Message framing, lexical concreteness, and controlling language in

Dutch nutrition education messages

Canan Ziylan

880102-988-050, BSc Nutrition and Health, Wageningen University

COM-80809 Extended Essay in Communication Science

Supervisor: Dr. Reint Jan Renes

June – July 2009

1

Content

Summary ................................................................................................................................................ 2 1 Background .................................................................................................................................... 3

1.1 Nutrition: the problem child among prevention behaviors ....................................................... 3 1.2 Presentational elements in nutrition education messages ...................................................... 4

1.2.1 Framing ................................................................................................................................ 5 1.2.2 Lexical concreteness ........................................................................................................... 7 1.2.3 Controlling language ............................................................................................................ 7

1.3 Overview of the present study ................................................................................................. 8 2 Methods ........................................................................................................................................... 9

2.1 Inclusion criteria nutrition education messages ....................................................................... 9 2.2 Criteria for presentational elements in nutrition education messages..................................... 9

2.2.1 Framing ................................................................................................................................ 9 2.2.2 Lexical concreteness ........................................................................................................... 9 2.2.3 Controlling language ............................................................................................................ 9

2.3 Verification of the classification of slogans ............................................................................ 10 3 Results .......................................................................................................................................... 11

3.1 General characteristics .......................................................................................................... 11 3.2 Presentational elements in nutrition education messages .................................................... 11

3.2.1 Framing .............................................................................................................................. 11 3.2.2 Lexical concreteness ......................................................................................................... 11 3.2.3 Controlling language .......................................................................................................... 11

3.3 Relation between source and presentational elements in nutrition education messages .... 13 3.3.1 Framing .............................................................................................................................. 13 3.3.2 Lexical concreteness ......................................................................................................... 13 3.3.3 Controlling language .......................................................................................................... 13

3.4 Interdependency between presentational elements in nutrition education messages .......... 13 4 Discussion .................................................................................................................................... 15

4.1 Presentational elements in nutrition education messages .................................................... 15 4.1.1 Framing .............................................................................................................................. 15 4.1.2 Lexical concreteness ......................................................................................................... 15 4.1.3 Controlling language .......................................................................................................... 16

4.2 Relation between source and presentational elements in nutrition education messages .... 16 4.2.1 Framing .............................................................................................................................. 16 4.2.2 Lexical concreteness ......................................................................................................... 17 4.2.3 Controlling language .......................................................................................................... 17

4.3 Interdependency between presentational elements in nutrition education messages .......... 18 4.4 Overall remarks ..................................................................................................................... 18 4.5 Study limitations .................................................................................................................... 19

5 Conclusion and implications for practice and future research ............................................... 20 References ........................................................................................................................................... 21 Appendix I – Details of included slogans ......................................................................................... 22 Appendix II – List of the included slogans in Dutch ........................................................................ 25

2

Summary

Although more is known about the beneficial consequences of healthy dietary behavior, four out of the

ten leading causes of death can be attributed to poor dietary behaviors. A possible explanation lies in

individuals’ educational level. Through the years, many health campaigns are set up in the

Netherlands with the intention to promote optimal dietary behavior. However, the achieved effects of

these campaigns were most of the time only marginal. In a study of Wevers, Renes and Van Woerkum

(2008) on theory use in lifestyle campaigns it became evident that many campaigns contained only a

small amount of evidence-based campaign components. Performed practice was most of the time

based on common sense and prior experiences. This study aimed at providing a systematic

assessment of performed practice in nutrition education messages. The objective was to give an

overview of slogans that are used on Dutch posters and brochures, and classify them depending on

their presentational characteristics. The four presentational components are message framing, single

action orientation, lexical concreteness, and controlling language. The materials themselves were the

only reference in this study, since no campaign developers were approached for more information on

performed practice. The assessment of the materials made clear that the majority of the included

slogans have 1) a gain frame, 2) an overall goal orientation, 3) a low level of lexical concreteness, and

4) a low level of controlling language. Therefore, the present research supports the findings of Wevers

et al., indicating that performed practice tends to be mainly based on factors other than evidence from

theory. The study also showed that there are many sources of nutrition advocacy, contributing to the

complexity of nutrition. Moreover, the available nutrition education materials vary widely between

sources, in both their presentational elements and their content. When the aim is to remove the

abstractness around nutrition in order to achieve a higher prevalence of individuals with a healthy

dietary pattern, this variation forms a significant barrier. The main implication for practice of this study

is therefore to centralize the dissemination of messages, and realize a single line of nutrition

education. In the ideal situation, the Netherlands Nutrition Centre would be the only source of nutrition

advocacy, disseminating clearly framed, single-action oriented, highly concrete, and low-controlling

messages. Only this kind of practice will lead to more individuals being aware of the large influence

that a healthy diet has on their own health.

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1 Background

Since the beginning of the 21st century, many studies showing the beneficial consequences of healthy

dietary behavior on future health are conducted (CDCP, 2004; Stein & Colditz, 2004; WHO, 1999,

2003). More and more is known about the prevention of coronary heart diseases (CHDs) and various

forms of cancer. It becomes clearer than ever that an individual has much more influence on his future

health through a healthy dietary pattern than previously assumed.

Given this knowledge one would expect a decline of the incidence and prevalence of CHD- and

cancer patients. Still, that decline is not seen in most of the western countries, the Netherlands

included. According to Johnson-Taylor et al. (2007), “four of the 10 leading causes of death can be

attributed to poor dietary behaviors.” Unfortunately, the public pays only little attention to this fact.

It is important to investigate the reasons behind the increasing incidence and prevalence of diet-

related diseases. Through the years, many health campaigns are set up with the intention to promote

optimal dietary behavior. However, the achieved effects of these campaigns were most of the time

only marginal. This could indicate that the Dutch population is not susceptible to mass media

campaigns, but that would not explain the achieved successes of campaigns dealing with for instance

smoking, and drinking and driving (Borkus et al., 2009). The difference in campaign topics, however,

does provide an explanation for the variation in success.

When promoting a ‘healthy dietary behavior’, the message is rather abstract. This abstractness

leaves many questions unanswered and asks for a lot of input from the reader. It is not clear what

‘healthy’ is, or what the consequences of unhealthy eating are.

On the other hand, if you want that people stop smoking, you can tell them to ‘stop smoking!’ That

is one, clear, non-confusing message. Of course it is necessary to tell why they have to stop, as is

indeed done in such campaigns.

With avoiding drinking when alcohol is consumed it is the same principle: ‘don’t drink and drive!’

This topic has the advantage that everyone knows the consequences of driving while drunk. Many

fatal car accidents where alcohol was the direct cause pose enough justification of this advice.

Since nutrition is not as clear-cut as the previous two topics, it is important to pay attention to the

manner on which a nutrition-related message is conveyed. There are several presentational

components that play a role in the formation of an educational message. Firstly, the choice needs to

be made whether the message will be formulated positively or negatively, known as message framing.

Another aspect of message construction is formed by the use of lexical concrete recommendations.

Lastly, campaign developers can choose to put forceful verbs in a message, qualified as controlling

language. When there are many factors to take into account when deciding on what message to

convey, it is the question whether campaign developers indeed do so.

This study will make a systematic inventory of performed practice in nutrition education messages.

The objective is then to give an overview of slogans that are used on Dutch posters and brochures,

and classify them depending on their presentational characteristics (i.e., framing, lexical concreteness,

and controlling language). This assessment will give an answer to the following research question: To

what extent do Dutch nutrition education messages reflect what scientific evidence proposes when it

comes to their presentation? The answer on this question will serve as a mirror for campaign

developers, showing how evidence based their end products are. Then, where necessary, measures

can be taken in order to increase the correspondence between science and practice. In their turn,

these measure can lead to an increased level of success of nutrition education messages.

1.1 Nutrition: the problem child among prevention behaviors

As mentioned before, nutritional messages are more abstract than messages about smoking and

drinking and driving. This abstractness arises already due to nutrition’s origin; healthy behavior varies

widely between individuals. Clearly, there are ‘mean values’ that apply to the ‘mean individual’, and

general recommendations like ‘two times fruit a day’ and ‘consume around the 2000 kcal per day’.

Still, these means are not plausible for every occasion, or are unclear, restricting their generality. An

apple and a banana are for example not similar to the consumption of two strawberries. Furthermore,

4

we are not capable to measure the calories of everything we eat and drink. Not only because of

logistic reasons, but also due to the motivational lack to scrutinize every consumption.

A second cause of abstractness is the grey area of recommended amounts of food and nutrient

intake. Unsaturated fatty acids and cholesterol are two main troublemakers when related to for

example CHDs. However, the other side of the story is that we also need them, though to a certain

degree. No nutrient is needed to be banned out of our diet; a widely used slogan of the Netherlands

Nutrition Centre is therefore ‘eet gevarieerd’ – ‘eat varied’. The recommendation to eat varied is yet

again an example of a message in which abstractness accumulates.

The last aspect where abstractness is the case is formed by the conflicting messages around food

and nutrients. Scientific studies are more often contradictory to than consistent with each other. Not

only scientists, but also the media cause confusion among people. As rightly stated in an article of

Johnson-Taylor et al. (2007), “they [the media] highlight how the result of each new study is at odds

with what the public thinks they know. (…) The trouble with this bias is that it leaves the impression

that the nutrition world is full of inconsistencies.”

Concluding the three reasons of abstractness, it seems very difficult to give a clear message to

others about healthy dietary behaviors. Therefore, it is important to make proper use of the knowledge

generated by many studies on educational messages. A question that needs to be addressed by

campaign developers is then “What theories should be taken into account while designing a nutritional

message?” This question underlines the importance of so-called evidence-based campaigns. They

involve theories that are believed to be effective based on systematic literature comparisons. Thus, it

is evident that health promoters should make use of theories when designing campaigns aimed at

promoting optimal dietary behavior. The question is then whether campaign developers indeed use

available evidence with respect to effective campaign elements.

In 2008, Wevers, Renes and Van Woerkum searched for an answer on this question, investigating

theory use in Dutch lifestyle campaigns. They made a distinction between three phases where theory

was used: the assessment of behavioral determinants (phase 1, intervention plan), the determination

of the appropriate messages and channels (phase 2, campaign plan), and the conversion of the made

choices in campaign elements (phase 3, implementation campaign plan). Their main finding was that,

although in phase 1 theories played an important role, the use of theory decreased when phase 3 was

reached (see also Figure 1). As they state, the campaign developers base their activities in the third

phase mainly on several other sources. In that state, experiences from a former campaign, the

pretesting of materials, and the engagement of an advertising agency contribute most to the

implementation of the campaign plan. This results in only a small amount of evidence-based campaign

components, decreasing the chance of success of lifestyle campaigns drastically.

Theory use will also be focused on in this study, although not similarly as in the study of Wevers et

al. While they specifically asked campaign developers about theory use in interviews, this study will be

limited to an assessment of the campaign materials. Moreover, the focal point will be the presentation

of messages, with message framing as the starting point. Because of the chosen focus, more attention

can be given to this specific part of nutrition education messages. This gives the opportunity to present

an elaborate view on one aspect instead of a short sight on many.

1.2 Presentational elements in nutrition education messages

In this study, the manner of presentation of Dutch nutrition education messages will be the focal point.

Although the presentational elements of campaigns logically do not cover a campaign in its whole,

there is an important reason why they are chosen to investigate in this study: their existence is not

widely known among campaign developers. Such ignorance could lead to leaving possible

advantages unused, which in its turn may contribute to the explanation of the small effect of nutritional

campaigns. Where theories fail to come into prominence, intuition tends to gain ground. For example,

the Theory of Planned Behavior (TPB) (Ajzen, 1991) and the Transtheoretical Model (Prochaska &

Velicer, 1997) are two theories that are widely known, also when nutrition is involved. Many articles

point at the importance of these theories, providing campaign developers with useful information about

their use. As mentioned before, first of all less is known about the effects of for example framing in

5

message

Figure 1: Extent of theory use in different phases of campaign development (as used by Wevers, Renes, & Van

Woerkum (2008))

nutritional campaigns. That could be one of the reasons that it is given less attention to while

designing a campaign, or the presentation of the message in its entirety. However, great danger lies

behind such manner of working. The effort put in designing an educational message based on a

behavior-determining element of the TPB is prone to be wasted when it is not assured that people will

look at the message in the first place. Content counts, but the ‘package’ determines whether the

content is noticed by the target group. It is rather naive to think that the presentation of a subject does

not need to be as evidence-based as the actual content. Where the importance of evidence-based

practice is acknowledged in many health-promoting activities, campaigns tend to fall behind when it

comes to their packaging. A slogan on a poster that ‘sounds nice’ but is not informative, does not

guarantee that the reader will look at the website for more information. Moreover, it fails in giving a

clear and concrete message. Similarly, such a slogan on a brochure will not by definition make sure

that the brochure is read, and will also fail in conveying a clear message. In the next paragraphs, three

presentational elements that can overcome these problems to a certain extent will be discussed, being

message framing, lexical concreteness, and controlling language.

1.2.1 Framing

Message framing can best be described as done by Gerend and Cullen (2008): “providing equivalent

outcome information in terms of either gains or losses”. The idea that choosing for either a positive or

negative approach while conveying a message is able to result in different consequences is first

proposed by Goffman (1974). Since then, many researchers studied the effects of framing in different

areas, varying from economic issues to health-related problems. There are four types of framing

possible, each of them underlining the positive consequences of compliance (gain frame) or the

negative consequences of non-compliance (loss frame), either focused on a desirable or undesirable

outcome (Figure 2). Gain-framed messages can focus on (1) attaining a desirable outcome, or (2)

avoiding an undesirable outcome. Examples are then (1) If you consume two times fruit a day, you

increase the chance of ageing healthy and (2) If you consume two times fruit a day, you decrease the

risk of developing esophageal cancer. Loss-framed messages can emphasize (1) attaining an

undesirable outcome, or (2) avoiding a desirable outcome. Corresponding examples are (1) If you do

not consume two times fruit a day, you increase the risk of developing esophageal cancer and (2) If

you do not consume two times fruit a day, you decrease the chance of ageing healthy.

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Figure 2: Constructed gain- and loss-framed appeals based on the action taken and desirability of the outcome

(as used by Rothman and Salovey (1997))

It is proposed by many researchers that gain-framed messages would be especially effective when

aimed at encouraging disease prevention behaviors. The main explanation for this suggestion origins

from the Prospect Theory as described by Kahneman and Tversky (1979). It proposes that potential

losses are more motivating than potential gains when risky actions are contemplated, but gains are

more motivating than losses for low-risk behaviors (Gerend & Cullen, 2008). Rothman and Salovey

(1997) explain in their article when an issue is either considered risky or involving low risk. They state

that the difference lies in the purpose of a behavior. Screening and detection behavior (e.g.,

mammography, colonoscopy) are meant to reveal a potentially life-threatening health problem, which

results in screening behavior to be viewed as risky. Contrary, because of the purpose of a preventive

health behavior (e.g., using sunscreen, eating fruits and vegetables) is to prevent disease, engaging in

these behaviors is typically viewed as safe.

Having this knowledge, a relatively simple conclusion could be drawn. Because of the preventive

role of a healthy dietary pattern, nutritional education messages should be framed in terms of gains.

Such framing is expected to be cause the most behavior change, as supported by many empirical

studies (Apanovitch, McCarthy, & Salovey, 2003; Kiene, Barta, Zelenski, & Cothran, 2005; Schneider

et al., 2001). However, when it comes to a healthy dietary pattern nothing is really that simple, so

neither is the conclusion that can be drawn from the prospect theory. It is evitable that one gain-

framed campaign is not going to affect behavior; the gain-framed message is not the only information

that is available about healthy dietary patterns. As stated by Rothman and Salovey (1997): “we must

consider how the framed information is integrated with prior perceptions.”

The possible benefits of using the theory about message framing in nutrition education messages

still need to be shown. Available literature is not able to draw firm conclusions on this topic. However,

generally researchers tend to conclude that the framing effects are marginal in this context. The most

given reason for this finding is that nutritional advice is rather too vague, and no explicit

recommendations can be given. According to the meta-analysis of O’Keefe and Jensen (2007), the

relevance of message framing decreases to a level that the use is not found necessary. However,

because most studies done on the effects of framing are highly artificial, problems arise around their

external validity. As Green (2006) stated, “the challenge is that most of the evidence is not very

practice-based.” According to Latimer, Salovey and Rothman (2007), the effect of solely framing will

never be measurable because of the impossibility to rule out prior perceptions and ideas of individuals.

However, they underline that there could still be an effect because of the accumulation of multiple

campaign elements.

Applying the knowledge on framing to the current study, it can be concluded that in general a gain

frame should be used in nutritional education messages. The expectation is that most campaign

developers are not aware of this theory. Furthermore, sometimes there is a tendency to use a certain

degree of fear in messages, while positive approaches are also seen. These different practices

possibly cause a discrepancy between scientific evidence on framing and the performed practice.

Therefore, it is expected that not all included slogans will have the characteristics of a gain frame.

Outcome

Desirable Undesirable

Actio

n A

tta

in

Cell A

(gain frame)

Cell B

(loss frame)

Cell A: Attaining a desirable outcome

Cell B: Attaining an undesirable outcome

Cell C: Avoiding a desirable outcome

Cell D: Avoiding an undesirable outcome Avoid

Cell C

(loss frame)

Cell D

(gain frame)

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1.2.2 Lexical concreteness

In light of the aforementioned three reasons of abstractness, the concreteness of a message plays an

important role in nutrition education messages. Lexical concreteness is “qualified by the use of

concrete versus abstract language” (Miller, Lane, Deatrick, Young, & Potts, 2007). When a message is

highly lexically concrete it provides specific details, while a message with low lexical concreteness

contains more abstract generalities. Other characteristics of lexical concrete messages are the use of

“descriptive-action verbs and perceptual features detailing a description of a single observable event”,

again according to Miller et al. When the message is for example that ‘Consuming 2 times fruit and

two ounces vegetables decreases the risk of developing esophageal cancer’, the reader is provided

with very concrete details. However, when the message is ‘Consuming fruit and vegetables is healthy’,

a rather general description is given, leading to a low level of lexical concreteness. Concluding,

concreteness refers to the specificity of a message, or as said by Miller et al., “the extent to which a

message details the information needed by the reader.” Abstract messages, on the other hand,

contain less details, giving receivers more space for interpretation.

The study by Miller and colleagues shows that more concrete messages are received with greater

attention and viewed as more important than less concrete messages. Another important finding was

that “the concrete message source was viewed as more positively than the abstract message source

on two of the most critical cognitive dimensions of source credibility – expertise and trustworthiness.”

These two dimensions also relate to what is known about response efficacy. In general, this term

refers to one’s beliefs about whether or not the recommended behavior is effective. Before someone

performs the advocated behavior, he must be convinced of its use. However, first it must be made

clear in concrete terms what the promoted behavior is. It is important to not only underline that one

must eat healthy, but also what exactly can be done to achieve this healthy dietary pattern. Supported

by the more positive evaluations of expertise and trustworthiness, response efficacy will also increase.

This will have a positive influence on the effectiveness of the conveyed message.

The importance of concreteness is also emphasized by Sheeran (2002), who stated that it is more

effective to promote a single action rather than an overall goal. A goal in this context is then, according

to Sheeran, “an outcome that can be achieved by performing a variety of single actions.”

Taken together, these findings confirm the importance of removing the abstractness around

nutrition, showing the need of individuals for concrete, clear recommendations. Due to the

experienced difficulty to give concrete nutritional recommendations, slogans are more likely to contain

general, abstract messages. In light of this study then, it is expected that the majority of the included

slogans will have a low level of lexical concreteness.

1.2.3 Controlling language

The last aspect relating to the presentation of nutritional messages is the use of controlling language.

When a message contains forceful adverbs like ought to, must, and should, it is considered as highly

controlling. As stated by Miller et al. (2007), “controlling language is characterized by increased use of

imperatives (i.e., commands and orders).” Low controlling language on the other hand contains

propositions or indirect suggestions, without the use of highly explicit, directive language. Miller et al.

found that “higher levels of controlling language lead to more negative cognitive evaluations of the

message, less positive assessments of the message topic, less intention to behave in advocated

ways, and more negative perceptions of source credibility.” These are alarming findings, pointing at

the importance of avoiding the use of controlling language. When compared to the previous element,

lexical concreteness, controlling language is related to the directiveness of a message, whereas

lexical concreteness stands for its descriptiveness. The conclusion that can be drawn is that a low

level of controlling language combined with a high level of lexical concreteness is able to exert the

highest positive effect in a nutritional context.

In the context of this study, the use of forceful adverbs and imperatives in slogans is expected to be

marginal because of common-sense practice of campaign developers (Wevers et al., 2008).

Consequently, the expectation is that most nutritional education messages will have a low level of

controlling language.

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1.3 Overview of the present study

Following the findings of Wevers, Renes and Van Woerkum (2008), it is expected that the use of

theories involving the presentation of nutritional messages is rather low. Campaign elements are more

likely to be based on experiences than on their corresponding theories. Therefore, it is expected that

the majority of the includes slogans will have (a) a gain frame, (b) a low level of lexical concreteness,

and (c) a low level of controlling language.

Since there are no studies done that assessed the manner of presentation of Dutch nutrition

education messages, this study will be more of an exploratory kind. The objective of this study is to

give an overview of slogans that are used on Dutch posters and brochures, and classify them

depending on their characteristics.

This study will merely give an assessment of performed practice, investigating the prevalence of

frames, single action messages, lexical concreteness and controlling language. Therefore, when for

example a gain frame is found, it is not possible to speak of ‘correct theory use’. The reason for this is

that campaign developers will not be asked whether they used that frame on purpose; it could be that

the found frame is in the slogan ‘accidently’. In light of this reasoning, the included materials will be

discussed in terms of what is seen.

By making such an assessment, it will be possible to look at commonalities in nutrition education

messages. This will give an insight on prevalent health education practice from several sources in the

Netherlands, a so-called cross-sectional study. Furthermore, a comparison will be made of performed

practice between 1999 and 2009 using brochures originating from The Netherlands Nutrition Centre.

This assessment will give an answer on the research question: To what extent do Dutch nutrition

education messages reflect what scientific evidence proposes when it comes to their presentation?

Thereby, it will be possible to identify possible latitudes in theory use in nutrition education messages.

Concluding, instead of providing evidence for practice, this study aims at offering evidence from

practice.

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2 Methods

2.1 Inclusion criteria nutrition education messages

For this study, only written nutrition education messages were taken into account. Materials containing

these messages were retrieved by visiting websites of the organizations. The materials originating

from the Netherlands Nutrition Centre and dating from before 2009 were collected during a visit.

Brochures and posters selected had to meet three criteria. First, the nutrition education materials

should origin from a Dutch organization, should be written in Dutch, aimed at the Dutch population.

Second, the written material should aim at primary prevention. This means for example that

materials with a focus on the promotion of losing weight of already obese individuals were excluded.

Third, the messages should contain a clear frame, either derivable from the slogan in front, or by

the accompanying sub-heading. Slogans of which the frames were readily noticeable from the slogan

itself are qualified as having a ‘real frame’. On the other hands, slogans of which the frame was

derived from a sub-heading are qualified as having a frame of lower recognizability. The latter ones

are indicated by the use of an italic typeface for the slogan in the table in Appendix I. Behind such

slogans, the main information as provided in the sub-heading is shown with underlined typeface.

The included materials will firstly be studied on the three presentational elements. Then, the

relation between these elements and the source of the materials will be investigated. Lastly, possible

interdependencies between the presentational elements will be described.

2.2 Criteria for presentational elements in nutrition education messages

2.2.1 Framing

As mentioned before, there are four types of framing possible, each of them underlining the positive

consequences of compliance or the negative consequences of non-compliance, either focused on a

desirable or undesirable outcome. The slogans of the included campaigns will be classified as having

one of the four possible frames, based on the division as discussed above. The four frames are:

1 Gain frame: attaining a desirable outcome

2 Gain frame: avoiding an undesirable outcome

3 Loss frame: attaining an undesirable outcome

4 Loss frame: avoiding a desirable outcome

2.2.2 Lexical concreteness

As mentioned before, lexical concrete messages provide the reader with specific details, while

messages with low lexical concreteness contain more abstract generalities. The criteria and examples

related to lexical concreteness can be seen in Table 1. Because the level of concreteness can have

different meanings when different topics are of interest, the criteria are specifically formulated with

regard to nutritional messages. In nutrition, the recommendation to eat healthy is rather low in

concreteness, since healthy eating does not provide the reader with specific information on how to eat

healthy. On the other hand, the advice to consume daily two pieces of fruit tends to be high in

concreteness. However, when the consequences of such behavior are not mentioned, in this study the

slogan will be qualified as high instead of very high. The reason for this is that it is important to give

readers concrete information about the justification of a given advice. Because of the abstractness

arisen around nutrition, it is very important to be as concrete as possible. This includes mentioning

both amounts of recommended intakes, and the consequences of complying with the recommendation

to justify it.

2.2.3 Controlling language

When a message contains forceful adverbs like ought, must, and should, it will be counted as highly

controlling. As stated by Miller et al. (2007), “controlling language is characterized by increased use of

imperatives (i.e., commands and orders).” Low controlling language on the other hand contains

propositions or indirect suggestions, without the use of highly explicit, directive language. The criteria

as used in this study are illustrated with examples in Table 2.

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Table 1: Criteria and examples related to lexical concreteness

Level of lexical

concreteness Criteria Example

Low

No (specific) eating behavior

mentioned, with or without

consequence

Eating healthy results in a healthy

weight! or Prevent overweight!

Intermediate

Specific eating behavior mentioned,

without specifying amounts or

specific consequences

Consume enough fruit and vegetables!

High – amount Specific eating behavior mentioned,

specifying amounts

Consume 2 times fruit and two ounces

vegetables per day!

High – consequence Specific eating behavior mentioned,

specifying consequences

Consuming enough fruit and

vegetables decreases the risk of

developing esophageal cancer!

Very high

Specific eating behavior and the

involved consequences mentioned,

accompanied by an amount

Consuming 2 times fruit and two

ounces vegetables decreases the risk

of developing esophageal cancer!

Table 2: Criteria and examples related to controlling language

Level of

controlling

language

Criteria Example

Low An advice, recommendation or remark,

without forceful adverbs or an imperative

Eating 2 times fruit a day helps

you staying healthy!

High An advice, recommendation or remark,

accompanied by a forceful adverb or an imperative

(You must) Eat 2 times fruit a

day to stay healthy!

2.3 Verification of the classification of slogans

The slogans are allocated to one of the four frames by using the corresponding, on beforehand

determined criteria. This is also done during the classification related to lexical concreteness and

controlling language. Although the criteria are described as objectively verifiable as possible, space for

interpretation differences could be present during the allocation. For this reason, the slogans are

classified by two independent researchers using the exact same criteria as shown above. By doing

this, possible personal interpretation influences are minimized, as discrepancies between the two

allocations are taken into account. Only two discrepancies were noticed, one at the division of lexical

concreteness, the other at controlling language, which led to an overlap percentage of 97%. The

discrepancy on the two points was removed after a discussion that ended with an agreement on how

the allocation eventually should be. The high overlap percentage led to the conclusion that the criteria

are well-described, ruling out interpretation influences to a large extent.

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3 Results

3.1 General characteristics

In total, 25 slogans from brochures and posters could be included to this study according to the three

inclusion criteria. Materials without a slogan were excluded, as were the ones with a slogan but

without a clear or derivable frame. The overall characteristics of the materials can be found in Table 3;

the details and classification of each included slogan are shown in Appendix I. Furthermore,

Appendix II contains the original (i.e., Dutch) versions of the used slogans.

Most slogans origin from The Netherlands Nutrition Centre (48%), followed by slogans from

materials from Municipal Health Services (40%). However, when looked at slogans of materials that

are currently used, The Netherlands Nutrition Centre contributes 16% to this study.

Materials were mostly aimed at adults (64%), and at parents with children between 4 and 12 years

old (24%).

The most chosen target behavior was achieving healthy diet, comprising 44% of the materials.

Other recommendations dealt with for example decreasing snack consumption (12%) and fat intake

(8%), increasing fruit and vegetables intake (8%), and having breakfast (8%).

3.2 Presentational elements in nutrition education messages

3.2.1 Framing

H1 predicted that the majority of the included slogans would have a gain frame. 88% of the slogans

contains the characteristics of a gain frame, thereby supporting H1 (Table 3). Of these slogans, 52%

is framed in the form of attaining a desirable outcome (cell A in Figure 2), and 36% focuses on

avoiding an undesirable outcome (cell D).

Loss frames are evidently less seen in the selected nutrition education messages, comprising only

12% of the total amount. Moreover, all of them belong to cell B in Figure 2, aimed at attaining an

undesirable outcome. No slogans contained a message that focused on avoiding a desirable outcome

(cell C).

In total, almost half of the used materials had a clear frame (48%), so one that was derivable from

the slogan only. The frames of 52% of the slogans were derived from contextual factors, primarily the

sub-heading (ten slogans, 83.3%) or the picture of an overweight child (two slogans, 16.7%).

3.2.2 Lexical concreteness

As much as 68% of the slogans had a low level of lexical concreteness (Table 3), mentioning no

specific eating behavior, most of the time limited to the advice to “eat healthy”. This percentage is in

support of H3, which predicted that the majority of the included slogans would have a low level of

lexical concreteness.

16% of the slogans had an intermediate level according to the determined criteria. This means that

they do mention a specific eating behavior (e.g., less fat, more fruit and vegetables), but do not specify

the behavior by means of amounts or related consequences.

There were four slogans that are characterized as having a high level of lexical concreteness

because they mentioned a specific eating behavior, accounting for 16% of the slogans. Of them, 8%

mentioned an amount related to the promoted behavior, and the other 8% mentioned the

consequences of unhealthy behavior, both elevating their level of lexical concreteness. No slogans

were found that have a very high level of lexical concreteness, mentioning a specific eating behavior,

supported by specific amounts and related consequences.

3.2.3 Controlling language

H4 proposed that the majority of the included slogans would have a low level of controlling language.

In up to 64% of the studied slogans a low level of controlling language could be seen, containing

recommendations and advices without the use of forceful adverbs and imperatives. In the other 36%,

12

the messages did contain imperatives, which points at a high level of controlling language. These

results, as can be seen in Table 3, lead to the sustainment of H4.

Table 3: Characteristics of analyzed nutrition education messages

Characteristic Amount Percentage

Source

The Netherlands Nutrition Centre (2009)

The Netherlands Nutrition Centre (< 2009)

Municipal Health Services (2009)

Dutch Cancer Society (2009)

Dutch Heart Foundation (2009)

Foundation of Idealistic Commercials (2004)

4

8

10

1

1

1

16

32

40

4

4

4

Target group

Adults

Parents with children 4-12y

Adolescents 13-18y

Parents with children 1-4y

16

6

2

1

64

24

8

4

Target behavior

Healthy diet

Snacks

Breakfast

Fat

Fruit and vegetables

Healthy body

Healthy lifestyle

Hot meals

Fibers

Lunch

11

3

2

2

2

1

1

1

1

1

44

12

8

8

8

4

4

4

4

4

Frame

Gain: attaining a desirable outcome

Gain: avoiding an undesirable outcome

Loss: attaining an undesirable outcome

Loss: avoiding a desirable outcome

13 (7)*

9 (4)*

3 (1)*

0

52 (28)**

36 (16)**

12 (4)**

0

Single action vs. overall goal

Overall goal

Single action

14

11

56

44

Lexical concreteness

Low

Intermediate

High – amount

High – consequence

Very high

17

4

2

2

0

68

16

8

8

0

Controlling language

Low

High

16

9

64

36

*Number of slogans of which the frame is derived from only the slogan itself, instead of from contextual factors

(sub-heading, pictures) ** Percentage of slogans of which the frame is derived from only the slogan itself, instead

of from contextual factors (sub-heading, pictures)

13

3.3 Relation between source and presentational elements in nutrition education messages

3.3.1 Framing

All twelve materials from The Netherlands Nutrition Centre are characterized by a gain frame. The four

brochures from 2009 unanimously focus on attaining a desirable goal. Two out of eight materials

dating from before 2009 have also this subtype of a gain frame; the other six are formulated on a

manner that aims at avoiding an undesirable goal.

Seven out of ten included slogans from Municipal Health Services had also a gain frame, all of

them formulated as attaining a desirable outcome. The other three slogans were loss framed, with a

focus on attaining an undesirable goal.

Both disease-related organizations, the Dutch Heart Foundation and the Dutch Cancer Society,

had a gain frame that was focused on avoiding an undesirable outcome. This type of gain frame was

also found in the slogan of the Foundation of Idealistic Commercials (SIRE).

3.3.2 Lexical concreteness

Three of four (75%) 2009-materials from The Netherlands Nutrition Centre scored low on the level of

concreteness, while the other one had an intermediate level of concreteness. In the materials from

before 2009, four out of eight (50%) had a low level of lexical concreteness. Moreover, one slogan

scored high on lexical concreteness (“Eat more: Every day 200 grams vegetables and two times fruit”).

Eight out of ten (80%) materials from the Municipal Health Services had a low level of lexical

concreteness. The other two were ranked high on the level of concreteness, either on the

consequence criterion (“Too much fat causes overweight!”) or on amount (“Snacks in between? Not

more than four times a day!).

In total, thirteen out of sixteen (81.3%) currently used slogans are characterized by a low level of

lexical concreteness, two out of sixteen by a high level (12.5%).

3.3.3 Controlling language

From the 2009-materials from The Netherlands Nutrition Centre, three out of four (75%) had a low

level of controlling language. From the older materials, five out of eight (62.5%) had also a low level of

controlling language.

The results were similar for materials from the Municipal Health Services. Seven out of ten (70%)

of the studied slogans scored low on the level of controlling language.

Finally, while the Dutch Cancer Society had a low level of controlling language for their slogan

(“Eating healthy, decreased chance of cancer”), both the Dutch Heart Foundation (“Live pleasant and

healthy! A healthy lifestyle helps preventing cardiovascular heart diseases”) and SIRE (“Don’t take

overweight too lightly - Say “no” more often”) scored high on this level.

In total, twelve out of sixteen (75%) currently used slogans contain low-controlling language.

3.4 Interdependency between presentational elements in nutrition education messages

Relation LC with framing. Figure 3 shows the distribution of two levels of lexical concreteness per

found subtype of framing. Low and intermediate levels are put together, as are the two forms of high

concreteness.

As can be seen, twelve out of thirteen slogans (92.3%) with a (gain-frame) focus on attaining a

desirable outcome had a low or intermediate level of lexical concreteness.

When the (gain-frame) focus was on avoiding an undesirable outcome, eight out of nine (88.9%)

slogans had a low or intermediate level of lexical concreteness.

Finally, of the three slogans with a (loss-frame) focus on attaining an undesirable goal, one had a

low or intermediate level of lexical concreteness (33.3%).

14

0

2

4

6

8

10

12

Gain: Attaining desirable

outcome

Gain: Avoiding undesirable

outcome

Loss: Attaining undesirable

outcome

Nu

mb

er

of

slo

ga

ns

Low/Intermediate lexical concreteness High lexical concreteness

Figure 3: The distribution of levels of lexical concreteness per framing subtype.

15

4 Discussion

4.1 Presentational elements in nutrition education messages

4.1.1 Framing

When looked at the framing of the slogans of the included materials, it becomes clear that a bare

majority fails to have a clear frame. Many brochures and posters were not even included to the study

because of a total lack of framing characteristics. Whereas posters contain slogans that ‘sound nice’

but are not informative, many brochures limit their slogan to ‘Healthy eating’. And then the hope is that

people are triggered enough to actually read the informative content of the brochure. As mentioned

before, it is important to give the reader at least one message, clearly visible on the material you want

them to read carefully. Of course such a slogan will not guarantee that the advocated behavior is

performed instantly. However, it will contribute to the realization of a more concrete image of

nutritional behavior. When individuals are primed with similar, unambiguous nutritional messages, they

will grow more confidence in the cause-effect relation between the promoted behavior and its positive

effects. This will increase the chance of behavior change of the target group, and at least change their

attitudes towards the behavior.

A clear majority of the slogans had the characteristics of a gain frame, mainly focused on attaining

a desirable outcome. This was as already expected, because of the current tendency in nutrition

education to formulate messages positively (Hekman, 2002). Consequently, the found frames are

most likely not the result of awareness of the theory about framing, but the result of common sense. If

framing would have been starting point, the materials would have had a more clear frame, in the form

of a behavior and its effect. Still, whether framing served as the basic rule or not, the fact remains that

there were only three materials with a loss frame. This indicates that performed practice regarding the

formulation of nutritional messages is as the framing theory proposes.

4.1.2 Lexical concreteness

As expected, the majority of the slogans had a low level of lexical concreteness. According to the

study of Miller and his colleagues (2007), low descriptiveness in messages leads to a low chance on

behavioral change. This relation is not surprising: a message that promotes a healthy diet leaves a lot

open for the readers’ interpretation, while advocating the consumption of two times fruit per day

provides them with a clear message.

In the materials, there were only two slogans that specify an amount and therefore rank high on the

level of lexical concreteness. One of them aims at fruit and vegetables intake, and the other at snack

consumption. No other amounts were mentioned, neither in the overall-goal slogans, nor in the single

action ones. This lack of concreteness has a negative impact on the expected effect of the messages.

This points to inadequate performed practice of the campaign developers of the included materials.

However, it is also important to acknowledge the difficulty in giving amount-supported advices in mass

media materials. As mentioned in the explanation of the complexity of nutrition, the amount of

recommended consumptions varies widely between persons. For this reason, it is not always possible

to give concrete recommendations about many food products. A solution could lie in, however,

stratifying the target group according to their nutritional needs. So, instead of aiming at adults in

general, a message can aim at women or men only. This stratification is already seen in materials of

the Netherlands Nutrition Centre aimed at parents of children – which are not included to this study

because of the lack of a slogan. They provide parents with information depending on the age of their

child. There are three different brochures, ranging from the age groups 1-4y, 4-8y, and 9-12y. This

kind of target group categorization would facilitate the achievement of an increased level of lexical

concreteness.

There was only one slogan that mentioned the consequence of a specified behavior, thereby

having a high level of lexical concreteness. This finding is in line with prior remarks where reasons for

the abstractness around nutrition were given. Although it would be a positive development when

cause-effect relationships between nutrition and diseases would be given, fact remains that it is

difficult to do so. Many relationships are yet to be proven convincingly, especially the effect of the

16

consumption of specific products on disease risks. Therefore, this finding was expected,

acknowledging the difficulty to describe cause-effect relationships.

4.1.3 Controlling language

In line with prior expectations, the majority of the included nutrition education materials scored low on

the level of controlling language. Still, the percentage of slogans that included a forceful adverb or an

imperative was rather high. The problem with the use of controlling language is that it for example

leads to a lower intention to behave in advocated ways. The reason for this is explained in the

psychological reactance theory, which posits that “individuals become psychologically aroused when

their perceived behavioral freedoms are threatened or reduced” (Miller et al., 2007). This state of

negative arousal causes the individuals to reject the message or simply avoid it. Therefore, a high

percentage of slogans with controlling characteristics indicates insufficient theory use.

Controlling language does not always increase reactance and message rejection by the audience.

This is the case when restoration of freedom is the issue, which comprises that an individual is given

back his “sense of autonomy and self-determination, thus mitigating feelings of reactance” (Miller et

al., 2007). That is the reason why in their study a restoration postscript ―provided after a high-

controlling language message― reduced the perceived explicitness of a message and the perceived

threat to freedom posed by the message. This finding indicates that high-controlling language does

not necessarily lead to negative effects on persuasion. On the contrary, sometimes it may even be a

more powerful method compared with low-controlling language. The reason for this is that the low-

controlling messages might “encourage ambiguity and obfuscate the intended meaning of a

persuasive appeal” (Miller et al., 2007).

Miller et al. focused on messages, which indeed gives the opportunity to restore the feelings of

freedom of the reader. Short slogans on the other hand are generally too short to contain both a high-

controlling persuasive appeal and a freedom-restoring postscript. When looked at the high-controlling

slogans in this study, no restoration of freedom can be found. Therefore it can be concluded that a

high percentage of slogans with high-controlling characteristics still points to insufficient theory use,

leading to reactance of and message rejection by the readers.

4.2 Relation between source and presentational elements in nutrition education messages

4.2.1 Framing

Source. If looked in more detail to the sources of the materials, the Netherlands Nutrition Centre

scores best on the prevalence of a gain frame. All materials originating from this organization were

characterized by a gain frame. A remarkable development can be seen in the difference between used

gain-frame subtypes through the years. The four brochures from 2009 unanimously focus on attaining

a desirable goal, while only two out of eight materials dating from before 2009 have this formulation.

This points at a former tendency to focus on a negative outcome, and a current trend to focus on a

positive outcome, although both in a gain frame. An explanation for this could lie in the mentioned

contemporary preference to formulate messages positively, which could lead to the outcome to be

formulated positively too.

The Municipal Health Services showed a high consistency in the formulation of gain frames. Seven

out of ten slogans had a gain frame focused on attaining a desirable outcome. The other three slogans

were loss framed, with a focus on attaining an undesirable goal. This could point to a tendency to link

gain (positive) frames to positive outcomes, and loss (negative) frames to negative outcomes.

Although this practice is probably performed unconsciously, it does cover practice as proposed by for

example Lee and Aaker (2004). In their study they found that, in comparison with a loss frame, a gain

frame has a larger effect on individuals when a positive outcome is promoted. The other way around,

a loss frame has in its turn a larger effect when it deals with a negative outcome. From this point of

view, current practice of the Netherlands Nutrition Centre seems also more in line with theory than

prior practice. Nowadays, they do focus on attaining a desirable outcome, whereas the last ten years

the gain frame was mainly characterized by the focus on avoiding an undesirable outcome.

17

Both the Dutch Heart Foundation and the Dutch Cancer Society also had a gain frame, focused on

avoiding an undesirable outcome. Although this practice is not as proposed by Lee and Aaker, in this

case the source does play a large role in the choice of formulation. Because of their focus on

diseases, they will be more likely to point at the preventive role of healthy nutrition behavior. Such an

approach comes up to the expectations that people have of this kind of organizations. It may lead to

an increased persuasive effect because of the anticipated expertise of these authorities on the field of

nutrition-related diseases. Therefore, in this case a gain frame with a focus on avoiding an undesirable

outcome may be the best choice anyway.

Lastly, a gain-framed slogan was used by the Foundation of Idealistic Commercials, also aimed at

avoiding an undesirable outcome. Similar to the discussion around the previous two sources, a side

note can be made in this case too. Despite of Lee and Aaker’s findings, in this case a gain frame was

probably not the most logical choice. The reason for this is that the posters are supported by TV-

commercials and make use of another, related theory: fear appeals. The best definition of fear appeals

is probably the one that Witte (1992) provided: “persuasive messages designed to scare or frighten

people into complying with a particular message by describing the awful and terrible things that will

happen to them if they do not act in accordance with the message”. The slogan “Don’t take overweight

too lightly - Say “no” more often” is accompanied by the picture of a child’s head on the body of an

obese adult. The expectation is that the campaign developers did not decided upon the use of a loss

frame, but on the use of fear, a negatively valenced emotion. Then, the choice made to focus on

attaining an undesirable outcome, being a child with overweight, can be explained more easily.

Sometimes, a fear appeal may exert a larger effect than a positively framed message. However, too

much fear could lead to the backfiring of the message by the audience, or lead to avoidance and

counter arguing (Witte & Allen, 2000). In this case the negative formulation has the advantage that the

level of fear is not really high, and that the slogan is targeted at parents of children. It points at the

responsibility that parents have over their children, aiming at behavioral change for parents without an

influence on themselves, but a positive, desired one on their children. Consequently, in this case a

negative, loss-framed approach may lead to higher effects on behavioral change among parents than

a positive, gain-framed one would.

4.2.2 Lexical concreteness

Source. There were no real differences between the studied sources, all of them having a high

percentage of slogans that scored low on the level of lexical concrete messages. However, there is a

difference in concreteness within a source, being the Netherlands Nutrition Centre. During the years,

more slogans of the nutrition education messages scored low on lexical concreteness. While in 1999

the messages did at least contain a specific behavior, since 2002 all included slogans aim at ‘healthy

eating’, ‘becoming fat’, ‘energy balance’, and ‘a healthy weight’. These messages contribute to the

abstractness around nutrition, even if the content of the brochure gives more insight by means of

details. Of course, when the brochure is read in more detail by people, more concrete information will

be available for the reader. However, the problem does not lie in these already health-occupied

individuals, but in people who are not aware of the positive consequences of a healthy diet. The latter

ones are not likely to be triggered to read further when a slogan says “Don’t become fat!” Moreover,

the lesson they learn is negligible, since it is limited to that you should not become fat. The current

trend in practice of the Netherlands Nutrition Centre indicates that lexical concrete messages become

less prevalent. And so does their newest – lexical abstract - campaign slogan: “The New Eating is

eating healthier little by little.”

4.2.3 Controlling language

Source. Similar to the findings at lexical concreteness, with controlling language no real differences

were present between the studied sources. The majority of slogans per source contained low-

controlling language, in line with what theory proposes. One remarkable difference can be seen in

slogans originating from the Netherlands Nutrition Centre between 1999 and 2009. Nearly all slogans

18

from 1999 scored low on controlling language, but starting from 2002 the slogans became more

controlling. Then, in 2009 the slogans turned back to containing low-controlling language, as it was

mainly in 1999. This could indicate newly attained insights since 2006, deciding on the use of low-

controlling messages. However, it could also point to coincidence, or other factors than the theory of

controlling language. Fact remains that current practice is promising when it comes to the use of

controlling language, since a majority of currently used slogans contain low-controlling language.

4.3 Interdependency between presentational elements in nutrition education messages

Relation with framing. A clear majority of the gain-framed messages scored low or intermediate on

lexical concreteness. That percentage was high for both messages focused on attaining a desirable

outcome and for the ones focused on avoiding an undesirable outcome. Based on the findings of

Miller et al. (2007), this abstractness point at low effectiveness in persuasion. This relation as such is

also taken as a starting point in the discussion above. However, other research indicates that concrete

language is not by definition more effective than abstract language. As mentioned by Miller et al. too,

there is an exception where abstract language may be a better choice. Evidence suggests that

concrete language is indeed most effective when used in combination with a negative outcome

(Cesario, Grant, & Higgins, 2004; Higgins, Idson, Freitas, Spiegel, & Molden, 2003). In this case, that

would be a gain-framed focus on avoiding an undesirable outcome. So, the found majority of

messages with a low level of lexical concreteness still indicates inadequacy in performed practice.

However, other evidence indicates that the use of abstract language may be more effective when

dealing with a positive outcome (Lee & Aaker, 2004; Semin, Higgins, de Montes, Estourget, &

Valencia, 2005). Here, the positive outcome focus is characterized by the gain-framed messages

focusing on attaining a desirable outcome. Then, the found majority of messages of this subtype with

a low level of lexical concreteness would point to adequately performed practice. Still, there are

discussions about whether abstractness would really have more benefits compared with

concreteness. It is suggested that these claimed benefits need to be studied in more detail before the

importance of concreteness can be wiped away. Therefore, in this study a low level of lexical

concreteness is still qualified as an inadequacy, especially because of the focus on the problematic

abstractness around nutrition.

4.4 Overall remarks

The present study demonstrates performed practice in Dutch written nutrition education messages,

investigating the prevalence of frames, single action messages, lexical concreteness and controlling

language. Most currently used materials that were included in this study originate from Municipal

Health Services, followed by materials from The Netherlands Nutrition Centre. Next to these sources,

the Dutch Heart Foundation and the Dutch Cancer Society also each have one brochure available for

Dutch citizens. It is rather questionable that there is a relatively large amount of nutrition education

messages available that originates from different sources. When there are several sources of

information about the same subject, it could lead to confusion among the readers of it. As mentioned

before, one of the main problems around nutrition is its characteristic abstractness. Such diversity in

availability can contribute to the existence of this abstractness.

Important to note is that the Netherlands are one of only few countries with a special centre for

nutritional practice. This given makes it even more surprising that for example Municipal Health

Services feel the necessity to develop own materials to promote healthy dietary behavior. In this study,

ten materials are included from these organizations, while the Netherlands Nutrition Centre

contributed only four currently used brochures. A side note that needs to be made is that currently,

there are more materials available than the sixteen used in this study. The reason for this is that

several materials were excluded from the present study because of the lack of a slogan (with a frame).

However, the percentage of excluded materials from Municipal Health Services and the Netherlands

Nutrition Centre are similar. Fact remains therefore that the Municipal Health Services, thirty in total in

the Netherlands, contribute most to the availability of nutrition education messages. As a result, the

19

found ratio of two out of five is a reliable reproduction of reality, with two standing for the materials

from the Netherlands Nutrition Centre.

Another side note is formed by the content of the materials originating from Municipal Health

Services. Many materials are based on information from the Netherlands Nutrition Centre, which is

indicated in the regarding brochures. This means that most of the time the advocated eating patterns

do not vary widely, disseminating similar recommendations across the materials. Still, variations do

exist, and in extreme cases even opposite behaviors are recommended. For example, the Municipal

Health Service of Zuid-Holland West promotes the consumption of muesli during breakfast. That same

muesli is qualified as “not so healthy” by the Municipal Health Service of Amsterdam. Even more

astonishing is then the performed practice of the Netherlands Nutrition Centre on their website, to

where they refer to in their brochures. While one webpage claims that it is healthy to consume muesli

during breakfast, the food choice table at another page states that you should consume it only

occasionally. This type of erroneous, confusing practice hinders nutritionists in their way of advocating

correct, healthy nutritional behavior.

4.5 Study limitations

The current study should be considered in light of its limitations, which provide opportunities for future

research. The collection of Dutch nutrition education materials was done by visiting the websites of the

mentioned organizations. In the case of older materials originating from the Netherlands Nutrition

Centre, a visit to their archives was necessary. Furthermore, several Municipal Health Services were

contacted about the availability of materials. The included materials attempt to give a rather

comprehensive picture of the availability of nutrition education materials with clear slogans in the

Netherlands. However, it cannot be guaranteed that the total picture is indeed provided with this study.

Future studies might benefit from visiting all Municipal Health Services and other nutrition-related

organizations to collect materials personally. Then, it will be made sure that the provided overview is

as comprehensive as possible.

Another limitation lies in the amount of included materials, which is not very high. A higher amount

would lead to more valid results and corresponding conclusions. However, several overall conclusions

can be drawn even with this number of materials, giving a reliable overview of performed practice.

The last limitation is formed by the manner of investigating the slogans. Since this study made only

an assessment of performed practice, nothing can be said about the thoughts behind the development

of the materials. Findings from the present study highlight several commonalities in the presentational

elements of nutrition education messages. Future studies may benefit from interviews with campaign

developers in order to gain insight in theory use during the development of nutrition education

messages. Only then, correct theory use across campaign development can be evaluated, instead of

being limited to a mere assessment of performed practice. The present study will be rather useful as a

starting point for such an investigation, since it provides an overview of currently available materials

with a clear, framed slogan.

20

5 Conclusion and implications for practice and future research

The present study aimed at providing an assessment of performed practice, investigating the

prevalence of frames, single action messages, lexical concreteness and controlling language in

nutrition education messages. The assessment made clear that the majority of the included slogans

have 1) a gain frame, 2) an overall goal focus, 3) a low level of lexical concreteness, and 4) a low level

of controlling language. Therefore, the present research supports the findings of Wevers et al. (2008),

indicating that performed practice tends to be mainly based on other factors (e.g., common sense)

than evidence from theory.

This study shows that there are many sources of nutrition advocacy, contributing to the complexity

of nutrition. An important finding was that the available nutrition education materials vary widely

between sources, not only in their presentational elements, but also in their content. When the aim is

to remove the abstractness around nutrition in order to achieve a higher prevalence of individuals with

a healthy dietary pattern, this variation forms a significant barrier. The question that needs to be asked

then is whether it is necessary that different sources develop their own nutrition-related materials,

especially when there is a specialized organization like the Netherlands Nutrition Centre present. It is

strongly recommended that the Netherlands Nutrition Centre complies with its name, and becomes the

centre of nutrition-related practice. Such a development would lead to progress in the direction of a

more healthy population.

Another essential implication is aimed at the used slogans of brochures and posters. The power of

a clear, informative slogan should never be underestimated, especially in the field of nutrition. In

today’s society, where information is disseminated from everywhere, people are in need of consistent,

unambiguous messages about nutrition. If a message like “Don’t become fat” is used, you know that it

is not informative at all, you just hope that the reader will feel triggered enough to visit the website.

However, you do not know whether you will succeed in enticing them to do so. Therefore, at least

provide them with a slogan with a real message, which is preferably single-action oriented, highly

concrete, and low controlling. Of course it is not scientifically correct to claim that “2 times fruit a day

prevents cancer!”, because it will not prevent cancer on its own. However, it is possible to exert a

more nuanced message, like “2 times fruit a day helps preventing cancer”. For many food groups, this

kind of nuanced messages can be thought of, providing individuals with a concrete, informative

slogan. By doing this, you still reach the already health-occupied individuals who will visit the website

for more detailed information. However, the real advantage lies in reaching individuals who are not

aware of the positive consequences of a healthy diet. And let it be just that target group in which the

prevalence of diet-related diseases is the highest.

The main implication for practice of this study is to centralize the dissemination of messages, and

realize a single line of nutrition education. In the ideal situation, the Netherlands Nutrition Centre would

be the only source of nutrition advocacy, disseminating clearly framed, single-action oriented, highly

concrete, and low-controlling messages. Only this kind of practice will lead to more individuals

becoming aware of the large influence that a healthy diet has on their own health.

21

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22

Appendix I – Details of included slogans

Source Target behavior

and group

Gain frame:

attaining a desirable

outcome

Gain frame:

avoiding an

undesirable

outcome

Loss frame:

attaining an

undesirable

outcome

Loss frame:

avoiding a

desirable

outcome

Lexical

concreteness

Controlling

language

MHS

Amsterdam

fat, adolescents

13-18y

Too much fat causes

overweight!

High –

consequence Low

MHS

Amsterdam

healthy diet,

13-18y

Healthy eating results in

a healthy weight! Low Low

MHS Brabant

Zuidoost

breakfast, pa-

rents of children

of 4-12y

Breakfast... take the time!

With tips for a good start

of the day.

Low High

MHS Brabant

Zuidoost

lunch, parents of

children of 4-12y

Lunch… you can go at it

again! With tips for tasty

and healthy lunching.

Low Low

MHS Brabant

Zuidoost

snacks, parents

of children of 4-

12y

Well… he has to grow

from it (otherwise:

overweight child)

Low Low

MHS

Rivierenland

healthy diet, pa-

rents of children

of 4-12y

A healthy diet… moves

you! Low Low

MHS IJsselland

snacks, parents

of children of 4-

12y

Snacks in between?

Not more than four

times a day!

(otherwise: cavities)

High –

amount High

MHS Zeeland healthy diet,

adults

Healthy eating? It’s your

decision! (to feel good

and fresh)

Low Low

MHS Zuid-

Holland West breakfast, adults

Make time for a breakfast

(for more energy) Low High

MHS Gelderland

Midden

healthy body;

adults

Having and maintaining a

healthy body Low Low

MHS = Municipal Health Services; italic text = frame derived from sub-heading; underlined text = main message in sub-heading

23

Source Target behavior

and group

Gain frame:

attaining a desirable

outcome

Gain frame:

avoiding an

undesirable

outcome

Loss frame:

attaining an

undesirable

outcome

Loss frame:

avoiding a

desirable

outcome

Lexical

concreteness

Controlling

language

Netherlands

Nutrition Centre

(2009)

healthy diet, pa-

rents of children

of 1-4y

Variation and regularity to

maintain a healthy weight Low Low

Netherlands

Nutrition Centre

(2009)

healthy diet,

adults

10 victory tips to stay in

energy balance Low Low

Netherlands

Nutrition Centre

(2009)

healthy diet,

adults

The New Eating is eating

healthier little by little (good

for your health)

Low Low

Netherlands

Nutrition Centre

(2009)

healthy diet,

adults

Eat healthy! 1. Varied

2. Not too much 3. Less

saturated fat 4. Lots of

vegetables, fruit, and bread

5. Safe (to feel healthy)

Intermediate High

Netherlands

Nutrition Centre

(2006)

healthy diet,

adults

Balance day: prevent

overweight! Low High

Netherlands

Nutrition Centre

(2002)

healthy diet,

adults Don’t become fat! Low High

Netherlands

Nutrition Centre

(1999)

fruit and

vegetables,

adults

Actually, do I eat

enough fruit and

vegetables?

(preventing diseases)

Intermediate Low

Netherlands

Nutrition Centre

(1999)

fat, adults

Do I eat too much fat,

perhaps? (preventing

diseases)

Intermediate Low

MHS = Municipal Health Services; italic text = frame derived from sub-heading; underlined text = main message in sub-heading

24

Source Target behavior

and group

Gain frame:

attaining a desirable

outcome

Gain frame:

avoiding an

undesirable

outcome

Loss frame:

attaining an

undesirable

outcome

Loss frame:

avoiding a

desirable

outcome

Lexical

concreteness

Controlling

language

Netherlands

Nutrition Centre

(1999)

fibers, adults

Actually, do I eat enough

fibers? (improving digestive

tract)

Intermediate Low

Netherlands

Nutrition Centre

(1999)

snacks, adults

Actually, do I eat

healthy? (preventing

diseases)

Low Low

Netherlands

Nutrition Centre

(1999)

hot meals, adults

Actually, do I eat

healthy? (preventing

diseases)

Low Low

Netherlands

Nutrition Centre

(1999)

fruit and

vegetables,

adults

Eat more: Every day 200

grams vegetables and two

times fruit (for more energy)

High –

amount High

Dutch Heart

Foundation

healthy lifestyle,

adults

Live pleasant and

healthy! A healthy

lifestyle helps preven-

ting cardiovascular

heart diseases

Low High

Dutch Cancer

Society

healthy diet,

adults

Eating healthy,

decreased chance of

cancer

Low Low

Foundation of

Idealistic

Commercials

(SIRE) (2004)

healthy diet,

parents of

children 4-12y

Don’t take overweight

too lightly - Say “no”

more often (with

picture of overweight

child)

High* –

consequence High

MHS = Municipal Health Services; italic text = frame derived from sub-heading; underlined text = main message in sub-heading; *Although not meeting the

criteria, still qualified as high, since a clear eating-related behavioral message is conveyed; for all criteria, see Methods-section

25

Appendix II – List of the included slogans in Dutch

Source Slogan in English Slogan in Dutch

GGD Amsterdam Too much fat causes overweight! Teveel vet veroorzaakt overgewicht!

GGD Amsterdam Healthy eating results in a healthy weight! Gezond eten resulteert in een gezond gewicht!

GGD Brabant Zuidoost Breakfast... take the time! With tips for a good start of the day. Ontbijt… neem de tijd!

GGD Brabant Zuidoost Lunch… you can go at it again! With tips for tasty and healthy

lunching.

Lunch… en je kunt er weer tegenaan!

GGD Brabant Zuidoost Well… he has to grow from it Ach, hij moet er nog van groeien

GGD Rivierenland A healthy diet… moves you! Gezonde voeding… zet je in beweging!

GGD IJsselland Snacks in between? Not more than four times a day! Even tussendoor? Niet vaker dan vier keer op een dag!

GGD Zeeland Healthy eating? It’s your decision! Gezond eten? Dat moet je zelf weten!

GGD Zuid-Holland West Make time for a breakfast Maak tijd voor een ontbijt

Hulpverlening Gelderland

Midden Having and maintaining a healthy body

Een gezond lichaam hebben en houden!

Voedingscentrum Variation and regularity to maintain a healthy weight Variatie en regelmaat. Dan blijft zijn gewicht goed.

Voedingscentrum 10 victory tips to stay in energy balance 10 overwinningstips om in energiebalans te blijven

Voedingscentrum The New Eating is eating healthier little by little Het Nieuwe Eten is stap voor stap gezonder gaan eten

Voedingscentrum Eat healthy! 1. Varied 2. Not too much 3. Less saturated fat

4. Lots of vegetables, fruit, and bread 5. Safe

Eet gezond! 1. Eet gevarieerd 2. Niet teveel 3. Minder

Verzadigd vet 4. Veel groente, fruit en brood 5.Veilig

Voedingscentrum Don’t become fat! Maak je niet dik!

Voedingscentrum Balance day: prevent overweight! Balansdag. Voorkom overgewicht!

Voedingscentrum Actually, do I eat enough fruit and vegetables? Eet ik eigenlijk wel genoeg groenten en fruit?

Voedingscentrum Do I eat too much fat, perhaps? Eet ik misschien toch te veel vet?

Voedingscentrum Actually, do I eat enough fibers? Eet ik eigenlijk wel genoeg vezels?

Voedingscentrum Actually, do I eat healthy? (snacks) Eet ik eigenlijk wel gezond? (tussendoortjes)

Voedingscentrum Actually, do I eat healthy? (hot meals) Eet ik eigenlijk wel gezond? (warme maaltijden)

Voedingscentrum Eat more: Every day 200 grams vegetables and two times fruit Eet meer: Elke dag 2 ons groenten en 2 keer fruit

Nederlandse Hartstichting Live pleasant and healthy! A healthy lifestyle helps preventing

cardiovascular heart diseases

Leef prettig en gezond! Een gezonde leefstijl helpt hart- en

vaatziekten voorkomen

KWF Kankerfonds Eating healthy, decreased chance of cancer Gezond eten, minder kans op kanker

SIRE Don’t take overweight too lightly - Say “no” more often Denk niet te licht over overgewicht – Zeg vaker nee