hutcherson’s character from “The Hunger Games”, was able to raise up from poverty and trying familial conditions to survive his fight to the death, US teens will be able to envision themselves achieving their dreams as a result of eating more healthfully when they watch these commercials. The support aspect of Advertising Theory will be fulfilled through music, images, and a compelling story. Finally, because both of these individuals are attractive and athletic, or at least the characters that they portray are, these commercials will fulfill the aspirations of US teens by indirectly imply that eating healthfully will allow them to achieve the goals of becoming more attractive and athletic, the two biggest motivating factors for US teenagers to eat better (3). Furthermore, this new intervention will successfully use Marketing Theory because the message will be specifically tailored to US teenagers, a factor shown to increase compliance with a recommended health behavior (17). Lastly, this message will be more effective because it comes from a low-authority source, a motivating factor for teens to adopt a given behavior (22).

Defense of Intervention Section 3:

Despite the beliefs of companies and organizations such as the USDA, humans do not always behave in a rational manner. In an aroused state, humans are more willing to engage in risky sexual behavior (29). In the same way that sexual behavior is not always made in a rational fashion, dietary choices and opinions can fluctuate given different contexts. It has been proven that nutrition knowledge, health awareness and the ability to self-assess nutrient intake do not necessarily lead to more healthful eating practices (23). For this reason, the proposed intervention will not use the Health Belief Model or focus on appealing to the core value of health. Instead behavior will be assessed and planned for at the group level through the implementation of alternative models of behavior change.

Diffusion of Innovations Theory, which states that certain events can serve as a “tipping point” in the adoption of a specific behavior (27), will be implemented in the commercials, hopefully leading to a mass change in teen nutritional behaviors. Once the “tipping point” occurs, practice of the modeled behavior increases exponentially. With these compelling and highly publicized commercials, teens will be influenced to adopt the modeled nutritional practices, leading to improved dietary choices among US teens. Similarly, with the increased percentage of US teens eating more healthful foods, social norms will be changed. This plays into another alternative social science model which has proven to be very effective, Social Expectations Theory. This theory essentially hypothesizes that mass change can be achieved just by changing social norms (30). Once social norms become more inclusive of healthful eating practices among teens, mass change will ensue. Lastly, these commercials will be highly effective because they will utilize Agenda-Setting Theory. This theory states that capitalizing on what is being covered in the media makes a message more effective. Since both of the chosen teens have generated high amounts of publicity due to recent successes, using them as the voice of the new campaign will lead to increased adoption of healthful eating practices among teens.

References

(1)Daniels, Judi. Obesity: America’s Epidemic: What goes up does not always come down. Is there a solution? American Journal of Nursing 2006; 106:40-49

(2)Johnson-Taylor, W. What Can Communication Science Tell Us about Promoting Optimal Dietary Behavior? Journal of Nutrition Education and Behavior 2007; 39: S1-S4.

(3)Schneider, D. International Trends in Adolescent Nutrition. Social Science and Medicine 2000; 51(6):955-967.

(4)Baranowski, T. Understanding the Behavioral Linkages Needed for Designing Effective Interventions to Increase Fruit and Vegetable Intake in Diverse Populations. Journal of the American Dietetic Association 2011; 111(10):1472-1475.

(5)Sapp, S. Examination of the Health Belief Model to Predict the Dietary Quality and Body Mass of Adults. International Journal of Consumer Studies 2007; 31(3):189-194.

(6)Levine, E. Evaluating MyPlate: An Expanded Framework Using Traditional and Nontraditional Metrics for Assessing Health Communication Campaigns. Journal of Nutrition Education and Behavior 2012; 44: S2-S12.

(7)US Department of Agriculture. ChooseMyPlate.gov Website. Washington, DC.

http://www.choosemyplate.gov/

(8)Bowman, S, Moshfegh, A, Friday, J, Martin, J. Teenagers consume far more discretionary calories and far less fruits and vegetables than that recommended in the Dietary Guidelines for Americans, 2005. The Journal of the Federation of American Societies for Experimental Biology 2008; 22:108.4.

 (9)Dillard, J. Lijiang, S. On the Nature of Reactance and its Role in Persuasive Health Communication. Communication Monographs June 2005;72(2):144-168.

(10) Brehm S, Weinraub M. Physical barriers and psychological reactance: 2-yr-olds' responses to threats to freedom. Journal Of Personality And Social Psychology November 1977;35(11):830-836.

(11) Peterson, C, Stunkard, A. Personal control and health promotion. Social Science & Medicine 1989; 28(8): 819–828.

(12)Silvia, P. Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistance. Basic and Applied Social Psychology 2005; 27(3).

(13)Moons, W, Mackie, D, Garcia-Marques, T. The Impact of Repetition Induced Familiarity on Agreement with Weak and Strong Arguments. Journal of Personality and Social Psychology 2009; 96(1):32-44

(14)Otten, J, Hekler, E, Krukowski, R, Buman, M, Saelens, B, Gardner, C, King, A. Food Marketing to Children Through Toys: Response of Restaurants to the First US Toy Ordinance. American Journal of Protective Medicine 2012; 42(1):56-60.

(15)Evans, W. Social Marketing Campaigns and Children’s Media Use. Children and Electronic Media 2008; 18(1).

(16)Wilson, B. Designing Media Messages About Health and Nutrition: What Strategies Are Most Effective? Journal of Nutrition Education and Behavior 2007;39(2):S13-S19.

(17)Kessels, L, Ruiter, R, Brug, J, Jansma, B. The effects of tailored and threatening nutrition information on message attention. Evidence from an event-related potential study. Appetite 2011; 56(1): 32-38.

(18)Hicks, J. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

(19)Wilson, E.V. Perceived effectiveness of interpersonal persuasion strategies in computer-mediated communication. Computers in Human Behavior 2003; 19(5):537-552.

(20)Kates, S, Goh, C. Brand Morphing: Implications for Advertising Theory and Practice. Journal of Advertising 2003;32(1):59-68.

(21)Wilson, B. Designing Media Messages About Health and Nutrition: What Strategies Are Most Effective? Journal of Nutrition Education and Behavior 2007;39(2):S13-S19.

(22)Jung, J, Kellaris, J. Responsiveness to authority appeals among young French and American consumers. Journal of Business Research 2006; 59(6):735-744.

(23)Story, M, Nanney, M, Schwartz, M. Schools and Obesity Prevention: Creating School Environments and Policies to Promote Healthy Eating and Physical Activity. Milbank Quarterly 2009; 87(1):71-100.

(24)Giskes, K, van Lenthe, F, Kamphius, C, Huisman, M, Brug, J, Mackenbach, J. Household and food shopping environments: do they play a role in socioeconomic inequalities in fruit and vegetable consumption? A multilevel study among Dutch adults. Journal of Epidemiology and Health 2009; 63(2):113-120.

(25)Monge-Rojas, R, Garita, C, Sanchez, M, Munoz, L. Barriers to and Motivators for Healthful Eating as Perceived by Rural and Urban Costa Rican Adolescents. Journal of Nutrition Education and Behavior 2005; 37(1):33-40.

(26)Cho, H, Nadow, M. Understanding Barriers to Implementing Quality Lunch and Nutrition Education. Journal of Community Health 2004; 29(5):421-435.

 (27) Harting, J ; Rutten, GMJ ; Rutten, STJ ; Kremers, SP. A Qualitative Application of the Diffusion Innovation Theory to Examine Determinants of Guideline Adherence Among Physical Therapists. Physical Therapy, 2009; 89(3): 221-232.

 (28)Shadel, W, Fryer, C, Tharp-Taylor, S. Tobacco Industry Manipulation Messages in Anti-Smoking Public Service Announcements: The Effect of Explicitly Versus Implicitly Delivering Messages. Addictive Behavior 2010; 35(5): 526-529.

(29)Ariely, D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: Harper Perennial, 2009.

(30)DeFleur, M. Theories of Mass Communication, Fifth Edition. New York, NY: Longman Inc. 1989.