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Sabri Ülker Food Research FoundationNutrition and Healthy Lifestyles 2017 Summit Proceedings

May 4, 2017, Istanbul, TurkeyThe Effects of Eating Behavior on Health

Volumes 55-56 • Supplement • October 2018 • ISSN 0899–9007

The International Journal of Applied and Basic Nutritional Sciences

nut_51_C_F300_1_0002_00000_Cover_2_Nutrit.indd 1 5/17/2018 11:10:31 AMProcess CyanProcess MagentaProcess YellowProcess Black

Founder and Emeritus Editor in Chief: Michael M. Meguid, MD, PhD

Editor in ChiefAlessandro Laviano, MD Italy

Deputy Editor in ChiefM. Isabel T.D. Correia, MD, PhD Brazil

Managing EditorDawn L. Jensen-Nobile, BA, NTP USA

Associate EditorsNutrition & PreventionJames DiNicolantonio, PharmD USA

Gastroenterology & Intestinal FailureLoris Pironi, MD Italy

Internal Medicine & GeriatricsLubos Sobotka, MD, PhD Czech Republic

Case ReportsMartin Crook, MBBS UK

Lipid Metabolism and Dyslipidemia Jacqueline Alvarez Leite, MD, PhD Brazil

Metabolism in Intensive CareWilliam Manzanares, MD, PhD Uruguay

MicronutrientsJan Frank, PhD Germany

Nutrition and FoodMichael Glade, PhD USA

Nutritional Status AssessmentJanicke Visser, M.Nutr South Africa

Obesity and Bariatric SurgeryChih-Yen Chen, MD, PhD Taiwan

OncologyIoannis Gioulbasanis, MD Greece

Parenteral Nutrition & EatingDisorders Lidia Santarpia, MD, PhD Italy

PharmacyRoland Dickerson, PharmD USA

Review and Meta-AnalysisUndurti Das, MD, FAMS USA

Sports NutritionMotoyuki Iemitsu, PhD Japan

SurgeryArved Weimann, MD Germany

Editors EmeritusAntonio Campos, MD, PhD Ibolya Nyulasi, MSc, MDAA Harumasa Ohyanagi, MD, PhD Alan Shenkin, PhD, FRCPath Tsann-Long Hwang, MD Demetre Labadarios, PhD, MBChB Alessandro Laviano, MD, PhD Peter Little, MD, PhD Marietjie Herselman, PhD Hans Biesalski, MD, PhD

Associate SocietiesCzech Society of Parenteral and Enteral NutritionVladimir Palicka, MD, PhD

Japan Society for Parenteral and Enteral NutritionHarumasa Ohyanagi, MD, PhD

Croatian Society of Clini-cal NutritionZeljko Krznaric, MD, PhD

Italian Society of Artificial Nutrition and Metabolism (SINPE) Luca Gianotti, MD, ScD

World Wide Web Address: http://www.nutritionjrnl.com

About the Cover Artwork

Nutrition is of vital concern to everyone. This is the silent caption to the illustration of our planet on the cover. The globe serves to remind us of human vulnerability and interdependency. Nutrition is a peer-reviewed journal that publishes original research in basic nutritional science and its clinical applications. Its variety of articles provides a multi-disciplinary

framework valuable internationally to both practitioners and researchers exploring the key role of nutrition in disease management.

It is our hope that the image of our planet will serve as a reminder that our scientific progress will mold the future of our home-planet earth, in vital and perhaps unimagined ways.

Editorial Advisory Board
Mahinda Abeywardena, PhDAdeladie, BC, Australia
Kasim Abdulkerim Baltaci, PhDKonya, Turkey

Lawrence H. Bernstein, MDChicopee, MA, USA

Hans Biesalski, MD, PhDStuttgart, Germany

Frederico Bozzetti, MDPrato, Italy

Riccardo CaccialanzaPavia, Italy

Philip C. Calder, MD, PhDSouthampton, England

Tommy Cederholm, MD, PhDUppsala, Sweden

Wei-Jao Chen, MD, DMScTaipei, Taiwan

Evan Paul Cherniack, MDMiami, FL, USA

Salvatore Chirumbolo, PhDVerona, Italy

Agata Chmurzynska, PhDPoznan, Poland

Yunhi Cho, PhDGyeonggi-do, Korea

Mark Daniel DeBoer, MD, MSc, MCRCharlottesville, VA, USA

Yalin Dikmen, PhDIstanbul, Turkey

Marinos Elia, MDSouthampton, England

Frida Fåk, PhDLund, Sweden

Sergueï O. Fetissov, MD, PhDRouen, France

Peter Gibson, MDBox Hill, Australia

Martin Gotteland, PhDSantiago, Chile

Tilman Grune, PhDNuthetal, Germany

Per-Olaf Hasselgren, MD, PhDBoston, MA, USA

Venkatesh L. Hegde, PhDColumbia, SC, USA

Sandra Hirsch, MD, MScSantiago, Chile

Akio Inui, MD, PhDKagoshima, Japan

Keiji Iriyama, MDKuwana, Japan

Khursheed N. Jeejeebhoy, MD, PhDToronto, ON, Canada

Zhu-Ming Jiang, MDBeijing, China

Haruki Koike, MD, PhDNagoya, Japan

Regina Komsa-Penkova, MDPleven, Bulgaria

Irina Korichneva, PhDNew Brunswick, NJ, USA

Zeljko Krznaric, MD, PhDZagreb, Croatia

Peter Little, BPharmD, PhDVictoria, Australia

Henry Lukaski, PhDGrand Forks, ND, USA

Alessio Molfino, MD, PhDRome, Italy

Timothy Moran, PhDBaltimore, MD, USA

M. Muntzer Mughal, MB, ChB, FRCS, ChMLondon, England

Sergiy M. Nadtochiy, PhDRochester, NY, USA

Yutaka Nakaya, MD, PhDTokushima, Japan

Etsuo Niki, PhDTokyo, Japan

Donatus Nohr, PhDHohenheim, Germany

Allal Ouhtit, PhD, MPhAl-Khod, Oman

Vladimir Pali�cka, PhD, MUDrPrague, Czech Republic

Marek Pertkiewicz, MD, PhDWarsaw, Poland

Claude Pichard, MD, PhDGeneva, Switzerland

Lindsay Plank, PhDAuckland, New Zealand

Ryszard Pluta, MD, PhDWarsaw, Poland

Sunil Rangarajan, MD, PhDBirmingham, AL, USA

Filippo Rossi-Fanelli, MDRome, Italy

Stéphane Schneider, MD, PhD, FEBGHNice, France

Pierre Singer, MDTel Aviv, Israel

Noel Solomons, MDGuatemala City, Guatemala

Krishnan Sriram, MD, FRCS, FACSChicago, IL, USA

Luzia Valentini, PhDBerlin, Germany

Nguyen Van Nhien, MD, PhDHanoi, Vietnam

Arved Weimann, MD, MA, PhDLeipzig, Germany

Xiaodong Zhou, MD, PhDLoma Linda, CA, USA

Thomas Ziegler, MDAtlanta, GA, USA

Nutrition is abstracted in Index Medicus/MEDLINE, Current Contents/Life Science Citation Index,Automatic Subject Citation Alert, CAB Abstracts, SCISEARCH, CINAHI, EMBASE/Excerpta Medica,Food, Science and Technology Abstracts, and “Referatinyi Zhurnal”.Publication information: Nutrition (ISSN: 0899-9007) is published 10 times a year by ElsevierInc., 230 Park Avenue, Suite 800, New York, NY 10169.USA POSTMASTER: Send address changes to Nutrition, Elsevier Customer Service Department,3251 Riverport Lane, Maryland Heights, MO 63043, USA.Annual subscription rates: United States and possessions: individual, $425. All other countries:individual, $481.Orders, claims, and journal inquiries: Please contact the Elsevier Customer Service Depart-ment nearest you: St. Louis: Elsevier Customer Service Department, 3251 Riverport Lane, Mary-land Heights, MO 63043, USA; phone: (800) 654-2452 [toll free within the USA]; (+1) (314)447-8871 [outside the USA]; fax: (+1) (314) 447-8029; e-mail: [email protected]: Elsevier Customer Service Department, The Boulevard, Langford Lane, Kidlington,Oxford OX5 1GB, UK; phone: (+44) (1865) 843434; fax: (+44) (1865) 843970; e-mail: [email protected]: Elsevier Customer Service Department, 4F Higashi-Azabu, 1-Chome Bldg, 1-9-15Higashi-Azabu, Minato-ku, Tokyo 106-0044, Japan; phone: (+81) (3) 55615037; fax: (+81) (3)55615047; e-mail: [email protected]: Elsevier Customer Service Department, 3 Killiney Road, #08-01 Winsland House I,Singapore 239519; phone: (+65) 63490222; fax: (+65) 67331510; e-mail: [email protected] information: Advertising orders and enquiries can be sent to: USA, Canadaand South America: John Marmero, Jr., Advertising Sales Department, Elsevier Inc., 230Park Avenue, Suite 800, New York, NY 10169, USA; phone: (+1) (212) 633-3657; fax: (+1)(212) 633-3820; e-mail: [email protected] (usage and editing services): Please write your text in good English (American orBritish usage is accepted, but not a mixture of these). Authors who feel their English languagemanuscript may require editing to eliminate possible grammatical or spelling errors and to con-form to correct scientific English may wish to use the English Language Editing service availablefrom Elsevier’s WebShop http://webshop.elsevier.com/languageediting/ or visit our customersupport site http://service.elsevier.com for more information.Reprints: To order 100 or more reprints for educational, commercial, or promotional use, con-tact the Commercial Reprints Department, Elsevier Inc., 230 Park Avenue, Suite 800, New York,NY 10169; E-mail: [email protected] information: For a full and complete Guide for Authors, please go to: www.elsevier.com/wps/locate/issn/0899-9007.Author inquiries: You can track your submitted article at http://www.elsevier.com/tracksub-mission. You can track your accepted article at http://www.elsevier.com/trackarticle. You arealso welcome to contact Customer Support via http://service.elsevier.com.

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Volumes 55�56 October 2018 Supplement Number S

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S1Halit Tanju Besler and Mehmet Uyar

Why aren't we making progress in promoting healthy lifestyles? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S2James O. Hill, Ph.D.

Drivers of food choice: A cognitive structure approach to the determinants of food choice and implications foraffecting behavior change. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S4Klaus G. Grunert

The chemical senses and nutrition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S6Richard D. Mattes, M.P.H., Ph.D., R.D.

Gastrophysics: The lens of psychological and sensory research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .S8Charles Spence

Food habits and cancer prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S11Omer Kucuk, M.D.

Ethical issues in health communication: Health-related news sourcing practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S14Bulent Capli, Sule Karatas Ozaydin and Serife Ozturk

Today's food landscape: Not a pretty picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S16Sylvia B. Rowe

Implementation of a “balanced nutrition education program” among primary school children in turkey . . . . . . . . . . . . . . . . S18Halit Tanju Besler, Reci Meseri, Özge Küçükerdönmez, et al.

The balanced nutrition test: An online dietary assessment tool adapted from the self check program foruse in turkey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S22Burcu Aksoy, Deniz Miray Arca and Halit Tanju Besler

INTRODUCTION

D1X XProf. Halit Tanju Besler D2X X, Guest Editor 1, D3X XProf. Mehmet UyarD4X X, Guest Editor 2

1 Eastern Mediterranean University, Faculty of Health Sciences, Department of Nutrition and Dietetics, Famagusta, North Cyprus2 Ege University Hospital, Department of Anesthesiology and Intensive Care, _Izmir, Turkey

Eating habits are linked to patterns of behavior, which differacross countries, cultures, ethnic and religious groups. Our eatinghabits also change over time and across generations.

Considerable learning about food and eating behaviors takesplace during the transition from exclusive breastfeeding to the dietestablished in the early stages of childhood. Food preferences arealso developed at this early age. At this point parents can influencechildren’s food preferences for certain tastes. This can lead to bal-anced eating behaviors or unhealthy habits such as compulsiveovereating and dysfunctional eating. In an obesogenic environmentthese may result in obesity and the health challenges associatedwith it.

At a later age, cognition plays a prominent role in food choices.However, possible predictors such as consumer behaviors havebeen shown not to be good indicators of diet quality. In addition,consumer demand is becoming more fragmented. The most signifi-cant factors influencing food choice include consumer trust, conve-nience, nutritional quality, and cost. The role of cognitive factorssuch as psychology should also be taken into consideration as wellas the cultural factors listed above.

The Sabri €Ulker Foundation organizes a Nutrition and HealthyLifestyles Summit biennially in May, bringing together colleaguesfrom academia, industry, government and the media as well ashealthcare professionals and key opinion leaders. The Foundation’s4th Nutrition and Healthy Lifestyles Summit focused on the factorsinfluencing eating behavior. “The Effects of Eating Behavior onHealth” was the main theme of the 2017 Summit, building on theoutcomes of previous summits on “New Approaches to Optimal

Nutrition,” “Understanding the Psychology of Food Intake and theImpact of Physical Activity on Health,” and “The Past, Present andFuture of Nutrition.”

These proceedings document the key points of the 2017 Sum-mit. The respective roles of cognition, environment, and parentalintervention on eating behavior are discussed. Areas where evi-dence is lacking are also highlighted, suggesting targets for futureresearch. It is hoped that the data summarized in this supplementalissue will help provide an update as to our current understandingabout nutrition and healthy lifestyles, inspiring future initiatives inthis important area.

Acknowledgement

These proceedings were supported by the speakers of 4th Nutri-tion and Healthy Lifestyle Summit, held May 4, 2017 in Istanbul,Turkey with the theme “The Effects of Eating Behavior on Health”and hosted by Sabri €Ulker Food Research Foundation. We thankthe speakers James O. Hill, Klaus G. Grunert, Richard D. Mattes,Charles Spence, Omer Kucuk, Bulent Capli, and Sylvia B. Rowe, whoprovided insights and expertise that greatly contributed to the pro-ceedings. Appreciation should also be expressed in this regard tothe Sabri €Ulker Food Research Foundation Scientific Board.

We would like to express our gratitude to Prof. Julian Stowellfor such comments and wisdom as greatly improved the manu-script, and also to, last but not least, guest editors Professors Halit,Tanju Besler, and Mehmet Uyar, and Editor in Chief Professor Ales-sandro Laviano, for their careful reading and suggestions.

https://doi.org/10.1016/j.nut.2018.07.0090899-9007/© 2018 Elsevier Inc. All rights reserved.

Nutrition 55�56 (2018) S1

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WHY AREN’T WEMAKING PROGRESS IN PROMOTING HEALTHYLIFESTYLES?

Prof. D1X XJames O. Hill D2X XPh.D.University of Colorado, Denver, Colorado, USA

Obesity is considered to be one of the most prevalent non-communicable chronic diseases that manifests as a symptom ofand a marker for unhealthy lifestyles including physical inactiv-ity, poor diets, ineffective sleep and ineffective stress manage-ment [1-3].

In recent years, obesity has become a truly global epidemicthat affects over 1.9 billion people worldwide along with anincreasing trend in prevalence in many countries in nearly allcontinents [2-5].

Maintenance of energy balance has been postulated to be bet-ter in individuals with a high rate of energy flow through thebody (i.e., high intake matched by high expenditure) than inthose with a low rate of energy expenditure [6]. A low energyflux refers to an unregulated zone with poor match betweenenergy intake and expenditure and thus higher likelihood of apositive energy balance [7,8].

For most of mankind's history, the primary challenge to thephysiological system for body weight control has been to obtainsufficient energy intake to prevent negative energy balance andbody energy loss. However, within the current environment, whereminimal physical activity is needed for daily life and the food iswidely available and high in energy density, the challenge to thecontrol system becomes to increase physical activity sufficiently toprevent positive energy balance. Accordingly, the prevailing condi-tions in the modern environment constitute a constant backgroundpressure that promotes weight gain and a transition in bodyweight control from an instinctual (unconscious) process to theone that requires substantial cognitive effort. Hence, the globalobesity epidemic is considered to be driven in large part by a mis-match between our environment and metabolism with limitedability to maintain healthy dietary and physical activity patternsunder conditions that discourages physical activity and encouragesexcessive energy intake [9-11].

To date, existing policies and interventions have not reversedthese trends, suggesting that new innovative approaches areneeded to transform obesity prevention and control [12,13]. Onthe basis of its global scope, heterogeneous patterns, wide-rang-ing impacts, lack of a single cause, and the failure of single solu-tions; the obesity epidemic is considered to be a systemsproblem, as opposed to a simple problem with linear cause-and-effect relationships [13-15]. Therefore, implementation of a sys-tems approach is suggested to address obesity that involves

multiple contributory factors acting at different levels, includinggenetics, biology (physiologic processes such as leptin sensitivityand individual metabolism), individual behaviors (dietary andphysical activity choices), social network dynamics (connectionsto family and friends, individual behaviors), the environment(food availability, green spaces for physical activity, and neigh-borhood safety) and the larger societal forces (economics, policy,education, health awareness, and culture) [13] (Fig. 1).

Looking at reducing obesity through the lens of the energy bal-ance framework provides the opportunity to recommend specificstrategies to reduce obesity. These include: increasing physicalactivity levels in populations to get more people in the regulatedzone of energy balance, maximizing the intrinsic biological mecha-nisms for managing energy balance and focusing on promotingsmarter eating without dramatic food restriction [16]. We arebiased toward energy conservation and predisposed to acquiremore energy and to not expending physical or cognitive energywithout a good reason [11]. Therefore, in our current environment,maintaining a healthy body weight for most people requires usingconscious effort and cognitive skills to help match energy intakewith energy expenditure and to overcome biological and environ-mental pressures to overeat and under exercise [16].

This emphasizes the need for focusing our efforts on providingthe knowledge, cognitive skills and incentives for controlling bodyweight and at the same time begin creating a supportive environ-ment to allow better management of body weight [11].

For weight loss, we provide specific recommendations forbehavior change (i.e. changing diet and physical activity). In thisregard, we have focused on the WHAT to do and less on the scienceof behavior change (HOW) and motivation (WHY). Our work sug-gests that combining the WHAT, HOW and WHY is necessary tocreate transformation in the person, which can support the newbehaviors and a new way of life at all levels (Fig. 2).

The WHY is particularly important. People have not been givena good enough reason for behavior change that is salient in thepresent moment on a day to day basis. The social and economicframework in most countries has not incorporated the real value ofgood health and disease prevention into the paradigm. Health maynot provide a compelling enough “WHY” and we should strive toidentify other sources of motivation, including social justice, globalcompetitiveness, academic and work productivity/performance,national security and climate change.


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In conclusion, to reverse obesity we need to think about theproblem in a new way including to identify a compelling WHY thatcan drive a cause, to work with the biology, to align individual and

collective purpose and to align behavioral purpose and motiva-tional context [11]. To really lower obesity rates, we need innova-tive thinking, recognition that both food and physical activity areimportant, and open minds about how to engage all of society inmaking changes [17].

References

[1] Murray CJL, Lopez AD. Measuring the global burden of disease. N Engl J Med2013;369:448–57.

[2] Kelly T, Yang W, Chen CS, et al. Global burden of obesity in 2005 and projec-tions to 2030. Int J Obes 2008;32:1431–7.

[3] World Health Organization. Media Centre: Obesity and Overweight. http://www.who.int/mediacentre/factsheets/fs311/en/; 2015 Accessed Sep 15, 2017.

[4] Finucane MM, Stevens GA, Cowan MJ, et al. National, regional, and globaltrends in body-mass index since 1980: systematic analysis of health examina-tion surveys and epidemiological studies with 960 country-years and 9.1 mil-lion participants. Lancet 2011;377:557–67.

[5] Shook RP, Blair SN, Duperly J, et al. What is causing the worldwide rise in bodyweight? US Endocrinol 2014;10:44–52.

[6] Mayer J, Roy P, Mitra KP. Relation between caloric intake, body weight, andphysical work: studies in an industrial male population in West Bengal. Am JClin Nutr 1956;4:169–75.

[7] Blundell JE. Physical activity and appetite control: can we close the energygap? Nutr Bull 2011;36:356–66.

[8] Blair SN, Hand GA, Hill JO. Energy balance: a crucial issue for exercise andsports medicine. Br J Sports Med 2015;49:970–1.

[9] Hill JO. Can a small-changes approach help address the obesity epidemic? Areport of the Joint Task Force of the American Society for Nutrition, Institute ofFood Technologists, and International Food Information Council. Am J ClinNutr 2009;89:477–84.

[10] Ford ES, Dietz WH. Trends in energy intake among adults in the United States:findings from NHANES. Am J Clin Nutr 2013;97:848–53.

[11] Peters JC, Wyatt HR, Donahoo WT, Hill JO. From instinct to intellect: the chal-lenge of maintaining healthy weight in the modern world. Obes Rev2002;3:69–74. Review.

[12] Roberto CA, Swinburn BA, Hawkes C, et al. Patchy progress on obesity preven-tion: emerging examples, entrenched barriers, and new thinking. Lancet2015;385:2400–9.

[13] Lee BY, Bartsch SM, Mui Y, Haidari LA, Spiker ML, Gittelsohn J. A systemsapproach to obesity. Nutr Rev 2017;75(suppl 1):94–106. Review.

[14] Bures RM, Mabry PL, Orleans CT, et al. Systems science: a tool for understand-ing obesity. Am J Public Health 2014;104:1156.

[15] Gortmaker SL, Swinburn BA, Levy D, et al. Changing the future of obesity: sci-ence, policy, and action. Lancet 2011;378:838–47.

[16] Hill JO, Wyatt HR, Peters JC. Energy balance and obesity. Circulation2012;126:126–32.

[17] Hill JO, Peters JC, Blair SN. Reducing obesity will require involvement of all sec-tors of society. Obesity (Silver Spring) 2015;23:255.

Fig. 1. Energy balance system

Fig. 2. Critical role of mindset and motivation in long-term success of solid nutritionand activity plans and behavioral transformation

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DRIVERS OF FOOD CHOICE: A COGNITIVE STRUCTURE APPROACH TO THEDETERMINANTS OF FOOD CHOICE AND IMPLICATIONS FOR AFFECTINGBEHAVIOR CHANGE

D1X XProf. Klaus G. Grunert D2X XMAPP Centre, Aarhus University, Denmark

Three factors are considered of critical importance in changingconsumer behaviors towards healthier choices: providing healthieralternatives to the consumer by introducing healthier reformula-tions of existing products, providing people with more knowledgeon the intricate relationship between food and health and themotivation of the consumer to make healthier choices. Ultimately,for a behavioral change to occur, all three factors need to be pres-ent. People can be very well informed about the consequences oftheir choices, but if they are not motivated to make healthychoices, this information will have no effect. Therefore, the firststep is to understand how consumers’ knowledge and motivationdrive their choices among the available choice options.

Means-end-chain theory is an approach based on personalconstruct psychology. It looks at the mental links that people con-struct between the attributes of the product they buy and whatthey think are the consequences for themselves. This is a mentalchain in which somebody links the attributes of a product todirect consequences for him- or herself. The basic idea is thatexploring the way in which people combine product knowledgeand self-knowledge may lead to an understanding of the driversand motives of the choices that they make. According to means-end-chain theory, a person buys a food product not because of itscharacteristics as such, but because of the consequences the per-son believes these characteristics will have for him-/herself, andwhat these consequences will mean for the attainment of his/herlife values [1-3] (Fig. 1).

The link between product-related knowledge (easy to change)and self-related knowledge (difficult to change) provides the moti-vation for choice. Consumer perception and choice of food productscan be analyzed through the pathway from the individual percep-tion of food product attributes to self-relevant consequences andlife values. From a behavior change perspective, this cognitivestructure approach to the determinants of food choice providesimportant insights regarding the basic motivational structure gov-erning food choice (stable over time, not subject to short-termchanges) and the consumer knowledge about product attributesand their consequences (amenable to change by information andproduct experience). This perspective therefore allows a realisticassessment of the potential for behavioral change, whether it is

based on providing information, new choice alternatives, or onchanges in the choice environment [1,2].

Employing the means-end-chain approach, we have investi-gated drivers of food choice for 6 product categories (breakfastcereals, ready meals, yoghurt, sweet snacks, biscuits, cold drinks)in five European countries (UK, Italy, Poland, France and Turkey)using the laddering technique in semi-structured in-depth inter-views. The laddering method led to a mapping of linkages betweenproduct attributes, self-relevant consequences and values throughhierarchical value maps (Fig. 2).

Our findings revealed that for breakfast cereals the two themeswere reasonably balanced in terms of health and enjoyment. Biscuitswere mainly related to enjoyment and indulgence, yoghurt wasmainly a health-related product and sweet snacks were mainlyabout indulgence, while ready meals were about convenience andcold drinks were mainly about enjoyment. Health and enjoymentemerged as the two dominant themes in food choice across all thecountries investigated in our study. Enjoyment and indulgence were

Fig. 1. The means-end-chain theory.


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related to attributes like happiness, comfort, relaxation, wellness andwell-being, while the health aspect was related to subjective theoriesof health (i.e. feeling at ease, more relaxed and more comfortable).

Our findings revealed that health and indulgence emerge as themain drivers of food choice, while considerable differences werenoted in the drivers of choice both across product categories andacross countries. In the UK, the health aspects of food products aremore dominant than in other countries, whereas in the Frenchdata enjoyment was a much bigger theme when it comes to talkingabout food. In Italy, the importance of brands was considered,whereas in Poland, the theme was food being viewed as somethingthat supports your ability to perform, function and achieve resultsin your work life. What was really special about the Turkish resultscompared to the other countries in the study was the complexityof food-related knowledge, with more attributes and more relevantconsequences, ultimately creating a more complex pattern linkingconsequences and values in the food choices which may be related

to a high degree of involvement with food [1] as well as being aless individualistic country leading to more holistic thinking, moreprocessing of context, and a more complex perception of causality[3] (Fig. 3).

In conclusion, understanding main drivers of food choice canfacilitate promotion of healthier choices through well-communi-cated product reformulation and product development. We cansupplement these approaches through non-informational, non-product-related initiatives like nudging.

References

[1] Walker BA, Olson JC. Means-End Chains: Connecting Products With Self. J Busi-ness Res 1991;22:111–8.

[2] Grunert KG. Means-end chains-a means to which end? Marketing JRM2010;1:41–9.

[3] K€uhnen U, Hannover B, Schubert B. The semantic-procedural interface model ofthe self: the role of self-knowledge for context-dependent versus context-inde-pendent modes of thinking. J Pers Soc Psychol 2001;80:397–409.

Fig. 2. Laddering method and hierarchical value maps.

Fig. 3. Major country differences in drivers of food choice.

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THE CHEMICAL SENSES AND NUTRITION

D1X XProf. Richard D. Mattes D2X XMPH, PhD, RDPurdue University, West Lafayette, IN, USA

The chemical senses are comprised of the senses of taste, smelland chemical irritation. They are often referred to as the minorsenses though considerable evidence documents their vital roles inhuman health, reproduction and the quality of life. In addition tobeing the primary driver of food choice, the chemical senses alsoserve as signaling systems that modulate appetite, digestion,metabolism, energy balance and body weight [1,2].

There has been considerable research attempting to link sen-sory responses to specific nutrients and health outcomes (e.g., salttaste and hypertension, sweet taste and diabetes, fat taste and obe-sity, bitter taste and thyroid disease, sour taste and renal dysfunc-tion), but this has been largely “unsuccessful,” due, in part, to thefact that a particular flavor principle is only one facet of the totalityof the meaning of a particular food. Additionally, there are a num-ber of steps in the pathway between sensory responsiveness andultimate behavior. The Thresholds (the lowest concentration of astimulus that can be detected or recognized), intensity and quality(descriptive stimulus attributes of sensation) are just the substratesupon which hedonic judgements are made. Hedonics then providesinput that allows decisions regarding type, quantity and brand of“food,” leading to performance of a behavior (consume or reject)and then ultimately determines the total energy consumption andbody composition. Moreover, each of these steps is modified byepigenetics, culture, social context, recent diet, and lifestyle (Fig. 1).

The health effects of sweetness and fattiness are examples ofareas with a good deal of misinformation. The common hypothesisstates that, in the case of sweetness/fattiness, there is somethingabout the sensation of sweetness/fattiness, sweeteners/fatty acids,or the palatability of these compounds that promotes excess con-sumption leading to a positive energy balance, weight gain and theonset and complications of various chronic disorders (e.g., dentalcaries, obesity, diabetes, cardiovascular disease, fatty liver, etc.).However, the overwhelming preponderance of evidence does notsupport a role for sweetness, sweeteners, or palatability as triggersfor excess consumption and people with obesity do not differ intheir sensory worlds with respect to these chemosensory sensa-tions. Meta-analyses have consistently shown that the use of low-calorie sweeteners is associated with lower BMI and when they aresubstituted for other energy sources in the diet, they can maintainthe palatability of the diet and thus result in lesser total energyintake and BMI reduction.

A similar evidence base exists for fat taste. A recent meta-analy-sis revealed no significant association between fat taste thresholds

and BMI. An analysis of taste intensity ratings of edible taste stripsimpregnated with varying concentrations (%v/v) of linoleic acid(LA) by 735 visitors to the Denver Museum of Nature & Science,noted that children rated all concentrations as more intense thanadults, while women and girls rated the highest concentration asmore intense than men and boys. However, percent body fat wasnot correlated with fat taste intensity ratings. Factors other thansimple adiposity status influence fat taste intensity ratings [2].

Additionally, there is a similar growth of palatability with con-centration in normal-weight individuals and those with obesity.Moreover, there is higher intra-group than inter-group variability(i.e. more diversity within normal weight or individuals with obe-sity than the diversity between the two) in responses to fat. Itshould also be noted that dietary fats are consumed primarily inthe form of triacylglycerol which provides an appetitive signal. Incontrast, most evidence indicates humans can only “taste” non-esterified fatty acids and these molecules are typically aversive tohumans. Consequently, in humans, fat taste likely functions as awarning system to discourage fat ingestion.

Recent advances in research methodologies (e.g., neural imag-ing, assessment of the gut microbiome) have raised new questionsabout potential adverse physiological effects of selected sensorystimuli. In accordance with concerns about global obesity trends,hypotheses have been suggested that sensory-active compoundsin the food supply may stimulate brain reward systems leading toaddictive behaviors and alter the gut microbiome to enhance theefficiency of energy extraction from food, both leading to positiveenergy balance.

Study of appetite, feeding and energy balance has transitionedover time. During the 1960’s and 1970’s, metabolic signaling theo-ries (such as glucostatic, aminostatic, and lipostatic theories) pre-dominated. With their weak predictive power for feeding anddiscovery of gut peptides (e.g., CCK, GLP-1 and PYY) associatedwith appetitive sensations, attention turned to gut-endocrinesystems during the 1980s to 2010s. While illuminating, findingsfrom this work also did not reveal clear endocrine-based interven-tions to manage body weight. Thus, this too gave way to the pres-ent focus on brain reward systems as drivers of over-consumptionof foods.

A current popular view holds that there is a dual system com-posed of a homeostatically controlled appetitive center in thehypothalamus and various non-homeostatically controlled rewardcenters in the brain. However, this view of competing control


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centers may not faithfully characterize the system since both ofthese centers are activated by the same exogenous factors, areresponsive to the same endocrine signaling molecules and thereare extensive neural connections between the two centers. As aresult, an integrated modulation of eating behavior rather than acontrol through a dual system seems more likely.

Advances in understanding of processes occurring in the GItract have spawned interest in how nutrient signaling influencesgut peptide secretion and glucose transport. Though effects havebeen documented in cell culture and animal models, these havenot consistently translated to humans trials. For example, low calo-rie sweeteners have been associated with all possible variations ofglucose, GLP-1 and insulin responses (i.e., no response or eleva-tions). Thus, no compelling link between low calorie sweetener useand these outcomes is presently supported by the data. Similarly,based on animal models, there is considerable interest in how thecolonic microbiota may influence glucose and insulin tolerance as

well as energy harvesting for the host. Again, in humans the effectsare not robust.

We have the opportunity to manipulate ingestive behavior toimprove health but we have to do it based on science rather thanon passion and on false assumptions. We have to be critical whenwe read the literature and design good quality science if we are tomove forward.

References

[1] Rogers PJ, Hogenkamp PS, de Graaf C, et al. Does low-energy sweetener con-sumption affect energy intake and body weight? A systematic review, includingmeta-analyses, of the evidence from human and animal studies. Int J Obes(Lond) 2016;40:381–94.

[2] Tucker RM, Nuessle TM, Garneau NL, Smutzer G, Mattes RD. No difference inperceived {ntensity of linoleic acid in the oral cavity between obese and nonob-ese individuals. Chem Senses 2015;40:557–63.

Fig. 1. Complex pathway between sensory responsiveness and ultimate behavior.

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http://refhub.elsevier.com/S0899-9007(18)30707-X/sbref0001








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GASTROPHYSICS: THE LENS OF PSYCHOLOGICAL AND SENSORY RESEARCH

D1X XProf. Charles Spence D2X XCrossmodal Research Laboratory, Department of Experimental Psychology, University of Oxford

The perfect meal may be something as simple as a picnic in asummer meadow or a once in a lifetime trip to one of the world’stop Michelin-starred restaurants. But a great eating experiencedepends on not just the food but far more on ‘the everything else’that surrounds the meal such as the mood we are in through to thecompany we keep, the environment and the plating, plateware,and cutlery [1-4].

The emerging body of research from the new field of gastrophy-sics (gastro from gastronomy and physics from psychophysics) ishelping to isolate just how important these various factors are toour perception and enjoyment of food [3]. The pleasures of thetable reside far more in the mind than we realize and perhaps evenmore in the mind than in the mouth. Gastrophysics is the new areaof research that takes us away from three decades of the moleculargastronomy approach (science in the kitchen) to the neglected areaof mental processes regarding the perception and enjoyment offood (scientific study of dining).

Hence, the role of the senses is considered of critical impor-tance in gastrophysics, including the appearance of food, thesound of food, forgotten flavor senses, the smell, the taste, thetouch, the texture as well as all the other oral and sensory inputsthat surround the food. Some of the most exciting recent exam-ples of the dynamic interplay between chefs, designers, and sen-sory scientists give rise to exciting new immersive, experientialand most definitely multisensory, dining experiences includinghow taste is influenced by sight, sound, and touch.

The recent interest in trying to understand eating experiencesthrough the lens of psychological and sensory research is increas-ingly highlighting the fact that the pleasure and enjoyment of fooddoes not depend solely on the edible elements laid out on the plate.Our food experiences are multisensory and integrated at percep-tual and semantic levels [5-10]. Therefore, the atmosphere or theenvironment in which the food is consumed, the visual and struc-tural arrangement of the elements on the plate, the weight of uten-sils that we use to eat with, the color and material of the cutlerysignificantly affect the diner’s perception of a dish including theperceived taste and flavor of the food [5-10].

For instance, in one study conducted in a realistic dining envi-ronment, two groups of diners were served the same three-coursemeal while the presentation of the starter (centred vs. offset plat-ing), the type of cutlery (light vs. heavy), and the shape and colourof the plate on which that dessert was served were varied [5]. The


results revealed that the diners’ appreciation of the food wasaffected by the presentation of the starter (centred vs. offset plat-ing), the weight and type of the cutlery used to eat, the shape andcolour of the plate in terms of liking, aesthetic value and willing-ness to pay for the food, thus supporting a growing body of gastro-physics research highlighting the importance of a host of food-extrinsic factors in modulating the diner’s opinion of the meal thatthey have been served [5] (Fig. 1).

In another study, we assessed whether placing the culinaryelements of a dish in an art-inspired manner would modify thediners’ expectations and hence their experience of food usingthree different presentations of the dish [6]. One was simplyplated (with all of the elements of the salad tossed together),another with the elements arranged to look like one of Kandin-sky’s paintings, and a third arrangement in which the elementswere organized in a neat (but non-artistic) manner [6]. TheKandinsky-inspired plating was rated more artistic, more com-plex, and more liked and people were willing to pay more forbefore consumption, while higher tastiness ratings after con-sumption. These results support the idea that presenting food inan aesthetically pleasing manner can enhance the experience ofa dish, and the use of artistic (visual) influences can enhancediner’s expectations and subsequent experience of a dish [6](Fig. 2).

In the hospital sector, data from Salisbury district hospital in theSouth of England showed that plate color really matters to patientswith simply changing the colour from white to a high-contrastblue or red resulting in a 30% increase in consumption, which issomething of the utmost importance, as it may help to reduce thelength of stay for these patients.

In addition, renaming the “Patagonian tooth fish” on themenu as “Chilean Sea Bass” led to an increase in sales ofmore than 1200% in North America, the UK, Australasia, andbeyond. Furthermore, given the predominant role of olfactionin what we think we taste, designing cans, bottles and lidsdifferently seems important to enhance the ability to orthona-sally sniff the aroma. In terms of the use of technology atthe table, the idea of sonic seasoning is a really exciting areabuilding on the documented existence of crossmodal corre-spondences between, for instance, sweet tastes and high-pitched sounds and between bitter tastes and low-pitchedsounds as well as other crossmodal correspondences between








Fig 1. Factors affecting diners’ appreciation of the food

Fig 2. The impact of placing the culinary elements of a dish in an art-inspired manner on the diner’s expectations and experience of food

C. Spence / Nutrition 55�56 (2018) S8�S10 S9

various parameters of musical composition and specific taste/flavor attributes [11-14].

In conclusion, gastrophysics represents an exciting new area ofscience where the focus shifts from the food to the mind of thediner who is consuming that food (and drink). The search for theperfect meal can lead to interventions that may potentially help totackle the growing obesity crisis, and may also provide someintriguing ideas about how to get us all to shift to a rather moresustainable diet in the decades ahead [15].

References

[1] Fisher MFK. The pale yellow glove. C. The taste culture reader: Experiencingfood and drink Korsmeyer. Oxford: Berg.; 2005. p. 325–9.

[2] Spence C. Multisensory flavour perception. Cell 2015;161:24–35.[3] Spence C. Gastrophysics: The new science of eating. London, UK: Penguin; 2017.[4] Spence C, Piqueras-Fiszman B. The perfect meal: The multisensory science of

food and dining. Oxford, UK: Wiley-Blackwell; 2014.[5] Michel C, Velasco C, Spence C. Cutlery matters: Heavy cutlery enhances diners’

enjoyment of the food served in a realistic dining environment. Flavour2015;4:26.










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[6] Michel C, Velasco C, Gatti E, Spence C. A taste of Kandinsky: assessing the influ-ence of the artistic visual presentation of food on the dining experience. Fla-vour 2014;3:11.

[7] Zellner DA, Loss CR, Zearfoss J, Remolina S. It tastes as good as it looks! Theeffect of food presentation on liking for the flavor of food. Appetite2014;77C:31–5.

[8] Harrar V, Spence C. The taste of cutlery: how the taste of food is affected by theweight, size, shape, and colour of the cutlery used to eat it. Flavour 2013;2:13.

[9] Spence C, Wan X, Woods A, Velasco C, Deng J, Youssef J, et al. On tasty coloursand colourful tastes? Assessing, explaining, and utilizing crossmodal corre-spondences between colours and basic tastes. Flavour 2015;4:23.

[10] Okajima K, Spence C. Effects of visual texture on taste perception. i-Perception2011;2:966.

[11] Crisinel AS, Spence C. As bitter as a trombone: Synesthetic correspondences innon-synesthetes between tastes and flavors and musical instruments andnotes. Attention, Perception, and Psychophysics 2010;72:1994–2002.

[12] Mesz B, Trevisan M, Sigman M. The taste of music. Perception 2011;40:209–19.[13] Spence C, Shankar MU. The influence of auditory cues on the perception of,

and responses to, food and drink. Journal of Sensory Studies 2010;25:406–30.[14] Crisinel AS, Cosser S, King S, Jones R, Petrie J, Spence C. A bittersweet sym-

phony: Systematically modulating the taste of food by changing the sonicproperties of the soundtrack playing in the background. Food Quality and Pref-erence 2012;24:201–4.

[15] Ayaz A, Inan-Eroglu E, Cetin C, Samur G. Impact of three different plate colourson short-term satiety and energy intake: A randomized controlled trial. Nutri-tion Journal 2018;17:46.



























FOOD HABITS AND CANCER PREVENTION

D1X XOmer Kucuk D2X XMDProfessor of Hematology, Medical Oncology and Urology, Director of Integrative Medicine Center, Emory University, Atlanta, Georgia, USA

Physical activity, healthy nutrition and lack of stress are thethree most important components of health. Inadequate levels ofphysical activity, obesity, unhealthy diet and chronic stress (e.g.tobacco, excessive alcohol and other harmful physical, chemical,biological, psychological and social stress) can induce an unhealthyand unhappy life that leads to chronic diseases such as hyperten-sion, diabetes and cardiovascular disease, cancer and Alzheimer’sand to premature death. The mechanisms are generally thought toinvolve increased oxidative stress, inflammation, epigeneticchanges and metabolic changes.

Recently, integrative medicine has become a very importantarea of medicine, which focuses on the entire patient, theirfamily and environment and healthy lifestyle rather than on adiagnosis and treatment of a particular disease. Integrativemedicine targets healthy lifestyle focusing on physical activity,diet (vegetables, fruit), botanicals (lycopene, genistein) andother natural compounds, mind-body approaches, stress reduc-tion (meditation, yoga), sleep hygiene (stress, BMI), acupunc-ture (pain control) and other methods such as massage, music,and thermal spa.

The US National Centre for Complementary and IntegrativeHealth (NCCIH)’s programs and organization incorporate threelong-range goals that are to advance the science and practice ofsymptom management, to develop effective, practical, personal-ized strategies for promoting health and well-being and to enablebetter evidence-based decision making regarding complementaryand integrative health approaches and their integration into healthcare and health promotion. NCCIH supports research that looksinto healthy lifestyles and other complementary and integrativeapproaches, while publishes guidelines for physical activity, exer-cise and botanicals.

Food habits are also very important in cancer risk as dietaryfactors are responsible for a third of all cancers [1-5]. A diet richin sugar and saturated fat as well as processed meat products isconsidered to be a cancer promoting diet. To the contrary, adiet rich in vegetables and fruit is generally associated withreduction in the risk of many types of cancer [6,7] (Table 1).Mediterranean diet (lots of vegetables, fruit, fish, olives andolive oil, nuts, seeds, herbs, spices and whole grain foods) hasconsistently been shown to be beneficial in preventing

cardiovascular disease as well as cancer, while not just diet buthigh levels of physical activity, social activity, mindfulness,love and compassion among the Mediterranean populationseem also play a role in this benefit. Thus, integrative medicineis part of the Mediterranean lifestyle.

While epidemiological studies indicate association of theconsumption of vegetable and fruit with decreased risk formany types of cancer, data from well-designed, cohort or inter-ventional studies failed to demonstrate the impact of reducedfat intake on postmenopausal breast cancer risk as well as noassociation between colon cancer and the consumption of fruitand vegetables in men and women [8-13]. However, while nosignificant decrease in the cancer risk a difference in cardiovas-cular risk was noted with a prudent diet that involved eatingmore vegetables and less fat [14] (Fig. 1). Therefore, we need tocarry out better designed and better controlled studies withdifferent end points. Notably, increased body mass index andobesity and lack of regular physical activity have been associ-ated with increased cancer risk for most cancers [15].

Population studies have shown that high intake of dietarylycopene is inversely associated with the incidence of certaintypes of cancers, including those of the digestive tract, prostate,and cervix [1,16]. Epidemiological studies show an inverseassociation between dietary soy consumption and the risk ofprostate, breast, and endometrial cancers [1]. Genistein is themost active and abundant isoflavone in soybeans with activityagainst a variety of cancer cells as associated with anti-oxidant,anti-inflammatory, anti-viral and anti-bacterial activities,induction of DNA demethylation and histone acetylation andinhibition of nuclear factor kappa-B, receptor activator ofnuclear factor kappa-B ligand, vascular endothelial growth fac-tor, matrix metalloprotease and epithelial mesenchymal transi-tion, enhanced chemo/radiotherapy, reduced toxicities ofchemo/radiotherapy and immune function potentiation as wellas enhancing effects on exercise mimetics and exercise endur-ance [17-20].

In conclusion, modification of food habits may prevent manycancers and result in a healthier population and significant savingsin healthcare expenditures.


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Table 1Proportion of cancer deaths attributed to various different factors [6] and role of certain foods in cancer risk reduction [7]

Percent of all cancer deaths

Factor or class of factors Best estimate Range of acceptable estimates

Tobacco 30 25-40Alcohol 3 2-4Diet 35 10-70Food Additives <1 -5 -2Reproductive & sexual behavior 7 1-13Occupation 4 2-8Pollution 2 <1-5Industrial products <1 <1-2Medicine & medicinal procedures 1 0.5-3Geophysical factors 3 2-4

Decrease in cancer risk*

Cancer type Vegetables Fruits Carotenoids Vitamin C

Mouth & pharynx 3 3 1Larynx 2 2Oesophagus 3 3 1 1Lung 3 3 2 1Stomach 3 3 1 2Pancreas 2 2 1Liver 1Colon, rectum 3 1Breast 2 2 1Ovary 1 1Endometrium 1 1Cervix 1 1 1 1Prostate 1Thyroid 1 1Kidney 1Bladder 2 2

*3=Decreases risk convincing, 2=Decreases risk probable, 1=Decreases risk possible

Fig 1. Fruit and vegetable consumption and the risk of cancer and cardiovascular disease.

S12 O. Kucuk / Nutrition 55�56 (2018) S11�S13

References

[1] Gullett NP, Ruhul Amin AR, Bayraktar S, et al. Cancer prevention with naturalcompounds. Semin Oncol 2010;37:258–81.

[2] Terry P, Hu FB, Hansen H, Wolk A. Prospective study of major dietary patternsand colorectal cancer risk in women. Am J Epidemiol 2001;154:1143–9.

[3] Van Duyn MA, Pivonka E. Overview of the health benefits of fruit and vegeta-ble consumption for the dietetics professional: selected literature. J Am DietAssoc 2000;100:1511–21.

[4] Steinmetz KA, Potter JD. Vegetables, fruit, and cancer prevention: a review. JAm Diet Assoc 1996;96:1027–39.

[5] Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin2008;58:71–96.

[6] Doll R, Peto R. The causes of cancer: quantitative estimates of avoidable risks ofcancer in the United States today. J Natl Cancer Inst 1981;66:1191–308.

[7] Glade MJ. Food, nutrition, and the prevention of cancer: a global perspective.American Institute for Cancer Research/World Cancer Research Fund, Ameri-can Institute for Cancer Research, 1997. Nutrition 1999;15:523–6.

[8] Colditz GA, Philpott SE, Hankinson SE. The Impact of the Nurses’ Health Studyon Population Health: Prevention, Translation, and Control. Am J Public Health2016;106:1540–5.

[9] Colditz GA, Hankinson SE. The Nurses’ Health Study: lifestyle and healthamong women. Nat Rev Cancer 2005;5:388–96.

[10] Belanger CF, Hennekens CH, Rosner B, Speizer FE. The nurses’ health study. AmJ Nurs 1978;78:1039–40.

[11] Giovannucci E, Ascherio A, Rimm EB, Colditz GA, Stampfer MJ, Willett WC.Physical activity, obesity, and risk for colon cancer and adenoma in men. AnnIntern Med 1995;122:327–34.

[12] Prentice RL. Research opportunities and needs in the study of dietary modifi-cation and cancer risk reduction: the role of biomarkers. J Nutr 2006;136.2668S-70S.

[13] Michels KB, Edward Giovannucci, Joshipura KJ, et al. Prospective study of fruitand vegetable consumption and incidence of colon and rectal cancers. J NatlCancer Inst 2000;92:1740–52.

[14] Hung HC, Joshipura KJ, Jiang R, et al. Fruit and vegetable intake and risk ofmajor chronic disease. J Natl Cancer Inst 2004;96:1577–84.

[15] Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, andmortality from cancer in a prospectively studied cohort of U.S. adults. N Engl JMed 2003;348:1625–38.

[16] Giovannucci E. Tomatoes, tomato-based products, lycopene, and cancer:review of the epidemiologic literature. J Natl Cancer Inst 1999;91:317–31.

[17] Kritz-Silverstein D, Von M€uhlen D, Barrett-Connor E, Bressel MA. Isoflavonesand cognitive function in older women: the SOy and Postmenopausal HealthIn Aging (SOPHIA) Study. Menopause 2003;10:196–202.

[18] Atteritano M, Marini H, Minutoli L, et al. Effects of the phytoestrogen genisteinon some predictors of cardiovascular risk in osteopenic, postmenopausalwomen: a two-year randomized, double-blind, placebo-controlled study. JClin Endocrinol Metab 2007;92:3068–75.

[19] Phillip CJ, Giardina CK, Bilir B, Cutler DJ, Lai YH, Kucuk O, Moreno CS. Genisteincooperates with the histone deacetylase inhibitor vorinostat to induce celldeath in prostate cancer cells. BMC Cancer 2012;12:145.

[20] Atmaca A, Kleerekoper M, Bayraktar M, Kucuk O. Soy isoflavones in themanagement of postmenopausal osteoporosis. Menopause 2008;15(4 Pt1):748–57.

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ETHICAL ISSUES IN HEALTH COMMUNICATION: HEALTH-RELATED NEWSSOURCING PRACTICES

Dr. Bulent Capli Prof. a, Sule Karatas Ozaydin b, Serife Ozturk c

a Bilkent University, TurkeybHacettepe University, Turkeyc Ankara University, Turkey

The field of health science communication (HSC) has multiplestakeholders including researchers, scientific societies and organi-zations, government agencies, universities, news and media organ-izations and public information officers [1,2]. The optimization ofHSC between researchers and the public is crucial in terms of itsimpact on governmental decision-making, health policies, healthpromotion, disease prevention and self-care [1,3]. Health commu-nication should adhere to the principles of beneficence, non-malef-icence, respect for personal autonomy, and justice [4].

The process of conveying scientific information through themedia has been linked to a “communications chain” which has thescientist and the journalist at the ends and in between is severalkey players such as editors, public relations and public affairs pro-fessionals, special-interest groups, and representatives of the food,pharmaceutical, or supplement industries [5,6]. Media misinforma-tion is considered to be driven by several factors, such as anunqualified spokesperson, a lack of context, or an inexperiencedreporter. It can also be biased to sell products or services, to dis-credit other sources or products, or to promote a particular agenda[5�7].

The Internet provides an easy vehicle for the transmission ofmisinformation. Consumers who seek health information throughan online search may get millions of results which are unfiltered orunrated in terms of the quality of the source [6�9].

The disparity between information and misinformation resultsin part from the conflicting goals, perspectives, biases, and agendasof the involved parties [8,9]. The media strives for scares, scandals,conflicts, and sensational headlines which are considered to bemore exciting, compelling, and profitable to report than substanti-ated science by the media, while industry-sponsored informationmay be scientifically accurate but present only one perspective[7,9].

In this regard, sourcing of the news is important as it helps thenews consumer to determine the credibility of the informationprovided. It is expected that news people should give as much con-text and detail as possible about sources (the number, transpar-ency, credibility and variety), whether named or anonymous, toverify information provided. The number of sources cited in the

story reflects the reliability of the stories. A story which does nothave many sources could be under reported and single source sto-ries are often not reliable. Transparency of sourcing helps the con-sumer to determine whether it is fact based reporting or rumorpresented as news. Hence, it is important that the reporter tellswhere the information comes from and the report makes clearwhat the sources of the information are.

Authority and credibility of the sources (being in a position tocomment on the subject, knowing the subject well, motives ofsources, and trust of reader) can be tough to judge for an outsider.Variety of sources is more than numbers; multiple sources helpreports make sure that they get things right and provide differentangles. Using a variety of sources and perspectives helps reportersprovide information that is accurate and fair.

When it comes to the health-related news, the sourcing issuebecomes much more critical, as generally people rely on news toobtain information. The media offer many powerful channels forcommunicating health information to the public. Consumers rankmagazines, newspapers, television, and the Internet among theirtop sources of health information. The general public is not welleducated about science or the scientific process. Therefore it isessential to analyze how the sourcing is presented in the news. Sci-entists are among the most qualified and credible sources of com-ment about nutrition research, but they have slipped from the topspot on reporters’ speed dials. Reporters usually are under tremen-dous time pressure to “get the story” and meet their deadlines.

In order to understand the sourcing practices of health-related news in Turkish internet news media, a total of 285health-related news items which had appeared in three mostpopular internet news websites, in the period between 8th and17th August 2017, were selected and analyzed. The focus of thestudy was to find out the number, variety and transparency ofthe sources used in the news and to see whether different anglesand perspectives are provided in the news. According to the find-ings, the type of news included slider galleries with images orphotographs (59.4%) and text based stories (40.6%). Whilst only5.3% of stories listed an author, the source of the information wasprovided in 59.6% of the articles (sources named in 10.2%, multi-source in 10.5%), while different perspectives and angles wereprovided only in 2.0% of news (Table 1).E-mail address: [email protected] (D.B. Capli).


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mailto:[email protected]







As the findings illustrated in Table 1, the sources of the health-related news have been mainly based on anonymous sources whichmeans the credibility of sources is controversial. Besides, thisresearch covering the analyses of 285 health- related news from thewebsites of three mainstream media of Turkey reveals discreditedsources account for 40.4% range. In other words, approximately halfof this health- related news was written without referencing anyhealth- related scientific study or source.

In another study regarding exploratory analysis of authorshipand information sourcing for health news on local TV websites inUS, authors noted that regarding the authorship of the (health)articles, 23.7% listed no author, while 76.3% of the stories listed anauthor, 23.7% of the news were attributed to multiple sources and61.9% attributed to single source with no attribution in 14.4% ofnews [10]. On comparing the US case to the Turkish one in the con-text of health- related news’ sourcing practices, it is found out thatthe use of single source in health news is common and widespread.

This practice discourages readers and/or viewers in conducting fur-ther investigations for validating the authenticity of the news.

In conclusion, the media is the consumers’ main source ofhealth information. News consumers should be more critical aboutthe sources of the news. Some stories included no attribution (i.e.,in-text reference of where the health information originated orwas first published) or direct quotes from health sources. From ajournalistic perspective, it is troubling to find stories that lackedany type of attribution because, ethically and legally, attributinginformation to a source contributes to the separation of fact fromopinion and allows a reader to understand from where, or fromwhom, the information originates. From a health communicationstandpoint, stories lacking attribution may leave a health consumerwondering where to turn for additional information.

References

[1] Fontaine G, Lavall�ee A, Maheu-Cadotte MA, Bouix-Picasso J, Bourbonnais A.Health science communication strategies used by researchers with the publicin the digital and social media ecosystem: a systematic scoping review proto-col. BMJ Open 2018;8:e019833.

[2] Marcinkowski F, Kohring M. The changing rationale of science communica-tion: a challenge to scientific autonomy. JCOM 2014;13:C04.

[3] Meisel ZF, Gollust SE, Grande D. Translating research for health policydecisions: is it time for researchers to join social media? Acad Med 2016;91:1341–3.

[4] Strasser T, Gallagher J. The ethics of health communication. World HealthForum 1994;15:175–7.

[5] Rowe S. Communicating science-based food and nutrition information. J AmDiet Assoc 2001;101:1145–6.

[6] Miller GD, Cohen NL, Fulgoni VL, Heymsfield SB, Wellman NS. From nutritionscientist to nutrition communicator: why you should take the leap. Am J ClinNutr 2006;83:1272–5.

[7] Quagliani D, Hermann M. Practice Paper of the Academy of Nutrition and Die-tetics: Communicating Accurate Food and Nutrition Information. J Academy ofNutrition and Dietetics 2012;112:759.

[8] Fern�andez-Celemin L, Jung A. What should be the role of the media in nutri-tion communication? Br J Nutr 2006;96(Suppl 1):S86–8.

[9] Goldberg JP, Sliwa SA. Communicating actionable nutrition messages: chal-lenges and opportunities. Proc Nutr Soc 2011;70:26–37.

[10] Tanner A. Friedman DB Authorship and information sourcing for health newson local TV web sites: An exploratory analysis. Science Communication2011;33:3–27.

Table 1Characteristics of health-related news in Turkish internet news media (n=285)

Type of news %Slider galleries with images or photographs 59.4Text based stories 40.6The authorship of the news %Stories listed an author 5.3Stories listed no author 94.7The source of the information %Provided total 59.6

sources named 10.2anonymous sources 49.4single source stories 49.1multi source stories 10.5national sources 31.9international sources 15.8Mixed sources 3.2

Not provided 40.4Different perspectives and angles %Provided 2.0Not provided 98.0

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TODAY’S FOOD LANDSCAPE: NOT A PRETTY PICTURE

D1X XProf. Sylvia B. Rowe D2X XPresident of S.R. Strategy, the USA

Food has emerged globally in the last decade as a very hot topicfor the media, government, opinion leaders and the public. This isdriven in large part both by heightened interest in health and well-ness and by concerns about obesity and chronic disease. A conver-gence of issues around food and food systems lead to a complexand challenging environment.

Trust and transparency are fundamental to today’s dialogue.According to the 2016 Edelman Public Relations Trust Barometer,for the first time in thirty years of research, a decline in trust wasfound in all four of our major institutions at the NGOs, industry,government and the media (Fig. 1) [1].

We have two escalating realities - changing science andchanging communications. While science and research still driveboth media and policy, science today requires consideration ofpractice-based evidence as well as evidence-based practice dueto multi-factorial issues like obesity and climate change. Thesecomplex issues necessitate a transdisciplinary or multidisciplin-ary approach. Also, currently there is a very quick transitionfrom science to communications to policy. This sits alongside afundamental tension between the scientific community lookingfor consensus and journalists looking for conflict. There is a dif-ference in perspective amongst the different stakeholders. Scien-tists are driven by the discovery, journalists by the story, andpolicy makers by the decision. All are considering the sameinformation [2]. Further tension is anticipated based on the cur-rent status of media coverage. We are in a rapidly changing envi-ronment with increasing background noise. The intersection of anearly instantaneous accessibility of information (as well as mis-and dis-information) and a global, 24-hour news cycle has cre-ated an attention-deficit-disordered news consumer, whospends his/her day ‘multi-tasking,’ by checking e-mail, Web surf-ing, texting, twittering, blogging, and engaging in mobile phoneconversations while attending meetings, meals, parties, etc.

The public dialogue includes a consideration of food as fuel,medicine, ethics/values and risk. During the last ten year period wehave moved further towards looking at the whole food system inthe broadest context rather than at individual foods or nutrients. Aglobal convergence is emerging in the dialogue around many ofthese issues (Fig. 2).

In terms of food as fuel, there is a focus on oils and sugars forrenewable energy and the competition that this will then havewith food. There is much promising research underway in thefield of food as medicine. One example is our increasing

knowledge of the role of the microbiome in health and disease.The really intriguing concept of personalized nutrition hasattracted considerable attention recently and there are manyother things on the list. Ethical considerations around food havebecome prominent during the last decade. These include consid-eration of sustainability. Whole foods, clean foods, animal wel-fare and social justice. Food as risk is an aspect that we readmuch about in the media. Many nutrition issues today areviewed through the eyes of obesity. Food insecurity and foodsafety issues are still very much on the agenda. The link betweenadded sugars in the diet and chronic disease remains a hot topicand the move towards more and more processed and ultra-proc-essed food is the subject of intense debate. It can be said thatobesity changed everything. This will attract more and moreattention as the true cost of obesity and chronic disease becomesbetter understood. According to recent McKinsey research, obe-sity and chronic disease have overtaken tobacco and violence interms of healthcare cost and loss of GDP on a global basis. Manyof us live in a culture of overconsumption with negative effectson people, pets and the environment. In response, the concept of‘one health’ is now emerging. This encompasses a healthy envi-ronment, the health of animals and the health of people. Manyglobal activities and national initiatives reflect the ‘one health’concept.

A widespread assumption within the scientific community hasbeen that if science communication were only done “better”, peo-ple would make choices more consistent with the scientific evi-dence. However, this widely held, simple model of what peopleneed from science communication (known as the deficit model) iswrong. Although people may indeed need more information or tohave information presented more clearly, a focus on knowledgealone often is not sufficient for achieving communication goals.People rarely make decisions based only on science. They do, how-ever, process scientific information taking into account their owngoals and needs, knowledge and skills, values and beliefs. Whenscientific facts provoke fear or make people feel like they have nocontrol over a situation, it becomes essential to have genuine,respectful dialogues with people [3]. The US National Academies ofSciences, Engineering and Medicine published a report on Commu-nicating Science Effectively which highlights the need to develop aresearch agenda for science communication [4]. This acknowledgesthat society’s need for science communication has never beengreater. Effective science communication is aimed at helping


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people to understand the science and its relevance to a particulardecision. It should recognize that other factors will also affect theiractions. Examples of current contentious issues related to scienceinclude climate change, stem cells, nanotechnology, vaccines,hydraulic fracturing, nutrition, genetically modified organisms,nuclear energy, education policy and obesity [5].

In conclusion, the current extreme gap between knowledge andbehavior, means that the challenges of communication are becom-ing increasingly acute. Today we must become more sophisticatedwith regards to the narrative around science-related contentiousissues. We must also show empathy for the people that are receiv-ing the narrative and get a better understanding of what is reallygoing to make a positive difference in their lives.

References

[1] Edelman Trust Barometer 2017 Global Report. https://www.edelman.com/research/2017-trust-barometer-global-results

[2] Peters HP. Gap between science and media revisited: Scientists as public com-municators. Proc Natl Acad Sci U S A. 2013 Aug 20;110(Suppl 3):14102–9.

[3] Funk C, Rainie L. Introduction. Americans, Politics and Science Issues. PewResearch Center 2015. July 1 http://www.pewinternet.org/2015/07/01/intro-duction-23/.

[4] https://www.nap.edu/catalog/23674/communicating-science-effectively-a-research-agenda

[5] National Academies of Sciences, Engineering, and Medicine. Division of Behav-ioral and Social Sciences and Education. Committee on the Science of ScienceCommunication: A Research Agenda. Communicating Science Effectively. AResearch Agenda. Washington (DC): National Academies Press (US); 2017 Mar8. ISBN-13: 978-0-309-45102-4ISBN-10: 0-309-45102-7.

Fig. 1. Trust in institutions

Fig. 2. Food system - 2017 Global Convergence

P.S.B. Rowe / Nutrition 55�56 (2018) S16�S17 S17

https://www.edelman.com/research/2017-trust-barometer-global-results

https://www.edelman.com/research/2017-trust-barometer-global-results



http://www.pewinternet.org/2015/07/01/introduction-23/

http://www.pewinternet.org/2015/07/01/introduction-23/

https://www.nap.edu/catalog/23674/communicating-science-effectively-a-research-agenda

https://www.nap.edu/catalog/23674/communicating-science-effectively-a-research-agenda






IMPLEMENTATION OF A “BALANCED NUTRITION EDUCATION PROGRAM”

AMONG PRIMARY SCHOOL CHILDREN IN TURKEY

D1X XHalit Tanju Besler D2X X1, D3X XReci Meseri D4X X2, D5X X€Ozge K€uc€ukerd€onmez D6X X2, D7X XHabibe SahinD8X X3, D9X XBet€ul Cicek D10X X3, D11X XEsra G€unes D12X X4,D13X XSule Aktac D14X X4, D15X XBurcu Aksoy D16X X5, D17X XBeg€umMutus D18X X5

1 Eastern Mediterranean University, Faculty of Health Sciences, Department of Nutrition and Dietetics, Famagusta, North Cyprus.2 Ege University, Turkey3 Erciyes University, Turkey4Marmara University5 Sabri €Ulker Food Research Foundation, Turkey

Key nutritional concerns in Turkey include excessive salt con-sumption (14.5 grams per day in 2012 against a WHO recommen-dation of 5 g/d) [1,2], iodine deficiency (27.8% of the population in2009) [3], low fruit intake with only 53% of females and 51% ofmales consuming fruit on a daily basis, low vegetable consumptionwith only 63% of females and 60% of males consuming vegetableson a daily basis, [4], low iron status (anemia in 21% of female and19% of male school children in 1993) [5], and potential high energyintake (3500 Kcal/day available in the food chain against a require-ment of1800-2500 Kcal/d) [5]. Sugar(s) consumption is not consid-ered to be an issue at 35.4 g/d in 2014 compared to the WHOrecommendation of 25-50 g/d [5] (Fig. 1).

According to the Turkey Demographic and Health Survey of2013 (TDHS-2013) [6], by age five 10% of children (11% for malesand 8% for females) are stunted (short for their age), whereas wast-ing is a less serious problem with 2% of children (no gender differ-ence) being underweight for their age.

The Sabri €Ulker Food Research Foundation was established in2009 in Turkey with the objective of enhancing nutrition scienceand knowledge, with a special focus on the Turkish populationand regional neighbors. The Sabri €Ulker Food Research Founda-tion is a member of the European Nutrition Foundations Net-work and key areas of activities include to encourage healthyliving by promoting healthy eating and a balanced diet, to sup-port and encourage new research, education and other initia-tives in the field of food and nutrition and to present the publicwith useful information derived from a variety of reliable sour-ces, both nationally and internationally.

The Balanced Nutrition Education Program is a school-basednutritional intervention program developed under the directionof the Sabri €Ulker Food Research Foundation and the Ministry ofEducation in Turkey to promote a healthy lifestyle in primary

school children. The program has been implemented since 2011,so far involving 1.5 million children from 500 primary schoolsacross Turkey. Material from the British Nutrition Foundation(BNF) has been adapted for local use [7]. The main theme of theprogram is “You can eat anything - as long as you keep it bal-anced. All you have to do is learn how to achieve a balance”.Intended for children aged 7-9 years, the program focuses on thefood groups, ways to establish a balanced diet, and the benefitsof exercise, hygiene, and drinking water, being offered in weekly2 hour lessons for 38 weeks throughout the academic year atselected primary schools (Fig 2).

A preliminary questionnaire survey was conducted between2014 and 2015 among 618 primary school (2nd to 4th grade) stu-dents (52% females) at four provinces in Turkey, including Istanbul(n=190, 32%), Izmir (n=210, 33%) and Kayseri (n=218, 35%) to evalu-ate the impact of the ‘Balanced Nutrition Education Program’ onfood intake, anthropometrics and physical activity levels of pri-mary school children.

A food frequency questionnaire and 3-day dietary recall wereapplied before and after the program in order to examine theamount and frequency of food intake (dairy, meats and legumes,cereals, fruits and vegetables, fats, sugars and other foods) toestimate daily energy and nutrient intake. Weight and heightwere measured and weight according to age, height according toage and BMI according to age were estimated according to WHOstandards (http://www.who.int/childgrowth/standards/en/).The participants of the impact evaluation were given a physicalactivity questionnaire covered intensity, duration, and frequencyof physical activities. The physical activity levels (PAL) were cal-culated by dividing physical activity ratio (PAR; expressed as amultiple of basal metabolic rate as multiplied for each activityand the energy in calories spent) by duration of day in minutes(24 hour=1440 minutes). PAL values between 1.40-1.69 are clas-sified as sedentary or light activity lifestyle; 1.70-1.99 as activeor moderately active lifestyle; and 2.00-2.40 were classified asvigorous or vigorously active lifestyle. Data from questionnairesand daily forms were entered in BEBIS program (a program for

HTB conceived the original idea, designed and directed (with BM) the project. RM,€OK, HS, BC, EG, SA performed the data collection. RM and HTB analysed the data.RM, BA drafted the manuscript and designed the figures in consultation with HTB.All authors have evaluated and approved the final version submitted forpublication.


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http://www.who.int/childgrowth/standards/en/







energy and nutrient analysis of food and beverages based onUSDA database) and converted to Statistical Package forthe Social Sciences (SPSS) to be coded and analyzed.

The survey results revealed that the “Balanced Nutrition Educa-tion Program” was associated with a significant decrease in totalenergy (p<0.001), carbohydrate (p<0.001), fat (p=0.003 in males,

Fig 1. Overview of key nutritional parameters in Turkey

Fig 2. Operational Model of Balanced Nutrition Education Project

H.T. Besler et al. / Nutrition 55�56 (2018) S18�S21 S19

p=0.001 in females) and animal protein (p<0.001) intake and a sig-nificant increase in PAL (p<0.001) among all students, whereas sig-nificant decrease in age-based BMI values (p<0.001) was notedonly in females (Table 1, Fig. 3).

In a cross-sectional study of 2519 students, aged 13�14 years,from 79 schools in Spain, students were asked to report their foodintake and physical activity over one week through the CAL-TASplatform from Alicia Foundation [8]. Authors noted failure toadhere the recommendations provided by the Spanish Society ofCommunity Nutrition in adolescents in general, presence of over-weight or obesity in 20% of students and the higher likelihood of

poor eating habits and inactivity in those with higher body massindex [8]. Given the consideration of early adolescence to be associ-ated with acquiring more independence and making own foodchoices and thus as a critical period to determine the state of healthin the adult period [8], the positive impact of Balanced NutritionEducation Project on eating habits and the physical activity in Turk-ish in school children of 2nd to 4th grades seems notable to indicatethe likelihood of early adoption of healthy dietary habits and of acorrect physical activity before the critical adolescence period.

In conclusion, the Balanced Nutrition Education Project hasshown significant improvements in a range of parameters in school

Table 1Nutrient intake, anthropometric and physical activity data before and after implementation of the Balanced Nutrition Education Program

Males FemalesBefore BNEP After BNEP p value Before BNEP After BNEP p valueMean § SD Mean § SD Mean § SD Mean § SD

Nutrient intakeEnergy (kcal) 1928.22 § 542.2 1761.26 § 453.14 <0.001 1847.7 § 516.59 1706.5 § 457.56 <0.001Protein (g) 65.82 § 20.58 63.38 § 29.25 0.183 62.76 § 18.42 60.67 § 19.29 0.046Animal protein (g) 38.78 § 16.03 39.39 § 1.60 0.721 37.67 § 14.40 37.35 § 15.96 0.731Vegetable protein (g) 27.04 § 9.53 23.99 § 7.25 <0.001 25.09 § 8.50 23.32 § 7.59 <0.001Carbohydrate (g) 221.38 § 60.11 196.70 § 53.67 <0.001 208.51 § 63.38 187.15 § 55.18 <0.001Fat (g) 83.87 § 30.90 78.16 § 24.61 0.003 82.21 § 27.27 77.31 § 23.76 0.001Fibre (g) 20.53 § 7.45 17.12 § 5.93 <0.001 20.19 § 7.09 16.75 § 5.88 <0.001Protein (%E) 13.81 § 2.36 14.53 § 5.57 0.040 13.77 § 2.36 14.19 § 2.43 0.012Carbohydrate (%E) 46.38 § 5.76 44.75 § 5.80 <0.001 45.20 § 5.82 44.03 § 5.97 0.001Fat (%E) 38.49 § 5.40 39.70 § 5.65 0.002 39.78 § 5.25 40.65 § 5.39 0.013AnthropometricsWeight for age percentile 68.16 § 30.61 66.06 § 31.91 0.072 62.50 § 30.26 57.47 § 31.95 <0.001

z-score 0.90 § 1.42 0.74 § 1.42 0.001 0.50 § 1.16 0.29 § 1.17 <0.001Height for age percentile 58.98 § 31.34 53.84 § 31.46 <0.001 52.13 § 31.22 48.03 § 31.73 <0.001

z-score 0.39 § 1.25 0.18 § 1.21 <0.001 -0.10 § 4.09 -0.03 § 1.18 0.728BMI for age percentile 67.48 § 30.23 65.89 § 31.77 0.233 62.41 § 31.19 58.52 § 32.04 <0.001

z-score 0.81 § 1.40 0.71 § 1.45 0.091 0.55 § 1.25 0.36 § 1.27 <0.001Physical activity level* 1.83§0.21 1.88§0.19 <0.001 1.79§0.17 1.84§0.19 <0.001

BNEP: Balanced Nutrition Education Program*3-day average

Fig 3. Balanced Nutrition Education Project

S20 H.T. Besler et al. / Nutrition 55�56 (2018) S18�S21

children of 2nd to 4th grades. Preschoolers and primary school 1st

grade students have been included in an extension of the programfrom the 2016-2017 academic years onwards.

Overall, the Balanced Nutrition education project has helpedstudents to improve their dairy product and green vegetableintakes. It has also encouraged increases in physical activity andhas helped to regulate energy intake and expenditure. Futureobjectives include integrating the Balanced Nutrition Project intothe school curriculum throughout Turkey. In addition it is intendedto regularly measure students’ weights and heights, and monitortheir health status. Schools will be encouraged to provide nutri-tious food and allocate sufficient space for physical activity. Theprogram will continue to focus on managing sugar, salt and fatintake, and increasing fruit and vegetable intake, thus enhancingdietary fibre. A certified education program will also be developedfor teachers.

References

[1] Erdem Y, Arici M, Altun B. The relationship between hypertension and saltintake in Turkish population: SALTURK study. Blood Press 2010;19:313–8.

[2] Erdem Y, Akpolat T, Derici U, et al. Dietary Sources of High Sodium Intake inTurkey: SALTURK II. Nutrients 2017;9:933.

[3] Erdo�gan MF, A�gbaht K, Altunsu T, et al. Current iodine status in Turkey. J Endo-crinol Invest 2009;32:617–22.

[4] Health at aGlance: Europe, 2012OECD. http://dx.doi.org/10.1787/9789264183896-en[5] T€urk€oz€u D, Ayhan B, K€oksal E. The Nutrition Transition in Turkey: Trends in Energy

andMacronutrients Supply from 1961 to 2011. Gazi Med J 2017;28:283–8.[6] The 2013 Turkey Demographic and Health Survey (TDHS-2013). Hacettepe Uni-

versity Institute of Population Studies, Ankara, Turkey. http://www.hips.hacet-tepe.edu.tr/eng/TDHS_2013_main.report.pdf

[7] Weichselbaum E, Hooper B, Buttriss J, et al. Behaviour change initiatives to pro-mote a healthy diet and physical activity in European countries. Nutrition Bulle-tin 2013;38:85–99.

[8] Roura E, Mil�a-Villarroel R, Lucía Pareja S, Adot Caballero A. Assessment of EatingHabits and Physical Activity among Spanish Adolescents. The "CookingandActive Leisure" TAS Program. PLoS One 2016 Jul 27;11(7):e0159962.

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http://dx.doi.org/10.1787/9789264183896-en







http://www.hips.hacettepe.edu.tr/eng/TDHS_2013_main.report.pdf

http://www.hips.hacettepe.edu.tr/eng/TDHS_2013_main.report.pdf








THE BALANCED NUTRITION TEST: AN ONLINE DIETARY ASSESSMENT TOOLADAPTED FROM THE SELF CHECK PROGRAM FOR USE IN TURKEY

D1X XDr. Burcu Aksoy D2X X1, D3X XDeniz Miray Arca D4X X1, D5X XProf. Halit Tanju Besler D6X X2

1 Sabri €Ulker Food Research Foundation, Turkey2 Eastern Mediterranean University, Faculty of Health Sciences, Department of Nutrition and Dietetics, Famagusta, North Cyprus

Novel technologies to assess dietary intake are designed toaid consumers in measuring their individual dietary intakes.Assessing their eating habits and nutritional status in this waycan help researchers and policy makers to better elucidate howdiet influences public health and well-being. As a novel tool,The Self Check Program is a scientifically based online question-naire developed by the Institut f€ur Ernaehrung und Praeventionand Hohenheim University to assess nutritional status. It pro-vides insight regarding individual’s eating habits and uniquerequirements based on dietary consumption, food preferencesand lifestyle characteristics such as smoking and physical activ-ity status [1-3].

The Self Check Program [4] was adapted as the “BalancedNutrition Test” for use in Turkey in accordance with cuisine andnutrition habits specific to Turkey. This involved collaborationbetween the Hohenheim University Department of Nutritionand Biochemistry and the Science Committee of the Sabri €UlkerFood Research Foundation The first Turkish adaptation of theSelf Check Program was developed in 2011. Subsequently amore user friendly version was created in 2017 with the inclu-sion of traditional Turkish foods in the program and thisupdated version was named as the Balanced Nutrition Test.

The test includes items on demographic characteristics (age,gender, height, weight), the frequency of consumption of cer-tain foods (several times a day, 1 per day, 4-6 per week, 1-3 perweek, 1-3 per month, less than 1 per month, never) and certainbeverages (more than 4 glasses per day, 4 glasses per day, 3glasses per day, 2 glasses per day, 1 glass per day, less than 1glass per day, never), life style determinants including smokingstatus [non-smoker, former-smoker, active smoker (less than 20cigarettes per day, more than 20 cigarettes per day)] and physi-cal activity (none, 0.5-2 hours per week, 3-5 hour per week,more than 5hours per week) and generates a score and mes-sages regarding the present nutrition status and ways toimprove it. The program’s score assessment is based on theresults of many epidemiological studies (such as the INTER-HEART Study and the Framingham Study), current score systems(such as the PROCAM Score) and the studies of national and

international professional bodies. The final score ranges from 0(the worst possible outcome) to 100 (best possible outcome)with scores of �80 indicating a very good condition, scores of60-80 a relatively good condition, scores of 40-60 an averagecondition, scores of 20-40 a bad condition and scores <20 a verybad condition (Table 1).

A study was undertaken to assess the nutritional status ofparticipants who accessed the Sabri €Ulker Food Research Foun-dation website and completed the “Balanced Nutrition Test”online between January 2015 and December 2016. Data from1241 adults who completed the Balanced Nutrition Test withinthe study period were analyzed. Nutrition scores revealed anaverage condition in 54% of adults. Overall, 30% of adults werenoted to consume fresh fruits, only 10% to drink milk regularly,only 24% to consume raw or cooked vegetables once a day and17% to consume whole grains at least one time per day. Mostadults did not adhere to recommended intake of fish as 2 timesper week as well as to daily vegetable and fruit consumptionrecommendations. Overall, 54% of adults have physical activityless than 1 hour per week, while only 19% of participants wereactive more than 1-3 h per week (Table 2).

Table 1Balanced Nutrition Test Lifestyle Score Categories

Test score Condition Ways to improve

Score �80 Very good You probably already have a very goodlifestyle

Score 60<80 Relatively good You can optimize your diet with someminor changes

Score 40<60 Average For a healthy lifestyle you should changesome habits in your diet

Score 20<40 Bad For a healthy lifestyle you should consid-erably change your diet

Score <20 Very bad You should change your diet in order notto harm your health. A conversation withyour family doctor or nutrition expertswould be useful


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The Balanced Nutrition Test scores highlight the role that thisprogram plays in terms of providing an insight into consumer eat-ing habits and ways in which they could improve their health andnutritional status.

In conclusion, the Balanced Nutrition Test encourages consum-ers to be more aware of their eating habits and health status. Inthis way it is hoped that it will provide the necessary incentives toencourage positive behavior changes.

The Balanced Nutrition Test findings also support the need forimprovements in nutrition and health in Turkey.

References

[1] Cade JE. Measuring diet in the 21st century: use of new technologies. Proc NutrSoc 2016;15:1–7.

[2] Arens-Volland AG, Spassova L, Bohn T. Promising approaches of computer-sup-ported dietary assessment and management-Current research status and avail-able applications. Int J Med Inform 2015;84:997–1008.

[3] Illner AK, Freisling H, Boeing H, Huybrechts I, Crispim SP, Slimani N. Review andevaluation of innovative technologies for measuring diet in nutritional epidemi-ology. Int J Epidemiol 2012;41:1187–203.

[4] Bigit Hug. Validierung und Weiterentwicklung eines Kurzfragebogens zur Beur-teilung des Ern€ahrungsmusters

Table 2Balanced Nutrition Test Scores of Participants (n=1241)

Test score n(%)

>80: Very good condition 26(2.1)60-80: Relatively good condition 487(39.2)40-60: Average condition 670(54.0)20-40: Bad condition 58(4.7)<20: Very bad condition 0(0)Physical activity status %Less than 1 h per week 53.51-3 h per week 27.6More than 3 h per week 18.9

Type of food Frequency of consumption (%)Never < 1 times per month 4-6 times per week 1-3 times per week 1-3 times per day Once a day

Fruits 0.3 10.8 13.6 26.2 18.9 30.2Vegetables 0.2 6.2 21.5 27.3 21.1 23.6Milk 9.8 36.6 8.6 26.1 5.5 13.5Yogurt 1.0 10.2 22.4 28.2 13.9 24.3Egg 2.5 10.6 16.1 45.4 2.8 22.5Fish 3.8 59.1 0.9 34.4 0.7 1.0Meats 1.5 8.5 22.6 44.2 4.6 18.5Legumes 0.4 20.0 11.7 62.4 1.9 3.6Whole wheat bread 9.5 32.4 10.1 17.0 13.5 17.6

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