Challenging Dogma - Spring 2009

Friday, May 1, 2009

"Small Steps: Limited Rewards" - The Failure of the National Diabetes Education Program's Diabetes Prevention Program Sharon Touw

According to data from the National Health and Nutrition Examination Survey (NHANES) and the National Health Interview Survey, in 2003, 23.6 million people in the United States had diabetes. In adults, type 2 diabetes accounts for 90 to 95% of all new cases of diabetes, so this paper will focus on this form of diabetes which is characterized by a gradually increasing resistance to insulin until the pancreas is no longer able to produce it. (1,2) According to data from the NHANES III, 9.7% of the US population, aged 40-74, had impaired fasting glucose (abnormally high glucose levels after fasting) and 15.6% had impaired glucose tolerance (abnormally high glucose levels after a two hour glucose tolerance test. (1) A person having one or both of these conditions is considered to have prediabetes, meaning that their glucose levels are high, but not high enough to be characterized as diabetic. Individuals with prediabetes are 5 to 15 times more likely to develop diabetes type 2. (3)
Diabetes is a long-term, chronic disease that requires extensive self-management and provider involvement in clinical care. The costs on the health care system, the family, the community and the individual can be devastating, so it is a worthwhile endeavor to try to prevent or delay the onset of diabetes. In 2007, diabetes cost the United States 174 billion dollars in direct medical costs and 58 million dollars in indirect costs such as disability, premature mortality and work loss. (2) Several randomized trials have shown that modest behavior modification can delay or even prevent the onset of type 2 diabetes when individuals make minor adjustments to their diet and moderately increase their activity level. (4-6)
Recognizing this, the National Diabetes Education Program (NDEP), a partnership of the Centers for Disease Control in partnership with the National Institutes of Health and other organizations, established the “Small Steps: Big Rewards” program to educate individuals at risk of developing diabetes. (7) The "Small Steps” program is trying to convey a message of hope that modest changes in diet and exercise can prevent or delay the onset of diabetes. Their core message is that with a small amount of effort and minimal behavior modification, people who have prediabetes, a family history of diabetes, BMIs characterized as overweight or obese, or other risk factors are capable of preventing or delaying the onset of diabetes. The program encourages people to walk or participate in other moderate physical activity for 30 minutes a day. The campaign also promotes healthier eating habits, such as eating fast food, choosing healthier fast food options, consuming more fruits and vegetables, eating smaller portions and avoiding fried foods. Their hope is that cumulatively these minor changes will have a major impact on the health of the individual resulting in weight loss, since elevated BMI is one of the strongest predictors of diabetes. (8) The "Small Steps" program encourages individuals to lose 5-10% of their body weight, which they deem an attainable goal.
The program is also trying to empower people and build their self-efficacy. It drives home the message that you as an individual are in control of your body. Genetic and other risk factors play a role, but ultimately, you need to take charge of your health and prevent the onset of diabetes. Messages include "Get Real. You don't have to knock yourself out to prevent diabetes." Another message aimed at older people states, "It's not too late to prevent diabetes." The Game Plan campaign provides educational and planning materials such as calories and activity trackers for individualized "game plans" for diabetes prevention. (7) Although the posters use different imagery and themes, the message stays the same – namely, you are in control of whether you develop diabetes and that by taking small, manageable steps, you can achieve better health.
The “Small Steps” campaign targets the groups at higher risk for developing diabetes, namely older Americans, African Americans, American Indians and Native Alaskans, Asian Americans and Hispanic Americans since diabetes disproportionately affects these groups. According to the Office of Minority Health, African Americans are 1.9 times more likely to be diagnosed with diabetes, American Indians and Native Alaskans are 2.3 times more likely and Hispanic Americans are 1.5 times more likely than non-Hispanic Whites in the same age group. (9)
The National Diabetes Education Prevention's campaign "Small Steps: Big Rewards" campaign will fail for three major reasons. First, they have based their intervention largely on the health belief model and the theory of planned behavior, ignoring some of the basic tenets that characterize human behavior. By focusing their strategy on individual-level risk factors, they did not contextualize these factors in the social and physical or built environments of the individuals. They also did not consider the challenges of building self-efficacy in a marginalized and disempowered community. Second, the “Small Steps” campaign does not recognize the challenges to participating 3o minutes of physical activity faced by the residents of many neighborhoods and communities. Third, the “Small Steps” intervention does not take into account that many low income neighborhoods lack access to nutritious, high quality food in low SES neighborhoods.
Laying the Foundation on the Individual-Based Models of Behavior Change
The NDEP's "Small Steps: Big Rewards" campaign is based on individual level models of behavior change. Specifically, it incorporates elements of the theory of planned behavior and the health belief model. The Theory of Planned Behavior developed by Icek Ajzen requires the individual to rationally weigh their personal behavioral beliefs, with normative beliefs, how they think their family and friends perceive the behavior and the importance of this perception. Additionally, the individual must have enough "perceived behavioral control;" namely, they must feel that they have both the ability and strength to make the behavioral change. (10)
The "Small Steps Big Rewards" includes each of these elements. It presents positive images about exercise and diet to try and impact a person's personal behavioral beliefs. It incorporates images of family members, spouses, children and grandchildren, to remind people of the importance of staying healthy for those who love them and depend on them. Finally, the “Small Steps” campaign is trying to build a foundation of self-efficacy or perceived behavioral control. It emphasizes repeatedly that only minimal action — "small steps" are necessary to garnish large rewards. The goal is to both influence a person's beliefs about the behavior and to help build the perceived behavioral control or self-efficacy needed to take on the challenge of losing weight.
The "Small Steps" campaign also brings in some elements of the health belief model. They present the benefits of adopting diet and exercise modifications and try to present these modifications as being easy to achieve and minimize barriers to achieving minor weight loss and other health goals.
Though the premise of the "Small Steps" campaign isn't wrong, it unfortunately fails to move beyond the individual level theories and is thus not very useful in effecting behavior change. Diabetes is a problem that is plaguing entire communities, and the focus on individual behaviors ignores the fact that the individual makes decisions and operates in a larger social and environmental context.
The “Small Steps” campaign did not leave room for irrational behavior. It makes the assumption that by presenting clear information and “simple” ways to change behaviors, that people would make the rational choice, especially to avoid the pain, suffering and complications of diabetes. Unfortunately, humans often make irrational decisions. This is especially the case in food consumption where external factor such as the eating behaviors of others or the amount of people present at meal have been shown to influence consumption. (11, 12) Furthermore, people do not even recognize that these external factors play a large role in their consumption patterns. (13) The "Small Steps" campaign also does not recognize the macro-level factors such as food prices, food trends (eating more meals outside the home and larger portions), advertising, and the increased consumption of soft drinks. (14) An individual's food habits have been steeped in American culture, and it will take more than a colorful poster or ad to change behavior that is so entrenched in the daily routine.
The “Small Steps” campaign did not account for the fact that people do not gain weight as individuals, but as groups. Using data from the Framingham Heart Study, Christakis and Fowler showed that a person had a 57 percent greater chance of becoming obese in a certain time period if she or he had a friend who became obese in this period. If one spouse became obese, the likelihood that the other spouse would become obese increased by 37 percent. (15) Since individuals are adopting unhealthy behaviors as a group, then successful interventions need to be targeted at the level of the family, neighborhood and community to truly tackle the roots of the obesity and diabetes epidemics.
Although the “Small Steps” campaign incorporates self-efficacy as a necessary component to translate a behavioral intention into action, the campaign did not take into account that their upbeat messages may not be enough to counter the lack of empowerment and felt by many in lower SES groups when faced with something as daunting as obesity and diabetes. A New York Times piece exposes the situation in East Harlem where people are dying of diabetes at twice the rate of people of people in the entire City. New York City already has a high prevalence rate of diabetes with one in 8 people having received a diagnosis. One of the people profiled in the article sums it up well by saying, "Around here if you make it to 40, you think, hey, I'm lucky, I made it to 40. You have to understand, the philosophy out her is we're going to die from something." Amongst those interviewed for the article, there was a prevailing attitude of despair and discouragement when looking at the diabetes in their own lives and in their communities. (16) Communities such as East Harlem where there is lack of engagement in the political process and less vehicles for community engagement are powerless in the face of such a daunting disease as diabetes. Disempowerment and powerlessness over disease has been shown to be a broad-based risk factor for disease (17)
Taking care of one's health often takes a place on the back burner in comparison with other more pressing concerns such as day-to-day survival, taking care of children and grandchildren, youth violence and drugs. Maslow’s Hierarchy of Needs can be used as evidence for the failure of the “Small Steps” campaign, especially among low SES communities. According to Abraham Maslow, people have a hierarchy of needs with physiological needs such as air, food and water, forming the basis of the pyramid, followed by safety/security needs. Before an individual can nurture needs related to esteem and self-actualization (which is where optimal or improved health might fall), s/he needs to feel that the basic physiological and safety needs have been met. (18) Since the “Small Steps” campaign is focused on fulfilling a higher level need, it does not work for many who are facing food and housing insecurity, violence or other more pressing problems.
Finally, a danger of focusing on individual level risk factors is that you take the risk of stigmatizing the individual, namely that a person develops diabetes because they are fat, lazy and don't care about their health. If interventions fail to look beyond the individual level risk factors, they are at risk of stigmatizing a group of people who are already struggling with a complex, time-consuming, and challenging disease.
30 Minutes of Daily Physical Activity – Not Such a Small Step
The physical environment in which a person lives, works, studies, shops, eats, and exercises, sometimes known as the built environment, may have a tremendous influence on individual risk factors. The CDC defines the built environment as "the buildings, roads, utilities, homes, fixtures, parks and all other man-made entities that form the physical characteristics of a community." (19) The built environment has always been of interest to urban planners, but in the past decade, it has become of more interest to the public health practitioner. There have been several studies that have looked at BMI, reported physical activity and its association with access to playgrounds, community centers or other places for recreation activity. (14, 20, 21) Gordon-Larsen et al. looked at the availability of recreational, facilities with in different census blocks and its association with physical activity and BMI in adolescents. They found that blocks with low SES groups and blocks composed of largely minority groups had fewer recreational facilities with many having no access to facility within 5 miles. The lack of recreational facilities was positively associated with less physical activity among the adolescents, more overweight and obese adolescents and an increased risk for developing type 2 diabetes. (21)
The study did not evaluate if the recreational areas were considered safe and if parents felt that children could walk to and from facilities safely, other important factors in the built environment. Public health practitioners need to evaluate the perceived safety of the environments in which people live. Parents may prefer that their children be home watching televisions and playing video games, safe and accounted for, rather than out engaging in their 30 minutes of physical activity as advocated by the "Small Steps" campaign. It's obvious that the designers did not take into account the environments in which many of those at risk of developing diabetes are living. The intervention was aimed at those individuals living in safe neighborhoods with access to adequate recreation facilities.
Evaluating Food Options and Costs
The "Small Steps" campaign also advises individuals to eat more fruits and vegetables, prepare more foods at home and to avoid high fat fried foods – all worthy and appropriate things to do in the effort to reduce the risk of developing diabetes. However, the campaign does not take into account the fact that the very people they are targeting may not have access or the availability to take these "small steps." For some, these steps may be a monumental task.
The businesses located in a neighborhood may not allow for individuals to comply with the dietary recommendations of their doctors or campaigns such as “Small Steps.” Researchers have begun to conduct neighborhood level analyses about what types of food-related businesses are available in particular neighborhoods. Neighborhoods characterized as lower SES often do not have stores that stock the types of foods that are recommended for diabetics, specifically, high fiber or low carbohydrate bread; fresh fruits; fresh green vegetables or tomatoes; low fat or skim milk; and diet soda.. Horwitz et al. conducted food availability surveys comparing East Harlem to the Upper East Side, two vastly different neighborhoods in New York City. In 1998, East Harlem’s population was 40% Black, 50% Hispanic and had a median household income of $21, 295. On the other hand, the Upper East Side’s population was 2% Black, 4% Hispanic and had an average median income of $74,130. The study showed that Upper East Side stores were 3.2 times more likely than East Harlem stores to stock all recommended food items. (22) Another interesting study looked at the food environment and its impact on residents' diets and found that only 8% of Black American lived in a census tract with at least one supermarket. For Black Americans, the presence of a supermarket was associated with increase intake of fruits and vegetables. (23) People may want to comply with the recommended daily servings of vegetables and other healthy foods, but may not have access to the stores that sells fruits and vegetables.
Other studies have looked at the number of fast food restaurants in different neighborhoods. A study by Block et al. looked at the geographic location of fast food restaurants and the socioeconomic characteristics of neighborhoods within New Orleans. They found that there were 2.4 fast food restaurants per square mile in predominantly Black neighborhoods in comparison with 1.5 in predominantly White neighborhoods. (24) Other studies have been carried out in different cities with similar results. (25) The “Small Steps” campaign’s colorful images of fruits and vegetables and inspirational messages do not alleviate the problems associated with lack of food choices and the ready access to unhealthy options that plague many lower SES neighborhoods.
It is also useful to look at the transportation in a neighborhood and the methods of transportation that are available for people to do their shopping. If the supermarket is in another neighborhood, is it worth the time, money and energy to take a bus or two to buy food to prepare a home-cooked meal? Does a busy mother or caretaker even have the time?
Fresh foods and vegetables are also more expensive and a person on a fixed income may not have enough resources to purchase them. Energy dense foods have been shown to be associated with lower costs, and these foods have been linked to over consumption. Families facing food insecurity often face problems with obesity as they choose processed food, and products with refined flours and sugars in order to be able to purchase enough food for the entire family. (26) The “Small Steps” campaign’s admonitions to eat fresh fruits and vegetables are competing with powerful forces of poverty and the price structures of food products that do not support healthy eating.
The “Small Steps” campaign did not look at the landscape in which people make their food choices and the money would have been better spent working to transform the built environment and encourage new types of businesses in the communities affected by diabetes.
Counter Proposal – Community Gardens: Growing Food and People
Community gardens are a viable option to combat diabetes and other chronic diseases since they do not seek to effect behavior change one individual at a time, rather, they are seeking to transform an entire community. The community garden movement began in the late 1960’s and early 1970’s when activists sought to fight urban blight by revitalizing vacant lots, often home to drug dealing and other illegal activities. Community gardens exist in urban, suburban, and rural areas, though they have thrived in urban areas especially in larger cities in the United States and Canada (27) Community gardens differ from private gardens in that they operate in the public domain to some degree in terms of the ownership, access and democratic control of the space. (28) Community gardens involve shared responsibility for common areas, work days where gardeners collaborate on larger projects and foster daily interaction as people tend their plots.
A community garden with a greenhouse, community kitchen/classroom, playground, and ideally staff members could have a tremendous impact in the fight against diabetes and other chronic health problems such as obesity, cardiovascular disease and mental health issues. The community garden, especially in urban environments, addresses problems related to the built environment, such as the lack of recreational facilities and safe places to exercise, while promoting community development and social cohesion. The kitchen could serve as a meeting place and a classroom where community members could eat and learn from each other as well as engage in more structured educational activities related to health promotion. Once the environmental issues were being addressed, the community would be more receptive to these types of educational and health promotion interventions. (29) Health promotion would be more effective in a community forum and with hands on activities rather than with messages on buses, billboards and PSAs on the radio. The same message of making healthier food choices and getting more exercise that has gotten limited results from the “Small Steps” campaign would yield positive results if it were crafted in the context of a community garden/kitchen which gave people the opportunity to share, interact and change their behavior as a community.
Community Gardening - Growing Community and Promoting Health
Community gardens provide a venue for neighbors to get together and form social connections. Not only are they places where people can have daily social interaction, they are often the sites of community events, such as festivals, potluck suppers, theatre, music and art events, etc. (27) Wakefield et al. interviewed gardeners in South-East Toronto and found that the gardeners felt that the gardens were beneficial to the community. They were viewed to be improving relationships and increasing community pride. (30) There was also evidence that the increased pride and ownership due to the community gardens led to less littering and to the perception that the community was cleaner and safer. (27, 30,31,33) Community gardens foster social interaction and build social networks, which in turn cultivates the organizational capacity of the community.
Additionally, in several studies, community garden were seen as mechanisms for broader community development since they build leadership skills and empower residents to be advocates for themselves and their communities. (27, 30,31) The gardeners start off sharing thoughts about gardening and food, working together, and sharing seeds, tools and cultural practices. The social cohesion built by these informal interactions often serves as a springboard for discussion about and action on other non-garden related issues in the community. Gardeners in upstate New York successfully advocated for better sidewalks and playgrounds, fought to keep a supermarket in the community, established crime watches and neighborhood associations, etc. (31)
The "Small Steps" posters and radio did not build self-efficacy in communities burdened by problems since the intervention did not offer real solutions. On the other hand, the community garden is a tangible solution to many problems and gives community members the opportunity to provide for their own families. The community garden builds individual pride and "nurtures community capacity." Stronger community capacity makes health interventions more effective. (32). Health promotion campaigns need to work on fostering self-efficacy on the broader level by supporting projects that build the capacity of the community as a whole.
Community Gardens – A Safe Place for Physical Activity
Gardening is considered a form of moderate exercise. Several gardeners in various studies reported increased physical activity and improved health as a benefit of gardening. (27, 30,33) A garden that offers a play area for the children would provide safe place for families to exercise while improving the appearance of the built environment. Gardeners reported that gardening kept them physically and mentally active and got them out their houses. This was especially true for elderly gardeners who tend to be more isolated in their homes. A gardener in Southeast Toronto called gardening, "a form of exercise, relaxation. . . getting away from the TV." (30) and this sentiment was echoed by gardeners in other areas as well. Community gardens often incorporate raised beds so that elderly and handicapped individuals can still participate, and for the elderly, this may be their one social outlet. Several gardeners also cited the relaxation and improvements to mental health as benefits to gardening. (27, 30, 31) A gardener was quoted as saying that the garden "helps you hold onto life." (30)
Some community gardens, especially in urban areas, the fenced-in space allows residents to feel safe outdoors. It was a place where their children could play outside safely. (30) This eliminates some of the hesitancy to exercise outdoors if parents feel there is a safe place for their children to spend their time. The perception that the communities were safer and cleaner also helps to facilitate physical activity in the larger community outside the garden fences as well.
Promoting Healthier Eating
The primary benefit cited by numerous studies about community gardens was better access to fresh fruits and vegetables. All studies reported that the gardeners consumed more fruits and vegetables, since joining the community garden. (27, 30, 31,33) This is particularly important in areas where there are no supermarkets or other foods stores that are providing good quality produce. The gardeners could also grow a wide variety of foods, and could grow those that were culturally appropriate. Latin American gardeners said that buying fruits and vegetables from their native countries in stores was not always possible, and when stores did carry these products they were very expensive and not fresh. Many gardeners also grow herbs which can be very expensive and difficult to find in local stores. (27, 31) Gardeners were proud of the fresh food that they were growing and the benefit it had on their families. (30) The garden was building self-esteem since it was allowing people to provide for their families, as well as a sense of ownership, even if it were just of a small plot of land.
The community garden also provides organic fruits and vegetables at a much lower cost than are sold in supermarkets. A gardener from NYC reported that he saved at least $200 per season by growing his own tomatoes. (27) Gardeners part of the Rutgers gardening program in New Jersey reported that they didn’t have to buy vegetables in the supermarket. They gardened to save money and planted the things that were found to be too costly for purchase at supermarkets. (33)
Many gardeners also reported giving produce to neighbors and friends and donating produce to local shelters, food pantries, churches, elderly residents and other social service organizations. (27,30,31) This signifies the larger community is benefiting from the community garden.
Other gardens are involved in economic activity setting up community supported agriculture shares and selling food at farm stands or farmers markets. The Food Project (34) based in Boston has both urban and suburban farms, and it sells fresh produce at farmers markets and through community supported agriculture shares. It sells produce in several areas such as Roxbury and at Boston Medical Center that don’t typically have access to fresh organic produce. This type of project should be replicated on a greater scale throughout the city and in other cities as well, so that small scale agriculture could become a source of economic development.
The money spent on developing slick ads for the "Small Steps" campaign would have been better spent helping to establish community gardens and providing much needed funds to gardens that are trying to become more stable fixtures in the community. These community gardens could be staffed with nutrition and gardening experts who could engage children and adults in growing their own food and choosing healthier food options. Community gardens could be used to address health promotion and diabetes prevention at a group level, and directly provide nutritious fruits and vegetables, as well as a venue for daily physical activity, as well as having numerous other benefits.

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