A1C Campaign; Early Phase Model Not Appropriate-Evan Johnson

Background

 

There are close to 300 million people in the United States, and 23.6 million of them have diabetes.¹  This accounts for 8% of the total population.  The total prevalence of diabetes increased 13.5% from 2005-2007. ¹ A screening test used for the early detection of diabetes is an A1C count.  This value informs doctors how much sugar, on average, has been attached to your blood cells over the past 3 months.  A normal blood sugar is approximately 120 mg/dL.  Studies have shown that if you keep your A1C count below 7.0, your chances of complications from diabetes are significantly lower.¹

 

In 2007, the Ad Council developed an intervention encouraging people to get their A1C checked.²  This involves a simple blood test that can produce results in about 30 minutes.¹  To put forth their message, they designed a commercial that shows individuals being warned of unpleasant events.² For example, a thief drives by a man packing a car for vacation and informs him that once he leaves, he’s going to rob his house.²  The advertisement makes the analogy between the robbery warning and the A1C value.  The Ad Council’s hope is that viewers will ask their doctors for an A1C check which will inform them of the likelihood they will suffer from diabetes and its complications.  The delivery of this preventative health behavior is flawed in three major ways. 

 

 

 

Perceived Severity

 

This commercial seems to have been designed largely around the Health Belief Model.  Individuals weigh the perceived risk and severity of a certain health problem and develop an appropriate healthy behavior change.³  A criticism of this intervention is that the perceived severity is not strong.  The ad briefly mentions that high A1C counts may lead complications of diabetes such as heart attacks.  If you would like people to start checking their A1C, this is not the way to go about it.  Most Americans have become numb to the warnings that certain behaviors can lead to heart attacks.  They are also aware of the medical benefits of good diet and exercise.  This ad is just basically throwing another term at the general public and will hardly motivate anyone to take the time to schedule an appointment with their doctor. 

 

Intention Leading to Behavior

 

Another criticism of the A1C intervention is maintaining the suggested behavior. One of the major draw backs of the Health Belief Model is the assumption that intention leads to behavior.³  Individuals decide the risk and the severity of the health problem is worthy of a behavior change.  They have every intention of inserting this new behavior into their lives.  The truth is that this new behavior is rarely maintained.  This advertisement might get people to check their A1C the next time they’re at the doctors, but do they make it a part of their annual checkups?  This could depend on what kind of result they receive from the test.  If the A1C value is below 7.0, one set of barriers will emerge.  If the value is greater than or equal to 7.0, a completely different set of barriers is generated that will prohibit the maintenance of the behavior. 

 

First, let’s assume the result is good, meaning under 7.0.  The individual makes a mental note of his physical status.  He or she will take notice of their weight, energy levels, strength, production, etc.  The problem occurs next year when the individual doesn’t bother with an A1C check because he or she physically feels the same as the year before.  This situation may lead to trouble.  The commercial states that individuals with an A1C of 7.0 or higher have a greater chance of developing heart disease.²  An A1C of 7.0 translates to having an average blood sugar of 170 mg/dL over the past three months.⁵  This is about 70 mg/dL higher from normal levels.⁵   Individuals will not be able to distinguish between a blood sugar of 100 mg/dL and 170 mg/dL.¹  The person feels fine, so why bother making the appointment?  In order to initiate and maintain this behavior change, individuals watching the commercial will have to blindly accept the 7.0 A1C cutoff value between healthy and unhealthy as they will not have any physical reinforcement telling him or her something is wrong. 

 

Now what if a poor A1C result is received by a patient?  Again, the behavior maintenance of regularly checking your A1C counts is in question.  The person might not have any physical indicators telling them something is wrong.  A high A1C value alone will not be enough to “trigger” a behavior change.  Studies have shown that a lot of successful behavior changes are the product of some kind of significant “trigger” that pushes a person into action.  This is sometimes referred to as a “cue to action” and is responsible for individuals engaging in a preventative behavior in the Health Belief Model.³  My concern is that the A1C value by itself is not a strong enough factor to guide someone into a healthy behavior and in fact may lessen the chance the A1C check will be performed the next annual checkup. 

 

Also, if people know their A1C count is higher than suggested; this will be a definite barrier towards future testing.  The stress involved with obtaining the blood sample and then waiting for your doctor to inform you that your blood sugar level is above the acceptable range might be too much for some people.  If people are expecting stress, chances are they will become stressed once they step foot inside the doctor’s office. As Dan Ariely states in his book entitled Predictably Irrational, “If we acknowledge that we are trapped within our perspective, which partially blinds us to the truth…”⁶  This kind of negative reinforcement is a strong supporting factor towards not participating in the new preventative behavior.  To make matters worse, this barrier would be strengthened if the individual was currently feeling no adverse health issues. 

 

Lastly, the Ad Council’s intervention is assuming people reason in rational ways.  The viewing audience will weigh the risks and severity and in turn will make a rational decision to perform the healthy behavior change.   Informing the public that a preventative measure is needed to avoid serious health risks in the future will not cause individuals to spring into action.  Dan Ariely discusses people’s choices towards preventative health behaviors in Chapter 6 of Predictably Irrational.    “So while our long-term health and longevity depend on undergoing such tests, in the short term we procrastinate and procrastinate and procrastinate.”

 

Health Belief Model is too Shallow

 

As stated before, this commercial is largely based on the Health Belief Model.  One weakness of this model, which is the third major weakness of the commercial, is that it’s very shallow.  It does not dive into the background of the A1C test.  It does not address the cause of the high A1C nor the ways to lower the value.  It doesn’t tell the viewer what the A1C is measuring.  The commercial does state that a value of 7.0 or higher increases your chance of heart disease, but it doesn’t mention why this is such an important factor.

 

One of the first steps in a more advanced behavior model, named Precaution Adoption Model, is a “pre-contemplation” stage in which an individual becomes aware of a health problem through education.⁸  This stage is not part of the Health Belief Model and is a definite reason why the intervention is considered weak.³  Simple background information provides support that may strengthen individual’s intentions, which in turn, could lead to maintaining a behavior change. 

 

Not only does the Health Belief Model lack social norms and interactions, but it is not addressing the environment variable that is present in the upper echelon models.⁸  Environment is a crucial component to any social model that addresses behavior change.  In the A1C commercial, all the individuals are middle class people in their 40’s, driving nice cars, living in nice houses, and ordering shrimp at restaurants.  The Ad Council’s attempt to target this one demographic weakens the commercials effectiveness towards others who might have an entire different set of barriers to deal with.  Individuals with a low social economic status will definitely have a hard time connecting to the images they see in this commercial.  Also, without adequate information regarding A1C testing, the importance of the 3 month average blood sugar test will be lost.

 

On a more positive note, the Ad Council does try to improve on the Health Belief Model by injecting some social structure into the advertisement.  The burglar stops to warn the Dad of the robbery while he is packing the car for a family vacation.  The ambulance that drives by the family in the car has a warning message informing the couple that their A1C count is greater than 7.0.  It has been well established how important the social component is to behavior change. 

 

Conclusion

 

The intention of the A1C campaign put out by the Ad Council was to initiate the action of individuals receiving A1C checks at their doctor’s office.  The message would be set forth by a commercial that was largely designed according the Health Belief Model.  This is the correct tool for a campaign without a ton of public knowledge; the idea being to get the suggested health behavior in the minds of the general public to entice some motivation.  I argued that this is not the correct approach to combat a disease as well known as type 2 diabetes.  The ground work has already been layed down.  The effectiveness of the Health Belief Model is moderately attenuated at the awareness level that type 2 diabetes has reached.  The advertisement addressed in this paper is piling on yet another term for the general public to link to diabetes.  The perceived severity of diabetes is downplayed by mentioning the risk of heart attacks; a condition any healthy man in his 30’s is subject to.  This message will impel few into action.  I believe more sophisticated interventions are needed to motivate individuals who have been hearing about heart attacks, diabetes, exercise, and diet for at least a quarter of their lives. 

 

 

 

 

 

 

 

 

 

 

 

Improvements to the Health Belief Model Approach

 

            To address the three main weaknesses of in the Ad Council’s intervention, I will propose a new strategy.   This new intervention will increase the perceived severity, improve the maintenance of the recommended new behavior, will implement more social factors, and incorporate a more sophisticated decision making process in order to reduce the shallowness of the model. 

            The new intervention will start with community bulletin boards that will display one of the extreme health conditions, other than heart attacks, associated with high blood sugars.   The all white canvases will also display a statistic linking diabetes to the condition.  For example, diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.⁹  The bulletin board will also briefly display  benefits of A1C testing and list the dates and times of local community testing centers.  The message can also be displayed via small posters hung at post offices, main intersections, shopping centers, etc.  The actual A1C tests will be performed by a few nurses and nursing assistants.  The results can be made available in about 20 minutes.  Public Health counselors will be on hand to answer any questions that people may have.  To add legitimacy to the operation, perhaps the town Mayor or Selectman/Selectwoman could also participate.  This will strengthen the community interaction and add a “social norm” element to the activity.  The results of each A1C can be discussed with the participants.  If they are high, they can schedule an appointment with their primary care physician.  If it is normal, the counselors can emphasize that it should be checked again during their routine annual doctor examinations.  I believe this approach will add the necessary social context, urge individuals into action, and eliminate a few of the potential inhibiting barriers. 

 

Enriched Behavior Model

 

As the Health belief model is too shallow for implementing a new long term health behavior.   The new intervention will focus around the Precaution Adoption Process Model.⁸  This model has 7 stages.⁸  The strength of this model is that it takes into account a number of processes involved when moving between the different stages.  The barriers that are encountered at one stage are completely different than the ones confronted at another. As this is an important element to this model, the stages must occur in order.⁸  Additionally, by using an advanced model as the initial framework, the new intervention will inject elements of individuals’ social environment.

 

The first step of this “advanced” model is the awareness that a problem actually exists.  This is called the “precontemplation’ stage and it is crucial.  The Ad Council’s advertisement seemed to be geared solely on this stage.  It lets people know that high A1C values are a problem and in turn, allowed individuals to progress from stage 1.  The next level, stage 2, includes people who are aware of the issue but are not going to do anything about it.  This stage contains people who do not believe the perceived severity and/or perceived risk is high enough to warrant action.  Unfortunately, this is where the Ad Council’s campaign loses its effectiveness.  The new campaign provides awareness through bulletin boards and posters that provide a more information about the importance of the A1C test and its correlation with Type 1 and Type 2 diabetes.

 

A goal of the new intervention would be to get individuals into stage 3 where the individuals are “engaged to act”.  To make the leap from stage 2 to stage 3 requires acceptance of perceived severity and perceived risk.  I believe perceived risk is not an issue.  Since the United States has a large obesity rate, the media is littered with information about the potential causes of diabetes.  The risk is well understood.  The perceived severity is not a strength of the Ad Council’s advertisement.  The general public needs to know that heart attacks are not the only adverse condition on the horizon for people with poor control.

 

Boosting Perceived Severity

 

The Ad Council needs to ratchet up the severity of Diabetes to motivate individuals from stage 3.  Even though heart attacks are an extremely serious condition, sadly, the threat of their occurrence has become ubiquitous.  The intervention needs to inject a few health conditions, which do not already have such a large prevalence in the United States.  The intervention should utilize the bulletin board showcasing ability of the fact that having continuous high blood sugars can lead to blindness, kidney failure, and amputations as its deterrent.  If you notify the public of these complications, it may trigger some action.  If you look at the current treatment options for kidney failure, blindness, and foot nerve damage, these complications trump the surgical treatments of heart disease in the realm of severity. 

 

Making Good on its Intentions

 

Assuming the horrible consequences of high blood sugars are now realized, the next progression is to stage 4 or stage 5.  Stage 4 is achieved when individuals ultimately decide not to act.  This stage is reached due to the individuals becoming overwhelmed by potential barriers.  The barrier discussed already is minimal physical indications of high blood sugar.  One way to compete with this barrier is through information that can be displayed on the bulletin board and posters.  A list could be created that identifies the top three signs that your blood sugar is too high.  According to the American Diabetes Association, the list would include an increase in thirst, an increase in urination, and lack of energy.¹   Unfortunately, this is not a perfect solution as some people wouldn’t develop any noticeable symptoms until their blood sugar reaches around 300 mg/dL.   One individual with a blood sugar of 200, which is still twice the normal level, might not notice any symptoms.  However this is a starting point.  Hopefully, the other information listed on the poster will persuade them to initiate a test.

 

Another barrier would be the fear of the doctor’s office.  This barrier is eliminated by having community screening sites for individuals who do not have access to doctors or a fear of doctors’ offices.   The A1C test requires a minimal amount of blood and results are available in about 20 minutes.  Individuals may be more comfortable receiving an A1C test in a mall, drug store, or town hall.  While waiting for results, a counselor could answer any questions the visitors have regarding the correlation between diabetes and A1C measurements.  After eliminating the barriers, a person will decide that action is the best decision and move on to stage 5. 

 

Once stage 5 is achieved and the decision to act is made, this still does not imply that the action will occur.  Stage 6 is where the action actually takes place.  The individual decides to get his or her A1C count measured in either a doctor’s office or community center.  The next challenge will be reaching stage 7;   maintaining the action.  In order to reach this final stage, Dan Ariely suggests that a good way to make sure people perform preventative health care measures is to package them into bundles.⁷  The workers at the testing site or the nurses at the doctors office can inform people that the A1C test is a simple blood test that does not require any additional blood collection other than what is already collected during a routine doctor’s visit.  This would be added to the other tests , for example cholesterol and sodium levels,  that are performed during an annual physical examination.  The important factor is getting initially tested.  Once that occurs, it will take minimal effort to convince them that it’s needed every time they visit the doctor’s office.

 

I believe the new intervention addresses the three major issues with the Ad Council’s commercial.  It boosts the perceived severity by providing not so common health risks.  Through the elimination of barriers it helps transform an individual’s position from just intending to adopt a new behavior into actually performing the behavior.  Lastly, the new intervention has social components and is also built around a more sophisticated model.  The enriched model includes two stages of awareness, two stages for engagement, and two stages for the decision to act.  

 

The Ad Council’s campaign is a terrific start.  It feeds important information to society about a simple routine test that can hopefully prevent an individual from developing Type II Diabetes.  Unfortunately, it was too little too late.  The prevalence of heart attacks and diabetes is too high to make people spring too action from a simple 30 second television advertisement. 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

1 American Diabetes Association. All about Diabetes: Diabetes Statistics.   Mt.  Morris, IL: http://www.diabetes.org/diabetes-statistics.jsp.

2 Ad Council. Diabetes – A1C  Warnings One-Restaurant. ISCI CNED-7383 McCann Erickson, Sep 05, 2007 .

³ Edberg M. Individual Health Behavior Theories . Essentials of Health Behav Soc and Behav Theory in Pub Health. 2007:35-39.

⁴ Ariely D.   Predictably Irrational.  The Hidden Forces That Shape Our Decisions. New York, NY:    Harper Collins, 2008.

5Medindia. Diabetes Tools. HbA1c or A1c Calculator for Blood Glucose. http://www.medindia.net/patients/calculators/bloodsugar-HbA1c-convertor.asp

⁶ Ariely D.  The Effect of Expectations (pp. 172). In:  Predictably Irrational.  The Hidden Forces That Shape Our Decisions. New York, NY:    Harper Collins, 2008.

⁷ Ariely D.  The Problem of Procrastination  and Self-Control (pp. 121). In:  Predictably Irrational.  The Hidden Forces That Shape Our Decisions. New York, NY:    Harper Collins, 2008.

⁸Edberg M. Individual Health Behavior Theories . Essentials of Health Behav Soc and Behav Theory in Pub Health. 2007:44-45.

⁹dLife: for your diabetes life! Vision Complications of Type 1 Diabetes Westport, CT:  http://www.dlife.com/dLife/do/ShowContent/type1_information/preventing_complications/vision

 

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.

References
1. Abusabha, R., Achterberg, C. Review of Self-efficacy and Locus of Control for Nutrition and Health Related Behavior. Journal of the American Dietetic Association 1997; 97(10): 1122-1132.
2. Adams, R. Bukowski, W. Peer victimization as a predictor of depression and body mass index in obese and non-obese adolescents. Journal of Child Psychology and Psychiatry 2008; 49(8): 858–866.
3. Baer, H., Benson, L., Kaelber, D. Trends in the Diagnosis of Overweight and Obesity in Children and Adolescents: 1997-2007. Pediatrics 2009; 123(1): 153-158.
4. Bandura, A. Social Learning Theory. New York: General Learning Press, 1997.
5. Burkhauser, R., Cawley, J. Beyond BMI: The value of more accurate measures of fatness and obesity in social science research. Journal of Health Economics 2008; 27: 519-529.
6. Cali, A., Caprio, S. Obesity in Children and Adolescents. Journal of Clinical Endocrinology and Metabolism 2008; 93(11): S31-S36.
7. Carpenter, C., Davis, B. Proximity of Fast-Food Restaurants to Schools and Adolescent Obesity. American Journal of Public Health 2009; 99(3): 505-510.
8. Centers for Disease Control and Prevention. Overweight and Obesity: Childhood Overweight. http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/index.htm.
9. Centers for Disease Control and Prevention. Social Ecological Model. http://www.cdc.gov/nccdphp/dnpa/obesity/state_programs/se_model.htm.
10. Communication Initiative. 5 A Day Campaign. http://www.comminit.com/en/node/118130/303
11. Daily Mail. 5 A Day Campaign Backfires. http://www.dailymail.co.uk/health/article-328864/5-Day-campaign-backfires.html
12. Davey, C., Nanney, M. Evaluating the Distribution of School Wellness Policies and Practices: A Framework to Capture Equity among Schools Serving the Most Wight-Vulnerable Children. Journal of the American Dietetic Association 2008; 108(9): 1436-1439.
13. Dehghan M., Akhta-Danesh N., Merchant A. Childhood obesity, prevalence and prevention. Nutrition Journal 2005; 4: 24.
14. Dietz et al. Policy Tools for the Childhood Obesity Epidemic. Journal of Law Medicine and Ethics 2002; 30(3): 83-87.
15. Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Massachusetts: Jones and Bartlett Publishers, 2007.
16. Finkelstein et al. Pros and Cons of Proposed Interventions to Promote Healthy Eating. American Journal of Preventive Medicine 2004; 27(3): 163-171.
17. Gable, S., Chang, Y., Krull, J. Television watching and frequency of family meals are predictive of overweight onset and persistence in a national sample of school-aged children. Journal of the American Dietetic Association 2007; 107(1): 52-61.
18. Haughton, B. Applying the social-ecological model to nutrition issues that promote health and prevent disease. Family and Community Health 2006; 29(1): 3-4.
19. Kramer-Golinkoff, J., Strasburger, V. Does adolescent media use cause obesity and eating disorders? Adolescent Medicine 2008; 19(3): 431-449.
20. Masse et al. Development of a School Nutrition–Environment State Policy Classification System (SNESPCS). American Journal of Preventive Medicine 2007; 33(4): S277-S291.
21. Mitka, M. Experts Weight Pros and Cons of Screening and Treatment for Childhood Obesity. Journal of the American Medical Association 2008; 300(12): 1401-1402.
22. Nichaman, B. The Public Health Problem of Increasing Prevalence Rates of Obesity and What Should Be Done about it. Mayo Clinic Proceedings 2002; 77(2): 109-113.
23. Rydell et al. Why Eat at Fast-Food Restaurants: Reported Reasons among Frequent Consumers. Journal of the American Dietetic Association 2008; 108: 2066-2070.
24. Story et al. Creating Healthy Food and Eating Environments: Policy and Environmental Approaches. Annual Review of Public Health 2007; 29: 253-272.
25. Rosenbloom et al. Influence of Race, Ethnicity and Culture on Childhood Obesity: Implications of Prevention and Treatment. Diabetes Care 2008; 31: 2211-2221.

"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.
Conclusion
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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