The US healthcare industry is too dispassionate

Target group segmentation for health communication in the field of nutrition - an innovative approach using the example of obesity risk groups

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1 Target group segmentation for health communication in the field of nutrition - an innovative approach using the example of obesity risk groups Inaugural dissertation to obtain a doctorate at Faculty 09 Agricultural Sciences, Ecotrophology and Environmental Management at JLU Giessen Submitted by Dorle Grünewald-Funk, Dipl. Oec. troph. Berlin, January 2013

2 Inaugural dissertation for obtaining a doctorate in the Faculty of Agricultural Sciences, Nutritional Sciences and Environmental Management at the Justus Liebig University in Giessen with the title Target group segmentation for health communication in the field of nutrition - an innovative approach using the example of obesity risk groups Disputation date: Chair: Prof. Dr. Sven Schubert 1st reviewer: Prof. Dr. Ingrid-Ute Leonhäuser 2nd reviewer: Prof. Dr. Hermann Boland Examiner: Prof. Dr. Adalbert Evers Examiner: Prof. Dr. Ingrid Hoffmann, MRI, Karlsruhe

3 Contents I TABLE OF CONTENTS Figures ... IV List of tables ... V List of abbreviations ... VII I Introduction Problem and objectives Structure of the thesis ... 3 II Nutrition and health communication as a contribution to the prevention of overweight and obesity Obesity prevention: initial situation due to epidemiological Situation Nutritional communication Definition of nutritional communication Forms of nutritional communication Core elements of the criticism of nutritional communication Conclusion Health communication Definition and understanding Levels of communication and forms of health communication Effect potential of media health communication State of research Conclusion ... 32 III From communication to action Change of behavior at the intrapersonal level Values, attitudes, behavior Theoretical models for the prediction of individual health behavior Media and their effect on behavior Key concepts of the media effect Communicationssc hwaves and overcoming them Conclusion ... 52

4 Table of contents II IV Target group segmentation for health communication Target group segmentation: state of research Segmentation criterion obesity risk Segmentation criteria lifestyle and media use Theoretical models of lifestyle research Empirical lifestyle research Lifestyle typology Sinus milieus as a target group instrument Conclusion Deriving research-leading questions of market-media selection ... 79 V Empirical research - methodology selection ... 79 V -Study Typology of wishes Data basis Description of the sample Examination of the data for suitability for a secondary analysis Target group instrument Sinus-Milieus in the TdW Implementation of the empirical study Identification of the obesity-risk environment Data analysis based on risk characteristics to identify the obesity-risk environment (analysis step 1) Data analysis for characterization the obesity risk environment (analysis step 2) data analysis on media use and topic preference of the Ri sikomilieus (analysis step 3) Summary VI Results Identification of obesity risk environment Characteristic values ​​in the sinus milieus Obesity risk typology Characterization of the obesity risk environment Body mass index

5 Table of contents III 2.2 Socio-economic factors Nutrition Attitudes and behavior Health care Leisure habits Media usage behavior Value orientation and living environment Accessibility of the obesity risk milieu Prevention requirement in the obesity risk milieu due to problem relation Accessibility via mass media Media usage duration Topic preference Summary of the results VII Discussion Discussion of the methodological approach Discussion of the content-related results Can be activated up to the point of action? VIII Outlook IX Summary X Summary XI Bibliography XII Appendix

6Weight decrease in the obesity risk environment 131 Figure 14: Media usage of the obesity risk environment in percentages 136 Figure 15: Accessibility of the obesity risk environment via the media 146 Figure 16: TV usage time of the obesity risk environment on working days 147 Figure 17: Radio usage time of the obesity risk environment on Working days 148 Figure 18: Newspaper usage time of the obesity risk milieu on working days 148 Figure 19: Magazine usage time of the obesity risk milieu on working days 149 Figure 20: The most popular TV genres and accessibility of the obesity risk milieu 151 Figure 21 Most popular magazine topics and accessibility of the obesity risk milieu 153

7 List of Tables V LIST OF TABLES Table 1: Levels of media health communication ... 25 Table 2: Synopsis of success factors for media health communication ... 30 Table 3: Involvement as a key dimension ... 47 Table 4: Model of linking lifestyles, socio-structural conditions and health Behaviors ... 66 Table 5: The milieu building blocks ... 71 Table 6: Brief characteristics of the Sinus milieus ... 74 Table 7: Representative market media analyzes in Germany and items relevant to the study ... 81 Table 8: Characterization of the study Typology of wishes ... 83 Table 9: Sociodemographic data (TdW 06/07) related to the sample ... 84 Table 10: Data on employment and income situation from TdW 06/07 related to the sample ... 85 Table 11 : BMI assessment depending on age: Comparison of the BMI reference values ​​and the BMI classification TdW 06 / Table 12 BMI classification in comparison with WHO reference values ​​and TdW 06 / Table 13: Percentage BMI distribution: comparison between TdW 06/07 and NVS II ... 89 Table 14: Self-reported frequency (in percent) of leisure activities associated with physical activity ... 99 Table 15: Items on health awareness and Diet behavior in the TdW 06 / Table 16: Variables on the duration and frequency of use in the Media module of the TdW study Table 17: Obesity-relevant risk constellation of the sinus milieus Table 18: Moderate movement (regular and occasional) in relation to the population and the sinus milieus Table 19: Characteristic categories and their risk assessment Table 20 Cross table with risk characteristics and typical milieu risk profile Table 21 BMI distribution in the obesity risk milieus of the TdW study Table 22 Attitudes and behavior of the obesity risk milieu with regard to health care Table 23 Media use of the obesity risk milieu in leisure time Table 24: Media reception on the topics of health and nutrition g by the obesity risk milieu Table 25: People affected by overweight (million) in the obesity risk milieu

8 List of Tables VI Table 26: TV genre preference patterns, consumer materialists Table 27: Topic preferences of consumer materialists in magazines

9 List of Abbreviations VII LIST OF ABBREVIATIONS ACTA ADM ARD AWA BCN Bev.Allensbacher Computer and Telecommunication Analysis Working Group of German Market and Social Research Institutes Working Group of the Public Broadcasting Companies of the Federal Republic of Germany Allensbacher Market and Advertising Media Analysis Burda Community Network GmbH Population BM Bürgerliche Mitte (Sinus B2) BMELV BMG BMI BZgA CD CDC CN DGE DEGS DGPH DVD Federal Ministry of Food, Agriculture and Consumer Protection Federal Ministry of Health Body-Mass-Index Federal Center for Health Education Compact Disc Centers of Disease Control and Prevention Communication Networks German Society for Nutrition ev Study on Adult Health in Germany German Society for Public Health e.v. Digital Video Disc ET Established (Sinus B1) EXP Experimentalists (Sinus C2) etc. GfK HED ICA IVV KA KiGGS et cetera Society for Consumer Research Hedonists (Sinus BC3) International Communication Association Fraunhofer Institute for Process Engineering and Packaging Communication Analysis Children and Youth Health Survey KON Conservatives ( Sine A12)

10 List of Abbreviations VIII KORA LAC LAE MA Cooperative Health Research Readers Analysis Computer Press Readers Analysis Decision Makers Media Analysis MAT Consumer Materialists (Sinus B3) NHANES MDR Mio National Health and Nutrition Examination Survey Study Central German Broadcasting Millions MOP Modern Performers (Sinus C12) MP3 MRI MW NOS NVS Moving Picture Experts Group Audio Layer III Max Rubner Institute Mean GDR-Nostalgic (Sinus AB2) National Consumption Study PM Post-material (Sinus B12) Pro7 RKI RTL SES Std. TdW Pro Sieben Robert Koch Institute Radio Télévision Luxembourg Socio-economic status Hour Typology of wishes TRAD Traditionally rooted (Sinus A23) TV VA WHO WZW ZDF Television Consumer Analysis World Health Organization Science Center Weihenstephan Second German Television

11 Introduction I I INTRODUCTION 1 PROBLEMS AND OBJECTIVES The population in Germany is to a large extent overweight or obese. This is shown repeatedly by the data from German health reporting, most recently in the study on adult health in Germany (DGES) (KURTH B 2012). Effects of being overweight and obese can be a burden. Concomitant or secondary diseases affect the cardiovascular system, the lungs, the gastrointestinal tract, the connective tissue, the skeletal system or the entire body (malignant diseases). Obesity-associated diseases such as cardiovascular diseases, diabetes mellitus type II, metabolic syndrome, back and joint problems can reduce the quality of life of the individual and increase the risk of mortality (LOBSTEIN L ET AL. 2004; WANG G ET AL. 2002). Preventive measures for healthy nutrition, exercise and relaxation are of central importance for prevention (JORDAN S ET AL. 2012). The high demand is offset by disappointing results from previous prevention efforts. It has repeatedly been found that nutritional communication, nutrition and health education fail (ROSENBROCK R 2006; SPIEKERMANN U 2006a; GÖPFERT W 2001) and that behavioral preventive measures that dominate the prevention landscape are only selectively adopted by health-conscious target groups (JORDAN S ET AL. 2012). In its current roadmap, the National Obesity Alliance states that, despite efforts that have already been made, there is still a lack of effective prevention and treatment programs that work under everyday conditions and are also successful across the population (HAUNER H ET AL. 2012). Systematic and targeted communication and nutrition education activities are therefore required for target groups whose nutritional and health behavior can be viewed as prone to risk. Target group-oriented prevention and health promotion are not yet widespread in Germany, although they are repeatedly addressed and demanded in scientific publications (BAUER U ET AL. 2012; ROSKI R 2009a: V; LEPPIN A 2004). In the practice of North American public health and health communication, on the other hand, target group orientation is a key element of action planning. Health communication measures are consistently based on the needs and wishes of the intended target group: In health communication, the audience is not merely a target (even if the terminology is very well established and used by practitioners around the world) but an active participant in the process of analyzing the health issue and finding culturally appropiate and cost-effective solutions (SCHIAVO R 2007: 12).

12 Introduction 2 Target group definitions based on German health reporting are based on medical indications linked to socio-demographic data. Psychographic and social aspects of lifestyle, values ​​of the target groups and media usage behavior based on empirical findings have so far been missing from target group segmentations for prevention and health promotion measures in Germany. Thus, the target groups to be reached are not described clearly enough (ROSKI R 2009b; BONFADELLI H ET AL. 2006: 34) to be able to carry out population-wide prevention measures efficiently and effectively. High scatter losses arise because the information does not reach the target groups. This reduces the effectiveness of health communication measures, and they cannot lead to the desired changes in behavior (ROSKI R 2009a: V). Population-wide measures are considered to be the most suitable for the prevention of overweight and obesity worldwide due to their reach, feasibility and cost-effectiveness. Among the most urgently recommended measures are the promotion of social awareness of the importance of a healthy diet, exercise and sport as well as legislative measures (e.g. advertising bans and taxation of alcohol) (WHO 2011: 4,56). Such measures must include mass media strategies, since messages with the necessary reach can only be conveyed via the media. However, the media landscape is now strongly characterized by individual user behavior and selective media selection (HAAS A 2007: 22; SCHENK M 2007: 679). More and more television channels, programs and formats, magazines, radio programs or online offers are competing for the audience or readership, so that only a small user group can be considered as an audience per program or per publication (HAAS A 2007: 22ff). The mass media are only aimed at a mass audience when it comes to current topics or certain outstanding television programs (e.g. sports, feature films, entertainment shows) 1.Other media offers are often received by homogeneous groups who have the same personality traits (taste public, media user types) (SCHENK M 2007: 765ff; MEYEN M 2004: 130ff). This requires a target group-oriented approach in the selection of the media used for the population-wide prevention of overweight and obesity. Another reason for addressing target groups is the risk of negative, unintended effects. Stigmatization and discrimination of obese, unnecessary attempts at dieting in people of normal weight, eating disorders or body dissatisfaction in vulnerable groups cannot be ruled out in population-wide media strategies. These risks can be avoided if sub-target groups in the population have 1 Therefore, in the present study, the term media is preferred instead of mass media.

13 Introduction 3 special prevention needs are identified (segmentation) and selected (targeting). Building on this, the media and message to be used can be planned and selected for the specific target group. The present empirical study is intended to contribute to filling the research gap with regard to target group segmentation for the population-wide prevention of overweight and obesity in adults in Germany. The aim is to segment target groups to identify target groups for health communication in the field of nutrition. Particular attention is paid to a description of the target group that is as comprehensive as possible based on all good practice criteria for target group segmentation: problem reference, sociodemography, lifestyle and media use. The investigation is carried out as a secondary analysis of the representative market media study Typology of Desires Intermedia (TdW). In addition to the attitudes to various topics such as nutrition, health and prevention behavior, the leisure behavior as well as the frequency, duration and content of various media of the German-speaking population (from age 14), the TdW collects information. In addition to the socio-demographic characteristics, it includes an evaluation of target groups based on the empirical lifestyle typology Sinus-Milieus, which is one of the most important target group models for communication planning. It can thus be examined whether target group segmentation related to the health problem of obesity is possible, which in turn can be linked to media use. The Sinus-Milieu-based dataset of the TdW 2006/07 on the questions mentioned was kindly made available by Burda Community Network GmbH. 2 STRUCTURE OF THE WORK In the theoretical part of the work, the basics of nutrition and health communication, theoretical models of public health, behavioral and communication sciences as well as target group segmentation methods are discussed (Chapters II-IV). Chapter II aims to introduce the research subject of the thesis. The aim is to show the connections between nutrition and health communication, health promotion and the prevention of overweight and obesity, reduce the complexity of the topic and identify research gaps. In addition, the status of impact research on population-wide health communication is shown and success factors for improved effectiveness are identified. Chapter III deals with the path from a message to a change in behavior on the basis of various psychological, theoretical and process-oriented models. Chapter IV discusses theoretical models and empirical concepts of the social situation, lifestyle and target group segmentation and derives the research-relevant questions. Chapter V is devoted to the methodology and the results of this work.

14 Introduction 4 met. It describes the identification of target groups for the prevention of overweight and obesity with the help of a sinus milieu-based risk typology.Then the risk types, the obesity risk milieu, their social context, their media behavior and the topic interests are characterized and the common accessibility for a media health communication is checked. In the following (Chapter VI) it is discussed which communication barriers exist and how they can be overcome. Recommendations for action for the target groups of media health communication for the population-wide prevention of overweight and obesity follow (Chapter VII).

15 Nutrition and health communication as a contribution to the prevention of overweight and obesity 5 II NUTRITION AND HEALTH COMMUNICATION AS A CONTRIBUTION TO THE PREVENTION OF OVERWEIGHT AND OBESITY Measures of nutrition and health education in Germany are described as having failed in the scientific literature (SPIEKERMANN U 2006a; GÖPFERT W 2001). Göpfert (2001: 131) calls it naive to assume, for example, that health education via the media alone can encourage millions of smokers to stop smoking sustainably. In a figurative sense, this can also be assumed for the nutrition communication defined below (see Chapter 2), because eating is an everyday routine that is not only planned rationally, but is also determined by available time, work constraints and much more (BARLÖSIUS E ET AL . 2006). In view of the prevention dilemma of insufficiently effective measures on the one hand and the high need for preventive measures on the other, the question arises of how effective population-wide communication measures should be designed. That is why this chapter discusses the initial situation of the prevention of overweight and obesity before giving an insight into definitions, understanding, connections and research status of nutrition and health communication, health promotion and prevention of overweight and obesity. The criticism of nutritional communication is also explained, the research status of impact research on population-wide health communication is shown and success factors for improved communication measures are identified. 1 OBESITY PREVENTION: INITIAL SITUATION DUE TO THE EPIDEMIOLOGICAL SITUATION Overweight and obesity are considered to be the greatest health problems both nationally and internationally. Due to the rapid increase in prevalence over the past 20 years, there is even talk of an obesity epidemic (BERGHÖFER A ET AL. 2008; HESEKER H 2008; BRAY GA ET AL. 2006; OGDEN C ET AL. 2006; LOBSTEIN L ET AL. 2004). Overweight is when the body weight is increased in an assessment according to the weight-length index body mass index (BMI). The body mass index is calculated from the formula BMI (kg / m²) = body weight / (body length) ². Obesity is defined as having a BMI of 30 kg / m² or more. A BMI between 25 and 29.9 kg / m² is known as pre-obesity or overweight. However, the term overweight for this BMI category often leads to misunderstandings because the usual WHO classification for the entire BMI range of 25 kg / m² also uses the term overweight (WIRTH A 2008). In this work will

16 Nutrition and health communication as a contribution to the prevention of overweight and obesity 6 therefore the term overweight is used for the BMI range of 25 kg / m², analogous to the obesity guideline (HAUNER H ET AL. 2007). Obesity is used when the overall phenomenon of obesity is considered or when explicitly referring to BMI categories of 30 kg / m² or more. The obesity prevalence in Germany has increased in the last few decades, both among children and adolescents and among adults. Currently, more than 20 percent of all adults are considered obese with a BMI 30 kg / m² and between 30 and 40 percent are pre-obese (BMI 25 29.9 kg / m²). Around 15 percent of children and adolescents (3 to 17 years of age) are overweight or obese (HAUNER H ET AL. 2012; KURTH B 2012; LANGE C ET AL. 2007). At the moment, the overall prevalence seems to have stagnated, but at a high level. The trend towards extreme obesity (BMI 40 kg / m²) in adolescents and adults is worrying (HAUNER H ET AL. 2012; KURTH B 2012). Obesity-associated complications are widespread. For example, around 25 percent of adults in Germany suffer from cardiovascular diseases including high blood pressure (BMELV, BMG 2007). More than 7 million people in Germany are treated for diabetes. 90 percent of them suffer from diabetes type 2, which is often associated with obesity. However, it can be assumed that significantly more people suffer from diabetic metabolic disorders and their long-term consequences, because the number of unreported cases is high. For every diagnosed diabetic 2 there is a person with undetected diabetes. It is particularly worrying that children and adolescents are increasingly being diagnosed with type 2 diabetes. Those affected are usually very overweight (HAUNER H 2012). At the same time, the effects of the obesity wave are a social problem that affects the German health system and the world of work, for example in the form of high and avoidable costs such as production losses, adjustments to the changed body dimensions and expenses for diagnostics, therapy or rehabilitation measures (HAUNER H ET AL. 2012; SCHNEIDER K ET AL. 2009; WITTIG F ET AL. 2009). The National Obesity Alliance puts the annual expenditure in the health system for the treatment of obesity consequences at 15 to 20 billion euros (HAUNER H ET AL. 2012). The Federal Statistical Office (2010: 39) puts the direct illness costs of obesity and overeating (for prevention, treatment, rehabilitation and care) incurred in Germany at 863 million euros per year The generic masculine is used in this work to ensure better legibility of the text. What is meant are diabetics, recipients, etc. The use of the masculine form does not represent a valuation.

17 Nutrition and health communication as a contribution to the prevention of overweight and obesity 7 diseases such as diabetes mellitus, hypertension, ischemic heart disease and osteoarthritis are coming (29 billion euros) (STATISTISCHES BUNDESAMT 2010: 39). In view of the endemic increase in overweight and obesity, a wide range of therapy and prevention efforts have been made in recent years. The prevention of obesity and the associated nutrition-related diseases is seen as one of the greatest health and nutrition policy challenges of the coming years (HAUNER H ET AL. 2012; BZGA 2010: 27ff; HEBEBRAND J ET AL. 2008: 198ff; BMELV, BMG 2007 ). It is not for nothing that the Advisory Council on the Assessment of the Development of the Health Care System in Germany has named primary prevention as a central field of action in health security in Germany in its reports for years. It is therefore alarming that, despite various preventive efforts, the study on adult health in Germany (DEGS) recently stated that the proportion of obese people has continued to increase in recent years (KURTH B 2012). The high demand for successful prevention is still offset by sobering successes (HAUNER H ET AL. 2012; HEBEBRAND J ET AL. 2008: 200ff; WANG G ET AL. 2002; CAMPBELL K ET AL. 2001). For example, the participation rates in health promotion measures of the statutory health insurance companies are described as meager. The programs are mainly used by young, health-conscious insured persons. Women and insured persons at the age of years dominate among the participants in courses and other behavioral preventive measures aimed at individuals or groups (ARBEITSGEMEINSCHAFT DER SPITZENVERBÄNDE DER KRANKENKASSEN 2006; FELIX-BURDA-STIFTUNG 2005). The middle class is well reached. Above all, high-risk groups are missed: children and adolescents, adults and older people, socially disadvantaged people and people with a migration background (HEBEBRAND J ET AL. 2008: 201ff; KOWALSKI C ET AL. 2008; ALTGELD T ET AL. 2007; KRONSBEIN P 2007; EXPERT RATING FOR EVALUATION OF DEVELOPMENTS IN HEALTH CARE 2007: 84). In its current roadmap, the National Obesity Alliance states that despite the efforts already made in research and practice, there is still a lack of effective prevention and treatment programs that work under everyday conditions and are also successful across the population (HAUNER H ET AL. 2012). 2 NUTRITIONAL COMMUNICATION Eating and drinking, food and meals as well as activities related to the production, selection or enjoyment of food permeate the everyday life of people in all cultures. People also communicate permanently, using gestures, facial expressions, symbols, language or writing. Because communication means a mutual understanding

18 Nutrition and health communication as a contribution to the prevention of overweight and obesity 8 through the transmission of symbols (MALETZKE G 1998: 37). Nutrition is often the subject of this communication effort. Even the design of dishes or the specificity of the food selection can be viewed as language or communication with the help of the food symbol (the culinary code) (KARMASIN H 2001: 19). The high intensity of everyday communication about food and drink could lead to the assumption that nutritional information and diet recommendations can be implemented successfully, since the target groups are already dealing with this topic. However, the opposite appears to be the case. The form and strategy of nutrition communication and nutrition education are criticized from various sides. Rosenbrock (2006) describes nutritional education and information as inadequate due to a wide range of disregard for dietary recommendations and the many tips for a healthy diet. The long-time President of the German Nutrition Society, Volker Pudel (2003, 1991, 1984), has repeatedly expressed himself critically. He ruled that nutritional education was a failure. Spiekermann (2006a: 39) even regards the history of health nutrition communication as a history of relative failure. Nutritional communication is effective in the presence of a threatening or acute illness, but remains ineffective for those who are free to choose (SPIEKERMANN U 2006a; SPIEKERMANN U 2006b). 2.1 DEFINITION OF NUTRITIONAL COMMUNICATION Communication about food and drink is ubiquitous, but it remains unclear what the term nutritional communication means. It is used in a variety of ways and is confusing. A search for the keyword nutritional communication via the internet search portal Google results in hit 3.These include very heterogeneous references such as links to marketing activities for wellness or fitness offers, to nutritional education measures, to nutritional advice or therapy, to risk communication in the event of food scandals or crises, to guides, books , Cooking shows and health magazines. In the scientific literature, terms such as public nutrition communication, nutrition education, nutrition information, political nutrition communication, state nutrition education, classic nutrition education, nutrition education, nutrition education, health nutrition communication, sustainable nutrition communication, nutritional advice, media nutrition communication, public information campaigns or consumer information are used (REHAAG R ET AL. 2005 ). 3 Stand

19 Nutrition and health communication as a contribution to the prevention of overweight and obesity 9 The process of defining the term nutrition communication is still in its infancy in Germany. The first approaches come from the research projects on the change in nutrition and consumption: Eberle et al. (2004: 19) describe in the food turnaround discussion paper No. 1 nutrition communication as a social achievement of mutual understanding and differentiate between closed interaction contexts (face-to-face) and public communication (mass media). In the further course of the research project, the food turnaround concentrates on communication mediated by the media with the aim of reaching the entire population (ROSENBROCK R 2006: 5; EBERLE U ET AL. 2004: 19). The term public nutrition communication is used for this (BARLÖSIUS E ET AL. 2006: 12). The level of face-to-face communication such as everyday communication 4, nutrition education or nutrition advice is explicitly excluded and not dealt with (ROSENBROCK R 2006: 5; EBERLE U ET AL. 2004: 19). Wilhelm et al. (2005: 7) define nutritional communication in the research project Konsumwende as all measures that () institutions carry out in order to convey information, competencies and positive attitudes on the subject of nutrition to different target groups. This working group also understands nutritional communication as intended communication that aims to provide the public with information about nutrition primarily via mass media (WILHELM R ET AL. 2005: 7). It is a communication that starts unidirectionally from the communicator and sends information to a recipient. Nutritional communication can be multifaceted in terms of content and include topics such as food production, food selection, preparation, food culture or culinary arts. In addition to agricultural, food and nutritional science topics, it also touches on topics such as the environment, sustainability and nutritional medicine. Communication activities for the prevention of lifestyle diseases such as overweight and obesity are also faced with the challenge of considering aspects from the fields of medicine, nutrition, exercise and relaxation (BZGA 2010: 54). It must be checked whether nutrition communication can become an integral field of action in so-called health communication. Maschkowski and Büning-Fesel (2010: 677) take this into account in a working definition 5: Nutritional communication encompasses the conveyance and exchange of knowledge, opinions and feelings in relation to nutrition. The providers and actors of nutrition communication are professional service providers such as nutritionists, doctors, media, companies, state and semi-state institutions, but also private 4 Eberle et al. (2004: 14) Face-to-face communication in everyday life, i.e. in the household, family, colleague or friend context. 5 based on the definition of health communication according to Hurrelmann and Leppin (2001)

20 Nutrition and health communication as a contribution to the prevention of overweight and obesity 10 people who are interested in nutrition. Mediation and exchange can take place as interaction between people, but they can also be mediated through the media. (MASCHKOWSKI G ET AL. 2010: 677). This working definition is more recipient-oriented than the aforementioned definitions and opens up the possibility of interaction with the recipient of the message. It sees itself as a communication activity that emanates from experts or those interested in nutrition. It is based on the definition of health communication by Hurrelmann and Leppin (2001), but it is thematically open and does justice to the multifaceted nature of nutrition communication. However, there is still no comprehensive scientific discourse on this working definition in the nutritional literature or scientific community. Nutritional education and training are not included in the working definition by the two authors, as they go beyond communication and convey knowledge, abilities, skills, i.e. competence to act, and thereby stipulate norms and rules. (MASCHKOWSKI G ET AL. 2010: 677) The underlying definition of health communication, on the other hand, explicitly includes educational measures such as Training for patients and the target groups of pregnant women, adolescents, parents, migrants and the elderly (HURRELMANN K ET AL. 2001: 13). Overall, it can be said that nutritional communication has hardly been a topic in communication science in Germany so far. According to Rössler (2006: 69), this is a heavily neglected field of research. In scientific terms, nutritional communication is discussed in a wide variety of disciplines such as nutritional sciences, psychology, education, economics or health sciences (MASCHKOWSKI G ET AL. 2010). Research activities on nutritional communication in Germany tend to have a selective character, whereas international universities (e.g. Australia, Canada, USA) already have Bachelor's and Master's degrees in Nutrition Communication with corresponding research activities. After a detailed analysis of strengths and weaknesses of research activities in Germany in the field of nutritional sciences, the study on the innovation sector of food and nutrition also comes to the conclusion that new academic behavior, consumption and communication research with substantial infrastructure is necessary to cope with future tasks IVV, WZW 2011: 22). 2.2 FORMS OF FOOD COMMUNICATION Communication partners in nutrition communication are (professional) laypeople, nutrition experts and media actors (FROMM B ET AL. 2011: 35).The criticism of nutritional communication described above generally relates to certain forms of expert communication: nutritional information, nutrition education and nutritional

21 Nutrition and health communication as a contribution to the prevention of overweight and obesity 11 advice, less often on nutrition education (ROSENBROCK R 2006; SPIEKERMANN U 2006a; SPIEKERMANN U 2006b; PUDEL V 2003; PUDEL V 1991; PUDEL V 1984). The definitions made here are based on the following publications: Practice of Nutritional Advice (PUDEL V 1991), Nutritional Psychology (PUDEL V, WESTENHÖFER J 2003), Study Book of Nutrition Education (HEINDL I 2003) and the framework agreement of the coordination group for quality assurance in nutritional advice and nutrition education in Germany (COORDINATION GROUP FOR QUALITY ASSURANCE IN NUTRITIONAL ADVICE AND NUTRITION EDUCATION 2009). Nutritional information is a specific communication on nutritional topics. Mediation is possible both via the media (including mass media) and in direct contact. Brochures and leaflets, but also answers from a specialist to questions put forward personally, fall under nutritional information. The task of nutritional information is to impart knowledge (PUDEL V, WESTENHÖFER J 2003; PUDEL V 1991). Nutritional information can be part of nutritional advice or therapy or nutrition education and can be offered by individuals or institutions (COORDINATION GROUP FOR QUALITY ASSURANCE IN NUTRITIONAL ADVICE AND NUTRITION EDUCATION 2009). Nutritional education refers to planned measures that address the population without them asking for it themselves. It aims to raise awareness of nutrition issues, to arouse attention and interest, and to create awareness of problems. Nutritional education is understood as a transfer of information that takes place indirectly in the mass media or in lectures. Federal and state institutions, non-governmental organizations, scientific societies and consumer representatives are among the providers of nutrition education (COORDINATION GROUP FOR QUALITY ASSURANCE IN NUTRITIONAL ADVICE AND NUTRITION EDUCATION 2009; PUDEL V, WESTENHÖFER J 2003; PUDEL V 1991). Nutritional advice is aimed at healthy consumers. In a client-centered, partnership-based discussion, she provides assistance that takes into account the existing skills and needs of the person seeking advice as well as his or her life situation. She sets problem-solving processes in motion, develops and practices the necessary skills [] together with the client. Information is provided on healthy nutrition, lifestyle factors and the prevention of risk factors (COORDINATION GROUP FOR QUALITY ASSURANCE IN NUTRITIONAL ADVICE AND NUTRITION EDUCATION 2009). The objectives of the advice are: to convey the principles of healthy, wholesome nutrition in order to avoid malnutrition and malnutrition and to reduce the risk of nutrition-related diseases,

22 Nutrition and health communication as a contribution to the prevention of overweight and obesity 12 Sustainable improvement of the individual diet and eating habits as well as, if necessary, the solution of nutritional problems, improvement of decision-making ability and action competence. Nutritional advice can also serve to identify malnutrition and, if necessary, to provide the client with nutritional therapy. (COORDINATION CIRCUIT FOR QUALITY ASSURANCE IN NUTRITIONAL ADVICE AND NUTRITION EDUCATION 2009) Nutritional therapy is understood as the treatment of nutrition-related illnesses or illness-related nutritional problems. The discussion situation is similar to that of nutritional advice: the patient receives help in a client-centered and partnership-based manner. In addition, nutritional therapy provides information on pathophysiological relationships that make it easier to understand and implement therapeutic measures (COORDINATION GROUP FOR QUALITY ASSURANCE IN NUTRITIONAL ADVICE AND NUTRITION EDUCATION 2009). The goals of nutritional therapy are: imparting the principles of healthy, wholesome nutrition in order to improve the state of health (secondary prevention) and prevent relapses / secondary diseases (tertiary prevention) sustainable improvement of the individual diet and eating behavior based on the medical necessity and the individual needs and desires of the Maintaining or improving the quality of life for patients (COORDINATION GROUP FOR QUALITY ASSURANCE IN NUTRITIONAL ADVICE AND NUTRITION EDUCATION 2009). Nutrition education contributes to the lifelong shaping of people of all age groups with regard to their abilities, while education means help for adolescents on the way to fitness and maturity (COORDINATION CIRCUIT FOR QUALITY ASSURANCE IN NUTRITIONAL ADVICE AND NUTRITION EDUCATION 2009). According to Heindl (2003), nutrition education describes the endeavors of people to build up a personally meaningful diet through a healthy lifestyle, in which they receive support and guidance. Nutritional education combines the transfer of knowledge and values, socio-cultural reflection and practical action. It aims, among other things, at a modification of the nutritional behavior and can take place in all areas of the education system. Nutritional education can be used for health promotion and prevention, whereby elements of nutritional information, nutritional education and nutritional practice include the imparting of knowledge and practical skills for the preparation of meals and meals. This includes dealing with food, including purchasing, storage and product knowledge, as well as conveying food culture. The basis for nutritional practice is established nutritional knowledge. (COORDINATION GROUP 2009)

23 Nutrition and health communication can be used as a contribution to the prevention of overweight and obesity 13 (COORDINATION GROUP FOR QUALITY ASSURANCE IN NUTRITIONAL ADVICE AND NUTRITION EDUCATION 2009). 2.3 CORE ELEMENTS OF THE CRITICAL COMMUNICATION ON FOOD The criticism of the strategy and implementation of nutritional communication, repeatedly expressed in various scientific disciplines, can point to potential for improvement. Therefore, the core elements of the criticism are analyzed and summarized below. The nutritional psychologist Pudel (2003; 1991) in particular denounced the rationality principle of nutrition education and a non-realistic view of the consumer. Rational information is given to a rationally thinking consumer with the aim of changing behavior, which is to be regarded as the cause of failure. He also found that too often a rigid control of eating behavior instead of flexible control is propagated (PUDEL V 2003). The historian Spiekermann (2006a; 2006b) cites a misdirected communication strategy and a lack of target group orientation as the causes for the failure of nutritional communication that he noted. From his point of view, nutrition experts base their communication measures on their own values ​​and life situation (socialization, middle-class canon of values, above-average earned income) and are not based on the values ​​of the recipient. A lack of common understanding between the main actors in nutritional communication about the subject, strategy and goals of nutritional communication was identified as the cause of failures in the research project on the turnaround in 2006. As part of this research project, the main actors in nutrition communication from various scientific disciplines, nutrition and consumer policy and the food industry were asked to explain their view of nutrition communication 7. Barlösius and Schieck (2006) analyzed the statements in search of an improved strategy. As a result, they found that there was no common definition of nutritional communication. The actors' ideal ideas of nutritional communication also differ: They ranged from being independent, transparent and scientifically sound to taking everyday practice into account and being integrated into concrete life contexts. The messages also pursue different goals. On the one hand, an increase in knowledge is expected, on the other hand, changes in consumer behavior are expected. Also un- 7 In the sense of a public nutritional communication that is addressed to the entire population. A consideration of face-to-face communication, e.g. It is common in individual nutritional advice and has been excluded (Section II 2.1).

24 Nutrition and health communication as a contribution to the prevention of overweight and obesity 14 it has been clarified which image of the consumer (mature, rational or participatory) should be used (BARLÖSIUS E ET AL. 2006: 7). Vögele (2007) sees the focus on conveying information, often using fear appeals with drastic descriptions of the negative consequences of unhealthy nutrition, as a weakness of nutritional communication in health promotion and education. In addition, complex, confusing and contradicting messages are used that can generate reactance in the recipient (VÖGELE C 2007). A scientific research primacy in nutritional science, an inadequate interdisciplinary view, orientation towards unrealistic images of people and a devaluation of everyday knowledge are further causes that are named as reasons for the failure of nutritional communication 8 in the literature (METHFESSEL 2006; SPIEKERMANN 2006a; RÖSSLER 2006; RÜTZLER 2005: 72; MEIER-PLÖGER 2004: 14; BARLÖSIUS 2000: 115; BARLÖSIUS 1999: 67). For the further development of nutritional communication, the following recommendations for action to improve the effectiveness of nutritional communication can be extracted from the discussions of recent years (STEINBERG A 2011: 50): Communicators should also adopt a recipient-oriented view 9, respect the consumer as an expert in their own everyday life and their specific knowledge, use their needs and individual lifestyle as a starting point for successful nutritional communication aimed at the entire population. This includes taking into account the diet and eating culture of the individual or larger groups. Cognitive knowledge transfer dominates, but shows hardly any success, especially with socially disadvantaged target groups. It should be supplemented or replaced by the imparting of skills and the ability to independently shape everyday nutrition. Interdisciplinary approaches do justice to the multidimensional nature of the topic of nutrition and should replace the dominant one-sided, scientific orientation of nutrition research, teaching and training. (STEINBERG A 2011: 50) 8 Also in the sense of public nutrition communication (Section II 2.1). 9 As usual for nutritional advice and therapy (Section II 2.2).

25 Nutrition and health communication as a contribution to the prevention of overweight and obesity CONCLUSION Some aspects of the term nutrition communication have meanwhile been defined consensually 10, but there is still a confusing inconsistent use of the terms. The cause is possibly the lack of a scientific definition of the generic term nutritional communication that covers all sub-areas and a theoretical, multidisciplinary foundation of the subject. Nutritional information and nutrition education are the only population-related concepts of nutrition communication. By definition, however, they are information-conveying approaches whose task is to convey (cognitive) knowledge. According to the definition, only nutrition education, advice and therapy have a role to play in influencing behavior. The population-related forms of nutritional communication - nutritional information and education - are also measured against the target parameter behavioral change and are therefore doomed to failure. As long as the main actors in nutritional communication do not have a common understanding of the subject, goals and strategies of nutritional communication in a population-wide approach and there is no understanding of modern, realistic consumer models and simple, clear messages, there is also a lack of the basis for successful communication activities. Due to the lack of or indifferent goals, nutritional communication measures can neither be conclusively assessed, nor will it be possible to improve the effectiveness of nutritional communication for population-wide prevention measures. In view of the identified deficits and research gaps in the field of nutritional communication, the aim is to investigate whether research and theory in the fields of public health and health communication offer approaches to solving the questions and problems at hand. 10 By ratifying the framework agreement of the coordination group for quality assurance in nutrition counseling and nutrition education in Germany in 2009, the German Nutrition Society (DGE), various professional associations, consumer protection organizations and 14 other institutions approved the definitions made there (DGE 2009).

26 Nutrition and health communication as a contribution to the prevention of overweight and obesity 16 3 HEALTH COMMUNICATION 3.1 DEFINITION OF TERMS AND UNDERSTANDING Health communication is a translation of the English term health communication. Translations are also used as medical communication or medical journalism (BAUMANN E ET AL. 2012; FROMM B ET AL. 2011: 19). While the translation into health communication suggests that health is the subject of this interdisciplinary research area of ​​North American communication sciences, the two medically oriented translations already suggest that the range of topics can be broader and that illness and therapeutic interventions are also discussed (FROMM B ET AL. 2011: 19; SIGNITZER B 2001). Health Communication is a multidisciplinary research and activity field of public health (SCHIAVO R 2007: 3), communication sciences, psychology, marketing and social marketing that has been developing for around 50 years. The starting point of the department were research activities on doctor-patient communication and large US community prevention studies of the 1970s. In the period that followed, there was lively research activities, corresponding courses of study, specialist journals and even a focus on research (LEPPIN A 2003; HURRELMANN K ET AL. 2001). Health Communication is an area of ​​study concerned with human interaction in the health care process. This early and much-cited definition of health communication comes from Kreps and Thornton (1984: 2). A synopsis of 15 different definitions of the international scientific literature, each focusing on different aspects and effects, was created by Schiavo (2007: 7ff). Based on this synopsis, it proposes the following new working definition: Health Communication is a multifaceted and multidisciplinary approach to reach different audiences and share health-related information with the goal of influencing, engaging, and supporting individuals, communities, health professionals, special groups, policymakers and the public to champion, introduce, adopt, or sustain a behavior, practice, or policy that will ultimately improve health outcomes (SCHIAVO R 2007: 7). Both definitions encompass communication and interaction processes in the care of the healthy and the sick with the aim of positively influencing health behavior. These are intended forms of communication with a defined target group (BAUMANN E ET AL. 2012; FROMM B ET AL. 2011: 19). Health communication scientists have been working together in a Health Communication section within the International Communication Association (ICA) since 1975. The first textbook on health communication appeared in 1984 and the first

27 Nutrition and health communication as a contribution to the prevention of overweight and obesity 17 Scientific journal Health Communication five years later in 1989 (FROMM B ET AL. 2011: 23; SCHIAVO R 2007: 10). Health communication is now recognized internationally as an integral part of public health measures and recognized as a science-based discipline with empirical roots. It can modify behavior through its strategic orientation and bring about a change in health opportunities (SCHIAVO R 2007: 7 ff). Signitzer (2001) notes, however, that the development of North American health communication, forced to solve pressing societal problems, led to the overemphasis on individual research topics. As an example, he cites the lively US research activities in the area of ​​doctor-patient communication. An increasing number of medical malpractice lawsuits against doctors in the USA made it necessary to concentrate on the communicative quality of the medical consultation (SIGNITZER B 2001). The European and German-speaking countries are still at the beginning of this development, with expansion and professionalization being forecast for Europe (BAUMANN E ET AL. 2012).For Germany, health communication is a very new specialist discipline, the terminology of which and, in particular, how it is differentiated from medical communication or medical communication is still being discussed (SCHNABEL P ET AL. 2012; HURRELMANN K ET AL. 2001; SIGNITZER B 2001). In Germany, there is currently no institutionalization as an independent subject and research field. Various disciplines such as communication and media studies, health sciences, medicine, psychology or sociology deal with this field of research (FROMM B ET AL. 2011: 23). Here, health communication shares the fate of the development of public health and health sciences in Germany, which, according to Hurrelmann (1999: 5), took a historically determined path in an international comparison: In the 19th and early 20th centuries, Germany played a pioneering role in science-based, population-wide public health care. During the Second World War, however, the first approaches to German health sciences were smashed and their representatives expelled. Under the umbrella of National Socialism perverted activities for the preservation of public health for racial hygiene with their atrocities and crimes. This discredited the health sciences in the successor states for decades. The state system of the German Democratic Republic (GDR) provided the subject area with new ideologies. The West German states of the Federal Republic of Germany, on the other hand, neglect it (HURRELMANN K ET AL. 2012a). A successful revival of the subject of health sciences in science and practice, mostly under the name of public health (out of fear of the historical burden of the name health sciences), has only been observed since the 1980s (GERMAN GESELLSCHAFT FÜR PUBLIC HEALTH (DGPH) 2012; HURRELMANN K ET AL. 2012a). The international ni-

28 Nutrition and health communication as a contribution to the prevention of overweight and obesity 18 level of public health has not yet been achieved (HURRELMANN K ET AL. 2012a). Structural obstacles, underfunding of research and a dominance of the medical discipline make development more difficult (DEUTSCHE GESELLSCHAFT FÜR PUBLIC HEALTH (DGPH) 2012; HURRELMANN K ET AL. 2012a). In Germany, health communication was first described in the years 2000 to 2003 in the first German-language collective works and in a themed issue of health communication in the journal Medien und Kommunikationwissenschaften. The contributions in these works consider health communication from the perspective of the respective individual discipline with an occasional look at neighboring disciplines (FROMM B ET AL. 2011: 23). In the meantime, scientific and journalistic activities are intensifying with an interdisciplinary orientation. The media and health communication network founded in 2003 with network conferences, the health communication course at Bielefeld University and other academic training at (TOLKS D ET AL. 2008) have contributed to this. The first German-language monographs were published in 2011 and 2012: Health Communication and Media (FROMM B ET AL. 2011) and Health Communication More Than Talking About Illness (SCHNABEL P ET AL. 2012). The objects of research are the communication behavior of all actors involved in the healing or prevention process (doctors, pharmacists, nursing staff, health insurance companies, health bureaucracy, etc.), the communication partners (patients, relatives, doctors, etc.), the levels of communication and the framework conditions for health communication (ethics, Economics, social or cultural issues) (FROMM B ET AL. 2011; SIGNITZER B 2001). In Germany there are two definitions for health communication by Schnabel (2009) and by Hurrelmann and Leppin (2001). According to Schnabel, health communication encompasses the entirety of all more or less organized efforts, the message of health at all levels relevant to mediation (individuals, organizations, entire societies), through the use of as many targeted strategies as possible (advice, organizational development, awareness-raising and information campaigns) and using them to disseminate a mixture of suitable media (books, press, radio, television, internet) in order to influence people's attitudes and behaviors in a way that they can determine themselves as much as possible, avoiding the risk of illness and strengthening health resources oriented lifestyle, which, if necessary, must also include the ability to assert one's own health interests against resistance (SCHNABEL P 2009: 39; emphasis in the original).

29 Nutrition and health communication as a contribution to the prevention of overweight and obesity 19 Hurrelmann and Leppin (2001) understand health communication to be any type of communication that deals with health, as human interaction in the health process or as conveying and exchanging knowledge and opinions and feelings between people who are involved in the health care process as professional service providers or patients / clients and / or as citizens who are interested in issues of health and disease and public health policy. (HURRELMANN K ET AL. 2001: 11). Baumann (2012: 462 ff) states that Schnabel's definition focuses on strategies and objectives of health communication measures and communication activities that convey the message of health. Hurrelmann and Leppin include health-related and disease-related topics. Its definition includes both media and interpersonal forms of communication (e.g. doctor-patient communication), layperson 11 and expert communication. It is also based on a more modern understanding of communication because it takes into account the perspective of the recipient and an interactive design of communication processes between experts and laypeople (BAUMANN E ET AL. 2012: 463). Schnabel (2009: 49) points out, however, that when applying the definition by Hurrelmann and Leppin, two different communication cultures with different concepts and approaches come together: On the one hand, the medical-clinical / curative view, which is contained in concepts of prevention and therapy, which are based on Orienting the risk of the individual and the pathogenesis, and on the other hand the population-related, resource-oriented view of New Public Health, which is committed to the principles of salutogenesis, participation, empowerment, setting orientation and health equality (see excursus: Public Health and New Public Health ). For reasons of conceptual hygiene, Schnabel - health communication should emancipate itself from the medical-curative paradigm and concentrate on core areas of health-scientific research and action, the promotion of health and the prevention of disease (SCHNABEL P ET AL. 2012: 144; emphasis in the original). Some health scientists share this view (e.g. BAUER U ET AL. 2012; ALTGELD T 2006). This means that the process of the conceptual definition of health communication in the German health sciences cannot be regarded as having been completed yet. Excursus: Public Health and New Public Health Public health in Germany sees itself as the science and practice of preventing diseases, extending life and promoting physical and 11 communication among (professional) laypeople (see Section II 2.2).

30 Nutrition and health communication as a contribution to the prevention of overweight and obesity 20 mental health, taking into account fair distribution and efficient use of available resources (GERMAN GESELLSCHAFT FÜR PUBLIC HEALTH (DGPH) 2012). Public health is aimed at maintaining the health of the entire population. It is therefore more comprehensive than clinical medicine, which focuses on individuals and the treatment of diseases (DEUTSCHE GESELLSCHAFT FÜR PUBLIC HEALTH (DGPH) 2012). For historical reasons, the German translation of health sciences is mostly used in Germany parallel to the English term public health. In scientific parlance, the terms health sciences or life sciences are also used (HURRELMANN K ET AL. 2012a). Public health strategies include both health promotion and disease prevention measures, usually referred to simply as prevention (HURRELMANN K ET AL. 2012b). Health promotion is a complex social and sociopolitical approach that aims to analyze and strengthen the health resources of the population or of subgroups. Health promotion aims to enable people to increase their control over the factors that influence their health and thereby improve their health (empowerment) (BZGA 2010: 24). Health promotion aims to improve both health-related lifestyles and health-related living conditions (BZGA 2010: 24). Health promotion sees itself as a salutogenic active principle that strengthens and promotes protective factors (resources) for maintaining health. This is based on the idea of ​​the existence of a dynamic sequence of health stages (from health to illness) (HURRELMANN K ET AL. 2012b). Health promotion goes back to the Ottawa Charter for Health Promotion of the World Health Organization (WHO) in 1986 and its follow-up conferences (HURRELMANN K ET AL. 2012b). Health promotion is the latest concept in health sciences (New Public Health). It emerged after the ineffectiveness of the previously implemented concepts and the close connection between living conditions and health opportunities and disorders had been recognized. In the literature, the development of the health promotion strategy is also referred to as the third public health revolution. The protection of the population against infectious diseases through improved hygiene and health protection is seen as the first revolution. The second revolution was the insight that health-related risk factors can be influenced by changing individual behavior and that the risk of illness can thus be reduced. Measures such as health education, information and advice (Old Public Health) (HURRELMANN K ET AL. 2012a) are based on this insight. However, health education and information are now viewed as ineffective and naive approaches (WEITKUNAT R ET AL. 2007; GÖPFERT W 2001): Health education with the aim of changing knowledge and attitudes is

31 Nutrition and health communication as a contribution to the prevention of overweight and obesity 21 a naive approach that fulfills all the requirements to win the trophy for the most frequently falsified hypothesis. Desired behavior usually has to be modeled, rehearsed and reinforced but not explained. (WEITKUNAT R ET AL. 2007: 25) The change to New Public Health is described as a change of perspective from medically oriented pathogenesis to salutogenesis. The term salutogenesis goes back to the medical sociologist Antonovsky (1997) and his scientific studies with Israeli women who showed stable health in old age despite stays in concentration camps. He changed the scientific perspective of his work from the question of what makes people sick? towards What keeps people healthy? In doing so, he discovered the importance of stress as a cause of illness and the importance of resistance resources in dealing with stress (ANTONOVSKY A 1997; 1993). The model of salutogenesis is based on empirical findings and theoretical considerations from stress research. In addition to the stressors / resistance resources already mentioned, the core elements of the model are the idea that health and illness are not static and can therefore also be influenced, as well as the feeling of coherence. The sense of coherence describes a person's inner attitude to dealing with life's challenges. What is meant is a lasting feeling of people's trust that life events can be explained (understandability), that the resources are available to deal with them (manageability) and that efforts and commitment to deal with them are worthwhile (significance / meaningfulness) (METHFESSEL B 2007; FALTERMAIER T ET AL. 2005: 63ff; BENGEL J ET AL. 2001: 28ff). The model of salutogenesis gave rise to a new view of the behavior of people, clients and patients. Health promotion measures now take a consistently target group-oriented perspective. The individual is granted the right to a greater degree of self-determination about their own health. Using forms of participation and other methods, health promotion measures are geared towards the needs of the target group (BZGA 2010; WRIGHT MT 2010; SCHIAVO R 2007; ALTGELD T ET AL. 2004). Empowerment, i.e. the strengthening and further development of personal or social resources, is a central component of health promotion measures (BZGA 2010: 103). Health promotion is based on two other important strategic approaches: creating intersectoralism and intervention activities in social systems (setting approach) (HURRELMANN K ET AL. 2012b). The strategy of creating intersectorality sees health promotion as a cross-sectional task of various political areas and social sectors. For example, you linked

32 Nutrition and health communication as a contribution to the prevention of overweight and obesity 22 political regulations with strategies of public education, educational activities in kindergartens, schools and educational institutions, activation of club and municipal structures and / or with legislative control elements (e.g. smoking bans in public buildings and places). The intersectoral strategy is often linked to health communication measures (HURRELMANN K ET AL. 2012b; ALTGELD T ET AL. 2004). Measures in social systems (settings, living environments) receive the greatest attention in practice. The setting approach assumes that health arises in everyday life and that social spaces such as e.g. Kindergartens, schools, companies etc. have a strong formative effect on the behavior and well-being of people. In the setting, personal measures can be linked with environmental strategies (HURRELMANN K ET AL. 2012b; EXPERT COUNCIL FOR THE EVALUATION OF THE DEVELOPMENT IN THE HEALTH SECTOR 2005; ALTGELD T ET AL. 2004). Disease prevention uses a different intervention logic, as it is based on the basic idea of ​​pathogenesis and the risk factor concept (HURRELMANN K ET AL. 2012b). Prevention aims to anticipate diseases and avert the risk of diseases occurring. Ultimately, however, like health promotion, it aims to improve the health and well-being of the population or of subgroups (HURRELMANN K ET AL. 2012b; BZGA 2010: 24). A classification of preventive measures according to the time at which they intervene in the disease process has been common for decades, but repeatedly leads to misunderstandings, since the various specialist disciplines assign them differently (HURRELMANN K ET AL. 2012a). The terms primary, secondary and tertiary prevention are commonly used. However, they are ultimately only auxiliary constructs for organizational purposes (LEPPIN A 2004), which could prove to be out of date in the future due to the difficulties in selectivity (HURRELMANN K ET AL. 2012b). Therefore, the present work is based on a division of the forms of prevention into universal and selective prevention. Universal prevention was aimed at large sections of the population in a broad approach. Measures of universal prevention on the subject of body weight are aimed at under-, normal- and overweight people of all socio-cultural origins in all walks of life. Primary prevention can also be subsumed under the term universal prevention (BZGA 2010: 24). Selective prevention (targeted prevention) is aimed at particularly vulnerable groups due to existing risk factors for a disease or a particular risk situation (e.g. social situation, migration). Secondary and tertiary prevention measures can be subsumed under this term (BZGA 2010: 24). In addition, the terms relative prevention and behavioral prevention are used. Relational prevention aims to protect the social, cultural, ecological and economic

33 Nutrition and health communication as a contribution to the prevention of overweight and obesity 23 mix Change environmental conditions and influence the emergence and development of diseases via living environments (setting approach) (LEPPIN A 2004). Behavioral prevention, on the other hand, focuses on people's individual behavior. Behavioral preventive measures should lead to a change in behavior, e.g. lead to a healthy lifestyle or they strengthen individual skills and resources. (BZGA 2010: 25) Prevention courses, health education offers or campaigns are common behavioral preventive measures. The separation of the two strategies of health promotion and prevention shown here is handled more strictly in German-speaking countries than, for example, in Anglo-American countries. There the terms health promotion and health prevention are mostly used interchangeably (LEPPIN A 2004).3.2 LEVELS OF COMMUNICATION AND FORMS OF HEALTH COMMUNICATION According to Signitzer (2001: 28), the four-level model by Chaffee and Berger (1987), which is widely used in communication sciences, is suitable for systematizing the research field of health communication. Accordingly, the communication levels of health communication can be differentiated into the levels of intrapersonal communication, interpersonal communication (doctor-patient communication, nutritional therapy or individual counseling), organizational communication and social / mass media communication. Signitzer (2001: 29ff) outlines the subject areas and research objects of the respective levels of health communication as follows: Intrapersonal level: Individual psychological and psychological processes that are relevant for the perception of one's own state of health and for health behavior are the subject of this level. Analyzes at the intrapersonal level are elementary for all other levels. Health attitudes and ideas of the individual, which influence their health behavior, and mental and psychological processes in connection with health and illness are analyzed. Interpersonal level: Interpersonal communication in dyads or groups is the subject of research at this level. Communication processes among and between laypeople and professional people working in the health sector (e.g. doctor-doctor, doctor-patient, patient-nurse, doctor-nurse, consumer-service provider, insurance employee-insured, etc.) are considered.

34 Nutrition and health communication as a contribution to the prevention of overweight and obesity 24 Organizational level: Internal and external health-related communication processes in organizations or settings (e.g. in hospitals, medical practices, retirement homes, self-help groups, etc.) are the subject of this research level. Social communication / mass communication: Research is carried out on population-wide communication activities and their social, cultural and media influence on health-related attitudes and behavior. Medical journalism but also communication campaigns via media such as television, radio, etc. can be assigned to this level. Population-wide health communication via (mass) media is assigned exclusively to the level of social communication / mass communication in the four-level model. Baumann, Lampert and Fromm (2012) show, however, that this classification is no longer up-to-date. The localization of (mass) media communication only on a societal level no longer seems appropriate, especially in view of the current penetration of all areas of life with media, the great importance of media communication strategies on the organizational level and the close mutual influence of interpersonal and media communication processes. (BAUMANN E ET AL. 2012: 467) For example, doctor-patient communication is no longer limited to a personal conversation, but can also take place via telephone / mobile phone or via the Internet via email or chat. Mass media offers (e.g. television or print media) are usually also linked to Internet offers, which in turn enable interpersonal communication in forums or chats. Fromm, Baumann and Lampert (2011: 30ff) therefore expand and systematize the research field of health communication via media. They introduce the term media health communication for this research field and adapt the communication levels on the basis of this point of view (Table 1). The subjects of media health communication research at the mass media level are media content, use and impact, the media influence on health-related attitudes and behavior, taking into account the perspective of the offer and the recipient, and the evaluation of campaigns (Tab. 1). The term communication campaign includes the conception, implementation and control of systematic and targeted communication activities to promote awareness of the problem and to influence the attitudes and behavior of certain target groups with regard to social ideas, tasks or practices in a positive, i.e. socially desirable sense. (BONFADELLI H ET AL. 2006: 15)

35