12 SECTION one Community Nutritionists in Action: Working in the Community
renewed by nations in 1998.34 At the World Summit on Sustainable Development, health
Social–ecological models
(SEMs) Focus on the nature
of people’s interactions
with their surrounding
physical and sociocultural
environments.
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was recognized as both a resource for and an outcome of sustainable development: “The
goals of sustainable development cannot be achieved when there is a high prevalence
of debilitating illness and poverty, and the health of a population cannot be maintained
without a responsive health system and a healthy environment.”35
When translating the global goal of “health for all” into action at the local level, one
challenge is to understand the many physical, biological, social, and behavioral factors
that influence the health of individuals and communities. Another challenge is to change
human behavior.
Nations differ in how they formulate health objectives in an effort to help their peo-
ple achieve behavior change, although there are common themes. Working groups in
the European Region of the WHO, for example, outlined the following prerequisites for
health:36
• Freedom from the fear of war—“the most serious of all threats to health”
• Equal opportunity for all peoples
• The satisfaction of basic needs for food, clean water and sanitation, decent housing,
and education
• The right to find meaningful work and perform a useful role in society
Achieving these necessities requires both political will and public support, according
to the working groups, which translated these prerequisites into specific targets for health.
One such target, for example, called for enhancing life expectancy by reducing infant
and maternal mortality. Other targets focused on enhancing social networks, promoting
healthful behaviors, controlling water and air pollution, and improving the primary health
care system.
In Canada, a new vision for promoting health and preventing disease among Canadians
was expressed in documents released by Health Canada that aim to promote a balance
between individual and societal responsibilities for health. These documents, Achieving
Health for All: A Framework for Health Promotion and Toward a Healthy Future, cite goals
to be met in achieving health for all: reducing inequities in access to and use of the health
care system, increasing prevention efforts to change unhealthful behaviors, and enhanc-
ing the individual’s ability to cope with chronic illnesses and disabilities. A key focus of
the proposed implementation strategies is the strengthening of community-based health
services, including worksite programs.37 This vision for health in Canada is a window of
opportunity for community nutritionists to promote food and nutrition policies in all
Canadian communities.
Social–Ecological Models of Health Behavior Although traditionally,
much emphasis was placed on strategies to change nutrition and health-related behaviors
by focusing on individual-level factors such as knowledge and skills, more recent interven-
tions focus on the contribution of environmental factors to the development of obesity and
other chronic diseases. Increasingly, ecological approaches to improving health have directed
intervention strategies to target factors at several levels of influence, such as improving the
health-promoting features of communities and reducing the abundance of high-calorie,
nutrient-poor food choices. The combination of environmental, policy, social, and individ-
ual intervention strategies is credited with the major reductions in tobacco use in the United
States since the 1960s, and this success has led to the application of similar approaches
to many chronic health conditions today.38 One way to frame this current thinking is the
social–ecological model (SEM), as shown in Figure 1-3, in which various levels of influence
are arranged by relative proximity to the individual.39 Thus, interpersonal relationships such
as family factors are more proximal to the individual, while structures, policies, and systems,
such as changes in food labeling or food costs, are more distant.
 CHAPTER 1 Opportunities in Community Nutrition 13

FIGURE 1-3 The

Structures, Policies, Social–Ecological Model
Largest
and Systems Local, state, federal policies,
impact Health promotion
and laws to regulate/support activities that focus on
Community healthy actions policy-, system-, and
Social networks, norms, and environmental-level
Institutions/ standards settings (community and
Organizations institutions/organizations)
Rules, regulations,
policies, and informal are more likely to have a
Interpersonal structures greater impact on health
behaviors and health
Family, peers, social
disparities than individual-
networks, and associations
level interventions.
Individual Knowledge, attitudes, Source: Adapted from the Cen-
Smallest
beliefs, and behaviors ters for Disease Control and
impact Prevention (CDC), The Social
Ecological Model: A Framework
for Prevention.

The SEM emphasizes multiple levels of influence (such as individual, interpersonal,

organizational, community, and public policy) and the idea that all elements of society
combine to shape an individual’s food and physical activity choices or other health behav-
iors, and ultimately one’s chronic disease risk. Table 1-4 provides a brief description of each

TABLE 1-4 A Description of Social–Ecological Model (SEM) Levels of Influence

DESCRIPTION
Individual Characteristics of an individual that influence behavior
change, such as knowledge, attitudes, behavior, beliefs,
lifestyle, self-efficacy, gender, age, genetics, religion, race/
ethnicity, sexual orientation, economic status, financial
resources, values, goals, priorities, literacy,
body image, and other personal factors.
Interpersonal Social networks and social support systems that can
influence individual behaviors, including family, friends,
peers, coworkers, health professionals, religious and/or
social networks, customs or traditions.
Institutional/ Organizations or social institutions with policies and
Organizational regulations that affect how, or how well, resources,
Settings services, or other items are provided to an individual or
group (e.g., policy for school vending machines).
Community Relationships among organizations, institutions, and
Settings informational networks within defined boundaries,
including the built environment (e.g., parks), community
leaders, businesses, and transportation.
Structures, Local, state, national and global laws and policies,
Policies, and including policies regarding the allocation of resources
Systems (e.g., eligibility requirements for food assistance programs).
EXAMPLES OF INTERVENTIONS TO DECREASE OBESITY
AT EACH SEM LEVEL OF INFLUENCE
• A social media campaign to educate adolescents and
young adults about the benefits of regular moderate
physical activity.
• A health educator seeks to increase the target
population’s knowledge and subsequently help form
positive attitudes toward physical activity.
• Public health nutritionist endeavors to increase
knowledge about healthy food choices and skills in
food shopping and meal preparation.
• Programs utilize relationships between individuals
to influence change. For example, peer support
groups, recipe swaps, and walking groups encourage
members to keep each other accountable to nutrition
and physical activity goals.
• A private business park replaces fast-food and
soft-drink options in the cafeteria with water, fresh
sandwiches, and salad bars to encourage employees
to replace unhealthy options with more healthy ones.
• In a town with disproportionately low access to
fresh fruits and vegetables, a working group of local
school officials, community leaders, and business
owners help establish a food cooperative as well as a
biweekly farmers’ market.
• Structural changes are made for the development
of safe parks, recreational areas, and sidewalks
statewide to help facilitate physical activity.

Source: Adapted from CDC’s Ecological Framework for Addressing Disparities in Obesity, 2013.

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14 SECTION one Community Nutritionists in Action: Working in the Community
Cognitions The knowledge
and awareness that people
have of their environment and
the judgments they make
related to it.
Attitudes An individual’s
positive or negative evaluation
of performing a behavior or
engaging in an activity.
١٢‫ﺑﻤﺜﺎل ﻣﺮﺿﻰ اﻟﺴﻜﺮي وﻓﯿﺘﺎﻣﯿﻦ ب‬
‫ ﻹﻧﮫ اﻟﻄﺒﯿﺐ ﺑﺘﻌﺎﻣﻞ ﻣﻊ‬،‫إﺳﺘﮭﺪﻓﻨﺎ اﻷطﺒﺎء‬
‫ ﻣﺮﯾﺾ ﯾﻮﻣﯿﺎ ً ﻓﮭﻮ ﺑﺴﺎﻋﺪﻧﻲ ﺑﺪل ﻣﺎ أﻧﺎ‬٥٠
‫ ﻣﺮﯾﺾ‬٥٠‫أﻟﻒ ﻋﻠﻰ ال‬
‫)إﺣﻨﺎ ﺑﻤﺠﺘﻤﻊ ﺑﺴﻤﻊ ﻟﻠﻄﺒﯿﺐ( ﻓﻠﻤﺎ ﯾﻜﻮن‬
‫اﻟﻄﺒﯿﺐ ھﻮ اﻟﻲ ﺑﺪﻋﻢ ھﺎد اﻟﺴﺒﻮك اﻟﻨﺎس‬
‫ﺑﺘﺘﻘﺒﻠﮫ ﺑﺸﻜﻞ أﺣﺴﻦ‬
WHO with UNICEF programe for
baby friendly hospital initiative
‫ ﺧﺪﻣﺎت‬،‫ھﻮ ﺑﺮﻧﺎﻣﺞ ﻋﺎﻟﻤﻲ ﺗﻢ ﺗﻄﺒﯿﻘﮫ ھﻮن‬
‫اﻟﻤﺴﺘﺸﻔﻰ ﺑﺘﺪﻋﻢ اﻟﺮﺿﺎﻋﺔ اﻟﻄﺒﯿﻌﯿﺔ‬
organizational level ‫ﻟﻤﺎ أﺷﺘﻐﻞ ﻣﻊ ﻣﺆﺳﺴﺔ‬
‫ﻛﻞ إم رح ﺗﯿﺠﻲ ﻋﻠﻰ ھﺎد اﻟﻤﺴﺘﺸﻔﻰ رح ﯾﻨﻌﻤﻠﻠﮭﺎ‬
‫ﻧﻔﻲ اﻟﺘﺪرﯾﺐ واﻟﺨﺪﻣﺎت ﻟﻜﻞ اﻷﻣﮭﺎت وﺑﮭﯿﻚ ﻣﺎ‬
‫رح ﺗﺘﺄﺛﺮ ﻣﯿﻦ ﻗﺪﻣﻠﮭﺎ اﻟﺨﺪﻣﺔ وﻣﯿﻦ اﻟﻨﯿﺮس اﻟﻲ‬
‫ﻛﺎﻧﺖ ﻻﻧﮫ ﻛﻠﮭﻢ ﻣﺘﺪرﺑﯿﻦ‬
…… … …… …………
MNT ‫ﻣﺜﺎل آﺧﺮ وھﻮ‬
‫اﻟﺘﺄﻣﯿﻦ ﺑﻐﻄﻲ أﺧﺼﺎﺋﯿﺔ اﻟﺘﻐﺬﯾﺔ ﻓﮭﯿﻚ ﺻﺎر دورﻧﺎ‬
organizational
‫اﺣﻨﺎ ﻋﻨﺎ ﻻ ﺑﯿﺠﻲ ﻣﻦ ﺣﺎﻟﮫ او ﺗﺄﺛﯿﺮ ﻣﻦ اﻟﻲ ﺣﻮﻟﯿﮫ‬
‫ﻟﻜﻦ ﺑﮭﺪﯾﻚ اﻟﺤﺎﻟﺔ اﻟﻲ ﺑﺄﺛﺮ ﻋﻠﯿﮫ ھﻮ ال‬
‫ اﻟﺴﺴﺘﻢ ﺣﻮﻟﺔ ﻷﺧﺼﺎﺋﯿﺔ‬organiztional level
‫ﺗﻐﺬﯾﺔ‬
‫ اﻟﺤﺪاﺋﻖ‬،‫ﻣﺜﻼً ﻓﻜﺮة اﻟﻤﺴﺎر اﻟﺮﯾﺎﺿﻲ‬
physical ‫اﻟﮭﺪف ﻣﻨﮭﺎ ھﻲ زﯾﺎدة ال‬
activety
‫اﻟﻤﻘﺎطﻌﺔ ﺧﻠﺖ اﻟﺪﻛﺎﻛﯿﻦ ﺗﻮﻓﺮ ﺑﺪاﺋﻞ‬
‫ﻧﻮﺗﯿﻼ وﺗﻜﻮن ﺻﺤﯿﺔ أﻛﺘﺮ وﺑﮭﯿﻚ‬
‫ أو‬،‫دﻓﻌﺖ اﻟﻨﺎس ﺗﺼﯿﺮ ﺗﺸﺘﺮﯾﮭﺎ‬
‫ﺑﺴﺒﺐ اﻟﻤﻘﺎطﻌﺔ ﻗﺮر اﻟﺒﻌﺾ ﻣﺎ‬
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?knowledge ‫ھﻞ ھﻮ ﻣﺎ ﻋﻨﺪه ال‬
awarness ‫ﺑﺸﺘﻐﻞ ﻣﻌﻨﺎﺗﮫ ﻋﻠﻰ ال‬
campaign
attitude ‫ھﻞ ھﻮ ﻣﺶ ﻋﺎرف ﯾﻐﯿﺮ ﻋﻠﻰ ال‬
behavior motivation ‫ﺑﺪي اﺷﺘﻐﻞ‬
of the SEM levels. The following section describes the various levels of influence found
within the model.40
• Individual level. The primary circle of the SEM is the individual—ultimately affected by
all other levels of influence. Factors such as age, gender, income, race and ethnicity, genet-
ics, and the presence of a disability can all influence an individual’s food intake and physical
activity patterns. Food intake is influenced by a constellation of biological, psychosocial,
cultural, and lifestyle factors listed in Table 1-2, as well as by our personal food preferences,
cognitions, attitudes, and health beliefs and practices. In order to change one’s knowledge,
attitudes, beliefs, and behaviors, these individual factors should be addressed.
• Interpersonal level. The next level in the SEM represents individuals’ interactions with
one another, or relationships shared within social networks such as families, friends,
peer groups, and health professionals. Food choices are strongly influenced by social
groups. Primary social groups such as families, friends, and work groups also influence
health and nutrition status. The family is a paramount source of values for its members,
and its values, attitudes, and traditions can have lasting effects on the members’ food
choices and health. This is especially true for children and teenagers. The calcium
intakes of teenagers, for example, are higher in families in which teenagers perceive
their parents’ attention, care, support, and understanding than in families with low
family connectedness.41 Likewise, children whose parents did not regularly drink soft
drinks were much less likely to consume soft drinks than children whose parents drank
soft drinks on a regular basis.42
• Institutional–organizational-level settings. People regularly make decisions about
food, physical activity, and health in a variety of settings, such as schools, worksites,
faith-based organizations, and health care organizations. Health promotion activities
implemented at this level facilitate individual behavior change by influencing organiza-
tional systems and policies. Health care systems, worksites, insurance plans, local health
clinics, and professional organizations represent potential sources of organizational
messages and supportive environments.43 Examples of interventions appropriate for
this level include: encouraging the expansion of insurance benefits for medical nutri-
tion therapy or adopting worksite policies that support healthy behaviors.
• Community-level settings. Communities are composed of individuals as they partici-
pate in interpersonal relationships within various groups of institutions and organiza-
tions.44 Healthy eating and lifestyle patterns can be influenced by availability and access
to recreational facilities, restaurants, fast-food outlets, supermarkets, convenience
stores, and other food retail establishments. Social and cultural norms and values are
guidelines that govern our thoughts, beliefs, and behaviors. These shared assumptions
of appropriate behavior are based on the values of a society and are reflected in every-
thing from laws to personal expectations. Making healthy choices can be more difficult
if those healthy choices are not strongly valued within a society. As mentioned earlier,
communities may be viewed on different scales: global, national, regional, local, cul-
tural, or by other shared characteristics.
• Structures, policies, and systems. The outermost tier of the SEM represents the local,
state, and federal structures and systems that affect the built environment surrounding
communities and individuals.45 Communities are influenced by many factors, such
as government and its programs and policies, public health and health care systems,
agriculture and its food and agricultural policies, industry, and media. Many of these
sectors determine the degree to which individuals have access to healthy food and
opportunities to be physically active in their own communities.
The social–ecological model helps explain the roles that various segments of society can
play in making healthy choices more widely accessible and desirable. Such a framework
 CHAPTER 1 Opportunities in Community Nutrition 15

encourages a paradigm shift to a society oriented around health promotion and chronic
disease prevention. To this end, the 2010 Dietary Guidelines included the following call
to action:46

“ Ultimately, Americans make their own food and physical activity choices at
the individual (and family) level. In order for Americans to make healthy choices,
however, they need to have opportunities to purchase and consume healthy foods and
engage in physical activity. Although individual behavior change is critical, a truly
effective and sustainable improvement in the nation’s health will require a multi-
sector approach that applies the social–ecological model to improve the food and
physical activity environment.This type of approach emphasizes the development of
coordinated partnerships, programs, and policies to support healthy eating and active
living. Interventions should extend well beyond providing traditional education to
individuals and families about healthy choices, and should help build skills, reshape
the environment, and re-establish social norms to facilitate individuals’ healthy

”
choices.

The social–ecological model provides guidance for developing successful programs.

The most effective approach to health promotion and disease prevention uses a combina-
tion of interventions at all levels of the model. Creating a social environment conducive to
change is important to making it easier for individuals to adopt healthy behaviors.

Healthy People: A Report Card

for the Nation’s Health
The health objectives for the peoples of the United States differ slightly from those of the
European and Canadian communities, reflecting the health needs of the U.S. population.
A national strategy for improving the health of the United States—known as Healthy Healthy People A set of
People—is released by the U.S. Department of Health and Human Services each decade. goals and objectives with
10-year targets designed
For the past three decades, Healthy People has provided a framework for promoting health
to guide national health
and avoiding preventable disease. Chronic diseases, such as heart disease, cancer, and promotion and disease
diabetes, are responsible for 7 out of every 10 deaths among people in the United States prevention efforts to improve
each year and account for 75% of the nation’s health spending. Many of the risk factors the health of all people in the
that contribute to the development of these diseases are preventable.47 The Healthy People United States.
initiative is grounded in the principle that setting national objectives and monitoring
progress can motivate action.
How did the nation do in terms of meeting the Healthy People 2010 goals? When
Healthy People 2010 was released in 2000, life expectancy was 76 years. Today, the average
life expectancy at birth is 78 years and death rates for heart disease, stroke, and certain
types of cancer have declined.48 However, health disparities remain evident among indi-
viduals, with significant differences between whites and minorities in mortality, morbidity,
health insurance coverage, and the use of health services.49
Almost no progress was made toward the Healthy People 2010 targets for objectives in
the nutrition and overweight focus area.50 Only one objective (calcium intake) showed
positive movement. In addition, statistically significant health disparities were observed
among racial and ethnic populations, as well as by sex, income, and disability status.
Since the 1980s, the prevalence of overweight has soared (see Chapter 8). In fact, over-
weight increased among all ethnic and age subgroups of the population. One contributing
factor is that people seem to be taking fewer steps to control their weight by adopting

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