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N EW S A N D V I EW S

DOI: 10.1111/nbu.12005

Human food choice and nutritional interventions

P. M. Chadwick*, C. Crawford and L. Ly
*Department of Diabetes, Endocrinology and Metabolism, Royal Free Hampstead NHS Trust, London, UK; MEND Central Ltd, London, UK

Summary

When it comes to changing human dietary behaviour, it is increasingly recognised that knowledge is not enough. Nevertheless, the majority of nutritional interventions designed to improve dietary quality are educational in nature and are predicated on the assumption that eating behaviour is primarily the product of a conscious and rational decision-making processes. The study of human food choice challenges the adequacy of this assumption and questions the sufciency of knowledge-based interventions. The determinants of food choice are complex and are shaped by biological, developmental, social, cultural and economic forces. This article presents a selection of food choice research relevant to the development of healthy eating practices and illustrates how interventions based on psychological and social inuences could lead to improved outcomes.
Keywords: behaviour change, food choice, nutrition, nutritional intervention, psychology

The evolution of taste

The professional lives of nutritionists involved in promoting healthy eating or weight management would be much easier if their clients were to like the taste of nutrient-rich, low energy-dense foods. However, one of the most common self-reported barriers to adopting healthier eating practices is taste; most individuals prefer to eat food that is familiar to them and resist acquiring new taste preferences (Glanz et al. 1998). Used in this context, the term taste is usually a synonym for avour; a composite subjective experience derived from the balance of a foods ve basic taste properties (i.e. sweetness, saltiness, bitterness, sourness and umami), in addition to the multi-sensory aspects of

Correspondence: Dr Paul M. Chadwick, Consultant Clinical and Health Psychologist, Department of Diabetes, Endocrinology and Metabolism, Royal Free Hampstead NHS Trust, Pond Street, London NW3 2QG, UK. E-mail: paulmchadwick1@nhs.net

food, such as mouth feel, appearance and smell (Duffy & Bartoshuk 1996). So, if taste is such a signicant determinant of food choice perhaps theories and research into taste acquisition could help to shape interventions that are more effective at overcoming this important barrier to healthful choices. Human beings have an innate propensity to nd sweet tastes pleasurable and bitter tastes unpalatable (Steiner 1977; Cowart 1989). The liking for sweet taste is retained throughout life and is universal to all cultures (Pepino & Mennella 2005). Beyond this innate hedonic appeal, it seems that humans are also biologically disposed to acquire preferences for energy-dense foods (Kern et al. 1993) and it has been found that children tend to prefer fruits and vegetables that are most energydense (Gibson & Wardle 2003). Evolutionary theory suggests that such hardwired tendencies serve two protective functions: to discourage the ingestion of toxins, hence, the dislike of bitter and sour tastes, as well as to ensure sufcient energy is gained from the early diet to enable rapid growth. However, for the body to grow

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and develop a wider range of nutrients is needed than is generally available in energy-dense foods. This means that a secondary taste acquisition system is required to enable the child to learn from experience and allow for the shaping of taste preferences that are specic to the food culture in which they are born. Learned taste preferences may develop through indirect or direct exposure to the avours associated with different foods and greater exposure to a taste is associated with greater liking and subsequent acceptance. Exposure in this context refers to the mere experience of tasting a food regardless of how this was achieved. Infants get exposed indirectly to the avours of the maternal diet in utero via transmission through amniotic uid and this is continued postnatally via the transmission of avours of the maternal diet from breast milk (Mennella 1995). What a mother eats during the early stages of an infants life has the potential to inuence which foods are accepted in later infancy and early childhood (Cooke & Fildes 2011). Direct exposure to avour initially occurs during weaning and later from caregiver feeding practices. The types of food that a child is given will determine what tastes they are exposed to, while characteristics of the weaning or feeding situation, such as the frequency and regularity of exposure, will determine the degree to which they become familiar with new avours (Wardle et al. 2003; Cooke et al. 2007). It is thought that there is a critical period (between one and three years) in which direct exposure is most likely to lead to the acquisition of taste preferences (Skinner et al. 2002). Since the mother is usually the primary determinant of what foods and therefore tastes that children are exposed to, understanding the factors inuencing feeding behaviour is critical. It seems that some infants are exposed to an unhealthy diet from weaning and perhaps beforehand. Infants as young as seven months have been shown to have obesogenic eating patterns, characterised by high exposure to, and consumption of, energy-dense, nutrient-poor foods (Fox et al. 2004). Furthermore, what infants are exposed to is strongly associated with what their mothers are eating. Robinson et al. (2007) showed that women whose eating habits largely complied with dietary recommendations had infants with similarly healthy diets, while women whose diets were characterised by high intakes of chips, crisps and sweets, had infants whose diets were similarly high energy and nutrient poor. If the maternal diet is so strongly predictive of the types of foods and tastes an infant is presented with in the critical period, it follows that interventions that tackle mothers eating and feeding

habits will help children to develop taste preferences that support healthy eating in later life. While parents and caregivers have a direct inuence on the tastes that children are exposed to, it is also the case that young children regularly exercise a form of choice through food refusal and in doing so reciprocally shape caregivers feeding practices. Familiarity with a food is an important factor inuencing the willingness of a child to accept it, and most children experience a period of neophobia (i.e. avoidance of or refusal of new or unfamiliar foods) during the critical period for taste preference development (Cooke et al. 2007). How a parent responds to the challenge of neophobia can have a profound inuence on which tastes a child comes to nd acceptable. There are critical thresholds for exposure to a new food that determine whether a child will accept it. This exposure threshold varies with age; children up to two years require 5 to 10 exposures to accept a new food (Birch et al. 1987), while children aged 34 years require as many as 15 tastes (Sullivan & Birch 1990). Studies of parents feeding practices show that parents rarely respond to food refusal in a way that is likely to successfully resolve neophobic reactions. Although, tasting food directly is required for exposure to work, it is common for parents to merely offer new foods rather than having their children directly taste them (Sullivan & Birch 1990), often concluding that their child does not like a food after just two or fewer exposures rather than the requisite 5 to 15 (Skinner et al. 2002; Caruth et al. 2004; Cooke 2007). Thankfully, neophobia can usually be overcome with a mixture of exposure, patience and determination. Indeed, behavioural research has identied various strategies that can help to increase childrens familiarity with and acceptance of new foods, thus promoting a more varied and healthful diet. Having regular and repeated opportunity to taste new foods in a non-coercive atmosphere increases liking and intake (Pliner & Stallberg-White 2000; Galloway et al. 2006; Paul et al. 2009), while use of tangible, non-food rewards (e.g. stickers), social praise (Cooke et al. 2011; Corsini et al. 2011; Remmington et al. 2012) and pairing new foods with familiar tastes (Zellner et al. 1983) can also increase acceptance.

Implications of the taste preference literature

Taste is generally acknowledged as an important determinant of food choice across the lifespan (Vartanian et al. 2008) and the principle mechanism driving the development of taste preferences is exposure. Early intervention, both neonatally and postnatally, appears

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crucial. Interventions designed to increase the neonate and infants exposure to tastes associated with a healthy adult diet could set the scene for more successful dietary modications at later stages of development. Education about the importance of a varied diet, high in fruits and vegetables, would also benet from being augmented by behaviourally informed interventions that support parents to break the unhelpful cycle of neophobia and food refusal. As maternal diet has such an important inuence on what avours a child is exposed to, it is reasonable to conclude that mothers eating habits should be directly targeted alongside those of the child. This may mean that early years nutritional practitioners need to acquire skills to support adults to change their behaviour.

The social context of eating behaviour

Eating is a profoundly social experience in all cultures, and the interpersonal context of eating behaviour inuences food choice in two ways: by directly facilitating exposure as described in the previous section and through the mechanisms of social learning (Bandura 1977). It is the childs social environment that reinforces the preferences established by exposure and shapes the childs future relationship with food. Modelling is the mechanism by which childrens eating habits are shaped by what they observe of and copy from the eating behaviour of signicant others. Modelling has been used to explain why parental consumption is associated with childrens intake of healthy foods (Harper & Sanders 1975; Jansen & Tenney 2001; Young et al. 2004) and unhealthy foods (McGowen et al. 2012), as well as exposure to a variety of role models has been shown to modify the willingness of children to acceptance of healthy or unfamiliar foods. Teachers (Hendy & Raudenbush 2000), unrelated adults (Addessi et al. 2005) and other children (Ducker 1938; Marinho 1942; Birch 1980) can all inuence what children choose to eat in healthful and unhealthful directions. The quality of childrens diets has also been linked with food-related parenting strategies. Authoritative parenting strategies, those in which, parents encourage children to choose from a limited array of choices and offer clear, logical and proportionate consequences for desirable and undesirable behaviour, are consistently associated with greater levels of breakfast eating, fewer unhealthy snacks and higher consumption of fruit (Grey & Steinberg 1999; Kremers et al. 2003; Videon & Manning 2003; Savage et al. 2007; Berge et al. 2010). Other aspects of food-related parenting behaviour that

are associated with unhealthy dietary behaviour in children include overtly restrictive feeding practices (Fisher & Birch 1999), pressure to eat and high levels of parental control (Lee & Birch 2002). When, where and how a family eats contribute to childrens food choices. Engaging in regular family mealtimes is consistently associated with behaviours linked to healthier lifestyles both inside and outside the home. Children who regularly sit down to eat with their parents tend to have higher levels of fruit and dairy consumption, eat breakfast more often and spend less time watching television (Pearson et al. 2009). Children in families that make mealtimes a priority and eat together in a positive atmosphere may be less likely to develop disordered eating patterns (Neumark-Sztainer et al. 2008). Children in families who regularly eat together describe more parental support for healthy eating than children in families who have meals together less often. They are also more likely to eat a greater proportion of their meals in the home environment and take food prepared within the home to eat outside, for example, taking a home-prepared lunch to school (Utter et al. 2008). The means by which family mealtimes exert their positive inuence on health are unclear but are likely to be related to the availability of such rich opportunities for social learning. A positive change to a childs food preferences and eating behaviour relies heavily upon parents willingness and ability to restructure the food environment. Research has revealed that the domestic food environment is largely under the control of one individual who is responsible for up to 72% of decisions about what food is bought and how it is prepared and eaten (Wansink 2006). These individuals have been termed nutritional gatekeepers and generally are women in the vast majority of families (Lewin 1943). As nutritional gatekeepers, factors which inuence womens nutritional decision making will cascade through to inuence the dietary behaviours of other family members. Research suggests that womens nutritional decision making is complex and strongly inuenced by psychological, social and cultural factors such as level of educational attainment (Lawrence et al. 2009), relationships within the family (Conners et al. 2001) and the extent to which a woman feels in control of her life (Barker & Swift 2009). Qualitative studies have also revealed a signicant degree of complexity in womens decision making about family food preparation. Women experience tensions between the desire to promote interpersonal connectedness and harmony set against the needs associated with physical health when considering what food to present to their families; whether to

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provide food which is unhealthy but readily accepted, or whether to provide food that is healthier but which might cause conict and argument (Conners et al. 2001). Such difculties may reect the tensions arising when a womens role as the nutritional gatekeeper conicts with her role as the emotional hub of the family.

Implications of the social context of eating

A childs social context can inuence the foods that he is exposed to, which in turn may inuence preferences and ultimately choice. Since much eating behaviour is social in nature it may be possible to engineer any social environment where eating occurs to promote healthy eating through the provision of healthful role models. This may be a particularly powerful way in which public institutions, such as schools, could inuence the health of the population. The family environment offers a plethora of opportunities to shape childrens taste preferences and eating habits through exposure, modelling and food-related parenting practices. Interventions that target family eating culture may be a powerful way of promoting lasting change that has benets for multiple individuals. Changing families requires changing parents; parental decision making and parenting practices are themselves complex behaviours shaped by powerful and pervasive social and cultural forces. Education-based models of nutritional intervention do not lend themselves to tackling these issues in a straightforward way. For example, empowering women to feel more in control of their lives may be beyond the remit of many nutritional practitioners, but a lack of mandate should not mean that the problem is ignored. The next generation of nutritional interventions should seek to understand the ways in which psychological and social forces limit the opportunities for nutritional behaviour change and devise interventions that directly address these. This might include widening the skills of nutritional practitioners to involve coaching and interpersonal problem solving, and perhaps by encouraging more multidisciplinary working with professionals such as psychologists.

The inuence of context and habit

It is common for overweight individuals to report that they cannot understand why they are overweight, based on their perceptions of what and how much they eat. Although this is often interpreted using complex and potentially pathologising psychological constructs, such as denial or resistance, research into the determinants of adult food choice shows that humans, regardless of

size, are consistently poor historians of what and why they eat. Research looking at the phenomenology of food choice suggests that adults typically make around 200 food-related decisions per day, but report being consciously aware of an average of only 14.4 of those choices (Wansink & Sobal 2007). Furthermore, while peoples eating behaviour is remarkably sensitive to inuence from diverse aspects of the food and eating environment such as ambience, packaging, size of food containers and serving utensils (see Wansink 2010). It is also the case that they consistently underestimate the degree to which they have been inuenced (Wansink & Sobal 2007) and maintain a belief in their immunity to such inuences, even when presented with direct evidence to the contrary. The implications of this research are clear; for most people, for most of the time, the real determinants of consumption are not routinely available for the processes of monitoring, reection and goaldirected behaviour required for successful behaviour modication. Environmental inuences on behaviour have also been shown to override many of the consciously held attitudes and intentions that inuence what people report they want to eat. The fact that so much of the purchasing, preparation and consumption of food occurs outside of awareness can be explained by understanding such behaviour as habitual; learned sequences of behaviour that are cued by the environment and executed automatically without engaging conscious processes of reection and control (Neal et al. 2006). Habitual patterns of behaviour develop when behavioural sequences (e.g. pouring oil straight from the bottle into the frying pan) are repeated sufcient times in the same environment (e.g. standing at the cooker) to form an association between the two in memory. Over time the environment will automatically trigger the behaviour without involving very much conscious thought. Research has demonstrated that the strength of a habit has a strong inuence on how likely it is that an individual will perform behaviour when presented with the environmental conditions in which it was learned. Furthermore, the environment can directly trigger eating behaviour even in the presence of potent cues that would normally prevent it. For example, Neal et al. (2011) showed that the regularity with which people ate popcorn at the movies inuenced the amount of stale popcorn they ate when watching lms in a cinema. When given the opportunity to eat stale popcorn in a cinema environment, individuals that did not usually eat popcorn ate very little because of its unpalatable taste. However, individuals who habitually ate popcorn carried on eating the stale popcorn despite its unpleas-

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ant taste. Studies such as these have the potential to explain another common feature of the phenomenology of dietary change; that many individuals are mystied as to why they continue to choose unhealthy foods, which are at odds with their conscious intention to eat more healthily. Research has also shown that educational and persuasive interventions are good at improving peoples intention to change their behaviour but poor at producing actual behaviour change, especially for behaviours that can be classed as habitual (Webb & Sheeran 2006).

Implications of context and habit

The research reviewed in this section suggests that the environment has a potent inuence on eating behaviour that is largely outside conscious awareness and may inuence food choice even when individuals are consciously aware of such inuence and wanting to behave differently. If a large part of eating behaviour is habitual under direct environmental control and outside of awareness then it follows that interventions directed at changing behaviour through improving conscious knowledge will have little effect. It may also explain why interventions derived from learning and selfregulation theory that make use of self-monitoring techniques are more reliably associated with successful dietary change compared with education (Michie et al. 2009). Such interventions equip individuals with the skills necessary to pay close attention to their behaviour and teach techniques to modify their responses in light of what is found.

peutic skills in working alongside people to support the implementation of behavioural change. Viewing nutrition decision making through the lens of behavioural science perhaps increases the perceived complexity of the area. Nonetheless, greater complexity also creates greater opportunity for the possibility of intervention. Based on research presented in this article nutritional interventions could involve such diverse activities as teaching caregivers parenting strategies that deal effectively with neophobia, using coaching skills to help women feel more empowered to deal with conict generated by provision of healthier food choices, and developing legislation or guidance on packaging and portion size. Nutritional and behavioural practitioners have much to offer each other and, by working together, have the potential to offer interventions that have a greater impact than either could achieve by working in isolation.

Conict of interest
The authors have no conict of interest to disclose.

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Conclusions
Nutritional interventions based on an educational model have met with limited success in changing human dietary behaviours. Behavioural scientists proceed from the basic assumption that interventions based on an accurate understanding of the cause of behaviour are the ones most likely to produce change. This article has described research that shows that many of the determinants of current eating patterns are historical, outside of conscious awareness and under environmental control. Since traditional educational approaches seek to change the conscious determinants of food choice, it is perhaps unsurprising that they meet with limited success in changing dietary behaviour. Such insights do not mean that nutritional practitioners should not continue to educate; only that the scope of the educational endeavour should be widened to include the teaching of skills in behavioural analysis and augmented by thera-

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