The Failure of Adolescent Nutrition Interventions: A Critique Based on the Social Learning Theory – Jena Diwan

Introduction

The epidemic of childhood obesity is continuing to rise and little attention is focused on adolescents (21). Data from the National Health and Nutrition Examination Survey (NHANES) surveys (1976–1980 and 2003–2006) show that the prevalence of obesity has increased for those aged 12–19 years from 5.0% to 17.6% (6). Obesity in this teen population is an increasing public health problem with this population facing major health problems as they age. Obese adolescents are more likely to become obese as adults. One study found that approximately 80% of children aged 10-15 years who were overweight were obese at age 25 years (8, 13).
The health concerns are immediate and therefore it is necessary for public health interventions to halt this rising problem. Nutrition in the adolescent population has been poorly addressed and is desperate need of a turn around. Teenagers are encouraged to consider that what they eat today will hurt their future. Public health professionals continue to engrave the long-term health effects of obesity, including, heart disease, high blood pressure, high cholesterol, and diabetes, into the minds of the American people. (22, 5, 12, 17, 3). There are no active programs to encourage these teenagers to notice more instant ramifications. It is important for public health practitioners to remember that this generation works on quickness and immediateness. Simply informing this population of hazards to arise in the future, will most likely be ignored and forgotten. The main limitations of current and past adolescent nutrition public health campaigns is that they do not address social norms, they do not have a desired outcome and there is no positive reinforcement for the requested actions.

Addressing Social Norms
Another necessary factor public health practitioners need to consider when implementing interventions to help prevent the rise of adolescent obesity is to consider the role social norms have an adolescent’s decision-making process. According to the Theory of Reasoned Action and the Social Learning Theory, an appropriate intervention would include perceived social norms into its model (15). The campaign should promote a healthy attitude and a decision within acceptance of social norms. Thus far, nutrition public health campaigns have failed to incorporate social norms successfully. There are a variety of elements to consider when looking at social norms of adolescents, including the desire to eat with friends and the role media has on promoting junk food.

Most adolescents eat out with friends on a regular basis. If their friends are all ordering hamburgers and French fries, they are more likely to order a hamburger than a salad. This sense of peer pressure is constant in an adolescent’s life (2). Fast-food restaurants are main source of poor diet selection. A recent study assessed why adolescents eat at fast-food restaurants. The study found that 92% ate fast food because it was quick, 69% said the food tasted good, 33% said it was a way to socialize with friends, 21% said it was nutritious and 12% felt that was fun and entertaining(23). It may be useful to implement a policy that provides adolescents with alternatives to fast-food restaurants (12).Junk food and sweet soft drinks are also popular among adolescents. These junk food items are even promoted at school. When a teen opts to eat at school, the poor food choices are still present. In order to generate additional revenue, most schools offer foods that are popular with students, such as candy, cookies, French fries and chips (16). Although the school setting is something that needs work, the mass media probably has the largest influence on teenager’s poor diet patterns. For example, there was a Doritos commercial in a Laundromat, where two men get the attention of an attractive woman by eating Doritos. This advertisement offered a “cool and sexy” behavior that is in acceptance with social norms.

Adolescents are at a developmental stage in which commercial products are an important factor in shaping their identities. They are less able to recognize the persuasive intent of advertisements and to critically evaluate advertising claims (16). The 5 A Day Campaign is boring and does not incorporate any benefits (11). Sprite commercials incorporate Kobe Bryant to reinforce poor eating habits with a sense of social acceptance. In one of these commercials, they have Kobe working out vigorously as he describes how he has overcome negative pressures. The commercial ends with Kobe saying, “What’s my thirst? Proving them wrong” and then drinking a Sprite. This commercial would be highly effective in a food/drink item that was healthy. Instead, it inspires adolescents to drink Sprite to be more successful and popular like Kobe.

We can use the Social Ecologic Model to describe the key differences between these campaigns. This model incorporates individuals, interpersonal groups, organizations, communities and society. The individual category focuses on changing people’s knowledge and beliefs (9). The interpersonal groups are used to encourage more healthful behaviors, giving individuals the knowledge and support they need to make good nutrition choices. Both of the campaigns focus on the individual. Organizations can help members make better choices about healthful eating through changes to organization policies and environments as well as by providing health information (9). For example, the Sprite commercial implies that sports can aid in doing this. Communities can work together to promote nutrition (9). Society encompasses all of the categories to work together for a change (9). If society would work together to fight against adolescent obesity this could make an impact on a larger scale (18).

Focusing on a Desired Outcome
One necessary factor public health practitioners need to consider when implementing interventions to help prevent the rise of adolescent obesity is a desired outcome. This element is outlined in the Social Learning Theory (1). This theory states that individuals are more likely to adopt a behavior if it results in a desired and valued outcome. The underlying element of the current interventions is punishment rather than desire and benefits.

One intervention, BMI Report Cards, exemplifies the weak underlying motive. It informs parents of their child’s potential weight problems (13). This intervention could be beneficial; however it does not promote self-efficacy or a desired outcome. Rather than an interactive tool that could provide the child with motivation and concern for diet, it fails to produce any sort of reward. Sending the child/adolescent home with a BMI report card, is just the same as sending a child/adolescent home with a notification of a poor score on an assignment or test. Another intervention that produces a punishment outcome is the American Medical Associations recommendation for physicians to implement dietary rules, such as suggesting 5 or more servings of fruits and vegetables per day, and parameters for television or computer viewing of no more than two hours per day (21). The two main elements, rules and parameters, in this recommendation are restricting and not desirable. This negative labeling lowers desire to adopt a particular behavior.

Another issue that needs to be addressed is providing younger populations with immediate outcomes. Current interventions discuss implications of health effects in the future as opposed to focusing on what they could be enjoying now if they maintained better nutrition. Many adolescents will brush these health warnings off thinking that it is something to worry about when they get older and would rather eat what they would like. Taste and cost often overrides nutrition goals when making food choices (1, 24). For example, involving students in taste testing and voting for school foods is another successful strategy for encouraging students to eat healthier while in school (12). Another example may be that outcome expectancies may explain the lack of popularity for many fat-free items. They are often considered unpalatable and expensive. Considering these factors, the expected outcome would be unfavorable toward adopting the desired behavior (eating fat-free foods) because short-term outcome expectancies outweigh long-term expectancies (1, 16). This is especially true for adolescents who are a generation that require instant gratification. When long-term outcomes are not clear (such as, heart disease and diabetes) and lack obvious immediate benefit, adopting the behavior change is challenging. Since no immediate benefits are presented, adolescents are less likely to adopt the behavior of maintaining a healthy diet.

It would be beneficial for public health practitioners to make eating healthier more appealing and interesting. Working closely with other fields that specialize in studying and shaping human behavior and interactions, such as sociology and psychology, would be beneficial in adding constructs to models explaining food and diet-related behavior(1). Understanding adolescent’s dietary behaviors is an important factor in creating an enticing appeal. In order to do this it can be helpful to combine the knowledge of school policy influences with measures of home, neighborhood, media and other influences (14, 20). Developing interventions that include a desired outcome is an important factor for improving the nutrition of adolescents.

Implementing Positive Reinforcement
Another necessary factor public health practitioners need to consider when implementing interventions to help prevent the rise of adolescent obesity is to implement positive reinforcement for adopting a healthy diet pattern. This concept is highlighted in the Social Learning Theory, as an important element in adopting a behavior. As discussed in class, people that are overweight and/or clumsy are less likely to exercise because of negative reinforcement. This negative reinforcement is found within social context and in current campaigns.
The 5 A Day campaign is an example of a campaign that attempted to motivate young adults to eat more fruits and vegetables but did not provide a beneficial outcome. The campaign was boring and dry and did not stimulate a motivation to change behavior. The “Fat Chance” advertisement is another example of a campaign that failed to provide positive reinforcement. Rather than providing an inviting image it negatively labels overweight/obese people and implies that they have no chance of ever changing. It is almost as if it creates a movement in the opposite direction desired. Rather than enticing a rebellion to change these standard beliefs of overweight/obese populations, it may settle with children and adolescents as a life sentence that they can never counteract or conquer. This type of negative reinforcement captures the failure of this particular intervention and exemplifies the need for a different approach.

As stated in the Social Learning Theory, individuals are more likely to adopt a modeled behavior if the model is similar to the observer and has admired status and the behavior has a functional value (4). Coding modeled behavior into words, labels or images results in better retention than simply observing (4). Although labeling individuals is a strong technique for adopting a desired behavior, negative labeling will have the opposite effect. Listening to an older stranger preach to you about healthy eating choices is most likely not going to settle well with teenagers. This method seems like it negatively labels teenagers and is not reassuring. This method is in desperate need of a change as it does not provide positive reinforcement and motivation for teenagers to adopt a healthy eating pattern. Role modeling may be the simplest form of making media a more positive agent in young people's healthy development (19). It would be beneficial to have a young celebrity, such as the Jonas Brothers, Miley Cyrus or Hayden Panettiere, sponsor one of these interventions. This would be perceived as inspirational and someone that the adolescents can actually relate to. There are ways to make media a more positive agent in young people's healthy development and it is up to public practitioners to recognize this and create interventions that develop positive reinforcements for incorporating a healthy diet into an adolescent’s life.

Conclusion
Current adolescent nutrition campaigns are failing to reach the intended audience’s acceptance. These campaigns are often delivered by an unknown, boring source. Elements of the Social Learning Theory, Theory of Reasoned Action and the Social Ecological Model would help public health practitioners gain insight as to how these interventions need to change in order to become effective. It is important to address not only individual behaviors but also the environmental context and conditions in which teenagers live and make choices/decisions. Individual behavior change is difficult to achieve without addressing the context and influences adolescents have when making decisions, including social pressure. In considering developing a desired outcome, adjusting for social norms, and providing positive reinforcement, public health campaigns should be able to address the nutrition problem in adolescents in a more effective manner.

“No Junk” Campaign: An Effective Public Health Intervention to Help Improve Adolescent Nutrition – Jena Diwan


Introduction
Current adolescent nutrition campaigns have failed to address the public health concern of the rising obesity epidemic in adolescents. The main limitations of current and past adolescent nutrition public health campaigns is that they do not address social norms, they do not have a desired outcome and there is no positive reinforcement for the requested actions. Individual behavior change is difficult to achieve without addressing the context and influences adolescents have when making decisions. Concepts from the Social Learning Theory can help shape these campaigns to be more productive.

Intervention
An intervention that could address the failures of the past adolescent nutrition public health campaigns is the “No Junk” campaign. This campaign will promote healthy eating patterns in males and females aged 13-19 (6, 25). It will discourage eating fast food and junk food by producing a variety of commercials promoting a healthy lifestyle endorsed by teenage celebrities.
The campaign team will be comprised of public health policy makers, sociology specialists, psychology specialists, marketing/advertising specialists and adolescents in order to properly deliver the best campaign possible. We will use this study team to conduct formative research on interests and desires of our target population. The slogan of the campaign will be “Put up a Fight While Eating Right!” This slogan will bring the images of the commercials and identity that they create into a brand that adolescents can relate to. The celebrity spokespersons for the “No Junk” campaign will be Shawn Johnson and the Jonas Brothers. They will help develop a desired outcome and provide positive reinforcement while addressing social norms.

Addressing Social Norms
Unlike previous campaigns, The “No Junk” campaign will take into account the role of social norms in an adolescent’s decision-making process. Peer pressure is constant in an adolescent’s life and perceived social norms need to be incorporated into the model as stated in the Theory of Reasoned Action and the Social Learning Theory (2, 15). The campaign will promote a healthy attitude/behavior and a decision within acceptance of social norms. By using the media as an outlet, this campaign will provide advertisements to show that eating healthy is accepted within social norms. It will do this by having celebrity endorsements of alternatives to fast food and junk food.

The media most likely has the largest influence on teenagers’ poor diet patterns. Media can be used as a more positive agent in young peoples’ healthy development. A commercial by the “No Junk” campaign that will exemplify this positive role will be a commercial against McDonald’s. In this commercial, you will see teenagers gathering pounds of packaged fat from pick-up trucks and dropping them in front of the McDonald’s headquarters. They will announce that this is the amount of fat put into the food that one McDonald’s store gives to their customers, that they put inside their bodies, each week. At the end of the commercial the screen will say, “This advertisement is brought to you by the ‘No Junk’ campaign: ‘Put up a Fight While Eating Right!’” This commercial will bring teenagers together to rebel against fast food restaurants from damaging their bodies and ruining their futures. It will address social norms as it will have a group of adolescents grouped together who will create a rebellion and a positive movement. This will incorporate individuals as well as a sense of the community and society.Through the combination of the community and a younger population, the “No Junk” campaign will strive to address social norms. A recent study found that 33% of adolescents said they eat fast food because it is a way to socialize with friends (23). This campaign will produce advertisements that will express to teenagers that there are plenty of other ways to socialize with friends within social norms, including eating at sandwich restaurants and going bowling.

Focusing on a Desired Outcome
The “No Junk” campaign will take into consideration the fact that individuals are more likely to adopt a behavior if it results in a desired and valued outcome. In support of the Social Learning Theory, it will promote self-efficacy and a desired outcome (1). Since the target audience of the campaign will be adolescents, it will focus on providing instant gratification. It will capture the audience’s attention quickly and provide an easy, quick and attractive behavior to be adopted. The ultimate way of getting the behavior adopted would be focusing on a desired outcome. The campaign will do this by also providing outcomes that are desirable in the foreseeable future.
The “No Junk” campaign will provide immediate outcomes. Rather than threatening the younger population with complications and health hazards in the future, this campaign will engage adolescents and provide them with encouragement to eat healthier. A main weakness of other adolescent nutrition campaigns is that they fail to recognize that short-term outcome expectancies outweigh long-term expectancies with their focus on preventing diseases in the future (1,16). This campaign instead will promote a “cool” perception of eating healthy and will help teenagers realize that there are tasty healthy alternative options.
An advertisement by the “No Junk” campaign that will create a desired outcome will include the Jonas Brothers. They will be in a school setting, with lockers surrounding them, juggling full-sized carrots. After juggling they will catch each carrot in their mouths. As they eat each carrot, beautiful girls will surround them in awe and adoration. The commercial will end with the screen showing, “This advertisement is brought to you by the ‘No Junk’ campaign: ‘Put up a Fight While Eating Right!’” This will create an enticing appeal that is desirable and within social norms for the adolescent population.
This campaign will not create an outcome that represents a punishment, like the BMI report cards do. It will also not negatively label the adolescent population so that it does not deter desire to adopt a healthy eating pattern. There will be immediate benefits to the campaign’s desired behavior so that adopting the behavior change will be easy and desirable. It will focus on making eating healthier more appealing and interesting with a more attractive and enticing appeal, such as the Jonas Brothers. The Jonas Brothers will still be able to maintain their popularity by eating healthy choices. This will help shape behavior and interactions to adopt this healthy eating behavior (1).

Implementing Positive Reinforcement
The “No Junk” campaign will be an intervention that implements positive reinforcement, as discussed in the Social Learning Theory, to help prevent the rise of adolescent obesity. The designers of the campaign will acknowledge that people who are overweight/clumsy are less likely to exercise because of negative reinforcement. It will remove the negative label of overweight teenagers and will produce a positive outlook on change and prevention of obesity in the future.
A commercial by the “No Junk” campaign that would imply positive reinforcement will include Shawn Johnson. It will be placed at a gymnasium and she will do a triple back flip off of a balance beam. As she lands she will grab an apple and conclude the commercial by saying, “What’s my hunger? Proving them wrong.” Once again the commercial will end with our brand, with the screen displaying, “This advertisement is brought to you by the ‘No Junk’ campaign: ‘Put up a Fight While Eating Right!’” This commercial will use a role model who will also be a teenager that will help stimulate motivation to adopt the desired behavior. It will be convincing by producing a desired outcome, which will be enforced by a teenage athletic icon.
As stated in the Social Learning Theory, individuals will be more likely to adopt a modeled behavior if the model is similar to the observer and has admired status and the behavior has a functional value (4). Role modeling may be the simplest form of making media a more positive agent in young people's healthy development (19). This is why it will be beneficial to use adolescent celebrities as the campaign’s spokespersons. The message that they deliver will most likely be perceived as inspirational as they will be people that adolescents can actually relate to, unlike previous campaigns such as the 5 A Day Campaign. Not only will they be a voice they can recognize, they will also keep the idea entertaining and desirable. They will not label overweight/obese children, while appealing to all adolescent populations, unlike the BMI report cards and the 5 A Day Campaign.

Conclusion
The “No Junk” campaign will revolutionize the adolescent nutrition public health world. The diverse campaign team will be useful in developing a more effective intervention for this rising epidemic. The spokespersons will step into the media light in order to deliver a powerful and permanent message for adolescents to adopt the behavior of eating a healthy diet. By addressing social norms, producing a desired outcome and executing positive reinforcement this campaign will successfully reach its target audience. The campaign will incorporate ideas from the Social Learning Theory by incorporating the individual, social and environmental level while considering self-efficacy, reinforcement and the structure of behavior. The “No Junk” campaign will be the beginning of an effective series of adolescent nutrition public health campaigns geared at reducing adolescent obesity.

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