A Critique of the Fruits and Veggies: More Matters Campaign- Tiffany Chua

Introduction
Infectious diseases have been replaced by chronic diseases as the major contributors to mortality in the United States (1). Cardiovascular disease is at the top of the list (1). It is largely considered a preventable disease and, because of this, has been the topic of many epidemiologic studies (1-4). Nutrition studies have investigated the effect of diet on cardiovascular disease and have found an inverse relationship between fruit and vegetable intake and cardiovascular disease (2-4). Along with the heightened focus on diet and nutrition, researchers have noticed the growing obesity rates in the United States, especially in children (5,6). As researchers have accumulated evidence supporting the protective effect of a healthy diet on such problems as cardiovascular disease and obesity, public health practitioners have designed programs to help fight these diseases. This critique will discuss a public health intervention that has attempted to improve people’s health by encouraging consumption of more fruits and vegetables. However, it is unlikely that the program will be able to realize its goals due to innate flaws in its design.

Fruits and Veggies: More Matters
Fruits and Veggies: More Matters is a public health intervention program that is run by the Centers for Disease Control and Prevention (CDC), Produce for Better Health (PBH), and several other entities including industry and nonprofit organizations (7). It launched on March 19, 2007 as part of the National Fruit and Vegetable Program and replaced the 5 A Day program under the National Fruit & Vegetable for Better Health (7). The 5 A Day program had been in effect since 1988, but in 2005 the Dietary Guidelines for Americans published a report that increased the recommended daily servings of fruits and vegetables from 5 servings to 5-13 servings (8,9). The mission of the Fruits and Veggies: More Matters program is to encourage people to eat more fruits and vegetables through awareness and education (7). An interactive website is available at www.fruitsandveggiesmatter.gov (7). The website includes a program that helps people calculate their personalized fruit and vegetable needs based on one’s age, sex, and activity level. There are printable resources such as recipes and tips for eating healthy that attempt to help people incorporate more fruits and vegetables into their daily meals. Links to other websites that promote healthy eating are provided as well.

The Health Belief Model
The failures of this public health intervention stem mainly from its basis upon the Health Belief Model (HBM). The HBM was the first model that was developed to explain behavior change (10). In brief, it proposes that a person’s decision to change a health behavior is dependent upon whether the perceived benefits outweigh the perceived costs (10). Although there are several weaknesses of the model, it is frequently used to design public health interventions. Additional details of this traditional model have been described previously, however the relevant aspects to this critique will be highlighted again.

Three major pitfalls of this public health intervention are related to three negative aspects of the health belief model. One negative aspect is the HBM’s exclusion of social and environmental factors. A second negative aspect is one that the HBM has in common with other traditional social behavior models - it is designed to address behavior change on an individual level. A third negative aspect is arguably one of the strongest negatives of the HBM – it assumes that people behave rationally.

Ignores Socioeconomic Factors that Affect Access
The Fruits and Veggies: More Matters program promotes a nutritious diet, but does not address any social or environmental factors that could prevent people from eating nutritiously. The program’s website includes a plethora of information, from the nutritional content of a wide variety of different fruits and vegetables to different ways to incorporate more fruits and vegetables in a diet. However, all of this useful information is available mainly to those who have a computer and internet access as well as the motivation to visit the website. Studies have shown that the demographic population in the United States that is least likely to eat sufficient amounts of fruits and vegetables are those with the lowest household income levels (11). These families are probably also the least likely to have internet access much less their own computer.

If economically disadvantaged people do manage to access the website and are interested in eating more fruits and vegetables, they may not be able to buy the fruits and vegetables that the website suggests for two reasons: due to the lack of supermarkets in their neighborhood that carry high quality, fresh produce or due to the financial inability to afford high prices of fresh produce. In general, large supermarkets tend to have a wider selection of produce that is more reasonably priced when compared to small grocery or convenience stores (11). Studies have shown that there are fewer large supermarkets in areas with greater populations of low-socioeconomic families and that high price is a major reason why low-income families choose not to eat fresh fruits and vegetables (11-13). These are critical issues, because people will not be able to take advantage of the information provided by the program if they cannot find a market from which to buy fresh fruits and vegetables or if they cannot afford to buy those fresh fruits and vegetables for their family. The program does not address the fact that fresh fruits and vegetables cost more than processed and fast food, nor does it address the additional inconvenience that may accompany more frequent trips to the supermarket.

These social and environmental factors are significant forces that may work against a person’s ability to adhere to the advice of the Fruits and Veggies: More Matters program. Additionally, the program may fail to reach the very population that needs the most encouragement by heavily relying on their website to educate people. These failures were demonstrated in a study that analyzed the success of the HBM in increasing fruit and vegetable consumption in urban black men, a low socioeconomic status population at increased risk of cardiovascular disease (14).

Targets Individual Adults
The Fruits and Veggies: More Matters program should reach out to both adults and children. With the increasing utilization of computers in children’s education, children have been spending more of their time on the Internet (15). However, the Fruits and Veggies: More Matters website is geared towards adult education. In one sense this is beneficial since studies have shown that there is a significant correlation between a mother’s nutrition knowledge and their child’s nutrition knowledge. This is mostly due to the fact that mothers are their children’s primary care givers and play a major role in shaping their eating habits (16). This serves as evidence to support ensuring that accurate knowledge is readily available to children’s parents to take advantage of this strong, positive relationship.
In another sense, it would be prudent to ensure that children, whose parents do not play a role in encouraging their children to develop healthy eating habits, are given the chance to learn about the nutritional benefits of fruits and vegetables for themselves. One reason why this is so important is because childhood and adolescence are crucial times during which children develop habits that will influence their health behavior throughout adulthood (17). As previously discussed, this development of a healthy diet into adulthood may have long-run beneficial health effects with respect to cardiovascular disease.

In addition to excluding children as part of their target population, the program addresses health behavior change on an individual level. As we have learned from Dr. Michael Siegel’s lectures, the program could be more effective and efficient if it were designed to address behavior change on a group level. The benefits from such an approach would not only be reaped by the individuals who adopt healthier eating habits, but also by society as a whole. The costs related to cardiovascular disease in the United States are expected to exceed $475 billion in 2009 (18). Since fruit and vegetable consumption has been shown to be negatively related to cardiovascular disease as well as obesity (5,6), health care costs associated with these diseases could potentially decrease substantially.

Disregards Irrational Behavior
The Fruits and Veggies: More Matters program assumes that people behave rationally. It believes that simply telling consumers that fruits and vegetables are healthier and that they potentially prevent various diseases will result in their making the choice to seek out and purchase fresh fruits and vegetables. This, however, is not the case with most people. As we have learned from Dr. Siegel, even if people intend to follow through with the behavior – in this case buying fresh fruits and vegetables – it still does not mean that the behavior change will occur.
Studies have shown that even when people are aware of the nutritional content of fruits and vegetables and the positive health effects a nutritious diet can have, they still do not change their eating habits. In children, this relationship has been observed mostly due to the fact they have trouble perceiving the future and thus the relevance of fruits and vegetables to disease prevention (19). In a population of adult black men, perceived health benefits were not associated with fruit and vegetable consumption either (14). Another study investigating the influences on eating habits in adults, taste was the top predictor of what people chose to eat, followed by cost. Only in those people that the study categorized as members of a “health lifestyle cluster” was importance of nutrition a predictor of eating healthful foods (19). Thus, by attempting to promote healthful eating based on benefits from disease prevention, the Fruits and Veggies: More Matters program may only be influencing the decisions of those people who are already attuned to living a healthy lifestyle.

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The Fruits and Veggies: More Matters program is a national public health initiative that promotes the benefits of fruit and vegetable consumption, but suffers from three flaws that may prevent it from reaching its goals. It does not address socioeconomic factors that influence fruit and vegetable consumption. It also fails to appeal to children, and falls into the all-too-familiar trap of assuming that people behave rationally.

Being supported by a wide variety of institutions, including the government, industry and nonprofit organizations, the program possesses great potential to reach its goals due to its access to financial and political resources through its contributors. These advantages put the well-intentioned program in a position to create positive change in the American population.
Having been launched a little more than 2 years ago, the program has been re-evaluated at a critical time. There is little question about the growing obesity problem in the United States. A program could have a big impact in the lives of adults, but most especially in the generation of current youths who are still in the position to adopt healthy eating behaviors. In order for this program to effectively improve people’s nutrition across all ages and levels of socioeconomic status, changes will need to be made to improve upon the three critical flaws.
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These three critical flaws can be addressed by structuring the design 0f the Fruits and Veggies: More Matters program around the Social Marketing Theory (SMT), including aspects of the Advertising Theory (AT), and the Social Expectations Theory (SET). These are population-level models that are ideal for addressing a wide-spread issue like fruit and vegetable consumption. The improvements that should be made include enacting policies that impose restrictions on supermarkets, implementing school programs, and incorporating media advertisement to promote the program.

Increase Access
A solution which takes social and environmental factors into account has two parts: increased access to education and increased access to fruits and vegetables. The problem with heavily relying on a website to educate people is its assumption that its target population has access to a computer and the Internet. Even fliers distributed at the grocery store do not address this problem since people first have to get to the grocery store in order to see the fliers. Instead of waiting for people to come to the information, the information should come to the people. This can be achieved through mailed pamphlets. Pamphlets should minimize the amount of text and maximize the use of charts and pictures to make them attention-grabbing. They will provide exposure to the benefits of eating more fruits and vegetables, the costs involved with eating more fruit and vegetables, and ways to access them.

The solution to the second part of the access problem adheres to the SET and focuses on changing current social norms, wealth and inconvenience, around fruit and vegetable consumption among the low-income population to affordability and accessibility. Two policy changes can help achieve this goal: one to increase physical access to large-scale supermarkets and one to increase financial access to fresh fruits and vegetables. Supermarkets should be required to locate their stores so that the average income level in the regions of all their stores within a state must not exceed a specified maximum. This would require them to locate their stores in lower income areas that they normally would avoid.

The second part of this policy change proposes a tax on so-called junk food due to their lack of nutritional content. The taxes will subsidize the cost of fresh fruits and vegetables to lower the price of healthy produce in relation to junk food and make nutritious diets financially feasible to low-income populations. Industries affected by these policies will be adverse to these proposals. There will likely be heated discussion concerning which foods to consider junk food and thus liable to the tax. Thorough research will need to be conducted to determine a minimum nutritional content for certain foods. Supporting institutions behind the program will need to harness their political influence to compete against lobbyists that may dispute these policy changes.

Target Children in Addition to Mothers
Policy change, in addition to education, should be used to include children in the target population. The main reasoning behind the original program’s focus on mothers is because, for the most part, they are responsible for buying the family’s groceries and preparing the meals. However, the program should directly target children in addition to mothers so as not to rely on mothers to instill nutrition values. Some mothers may not provide their children with the environment or resources conducive to developing nutritious eating habits. This should not prevent the children of these mothers from having the same opportunity to learn about nutrition as other children.

A Fruits and Veggies: More Matters educational program should be developed and implemented in schools for first through eighth graders. In an article that reviewed the successfulness of obesity interventions based on several different theoretical models, population-level interventions that were tailored to specific groups were the most successful (20). School programs containing two key components will certainly achieve this goal. One component is interactive classroom learning. The Fruits and Veggies: More Matters program should not take the form of another lecture to which children must passively listen. The same article that reviewed obesity interventions found that interactive intervention is more successful than its counterpart; therefore the program should use hands-on activities to teach kids about healthy eating habits (20).

In accordance with the “four Ps” of the SMT, formative research should be done among the different age groups since a six-year-old in first grade will respond to an activity differently than a thirteen-year old in eighth grade. This research should illuminate how one can benefit from changing his/her eating habits, what costs are involved in changing eating habits, and the best ways to gain access to fresh produce. The second component of this educational program is requiring school lunch programs to provide multiple fresh fruit and vegetable options. Provision of these options will give children who eat school lunches the opportunity to choose, and thus practice, actually making healthful decisions.

One may ask where the program plans to get the financial resources to implement this educational program and policy change. Since these changes will only apply to public schools, a portion of school budgets that state governments allocate to public schools will need to be used for this program. Additionally, funding from the health care sector will be sought as Fruits and Veggies: More Matters is a heath promotion program that will result in cost savings in the long-run due to prevention of chronic diseases associated with obesity.

Appeal to People’s Emotions
The solution to the third critique of the Fruits and Veggies: More Matters program utilizes the AT. People’s irrational behavior concerning their food choices should be addressed in ways similar to those that conventional industries use to market their products. In a paper highlighting use of advertisements to promote conventional consumer products, successful advertisements have utilized the emotions of the consumer to help sell their goods (21). There is no reason why public health intervention should not adopt the same tactic for promoting health behavior change. The way that the Fruits and Veggies: More Matters program should achieve this is by creating a brand, a slogan, and a promise. The brand will be a set of values that appeal to both youths and mothers, including physical attractiveness and carefree fun. Commercials, billboards, and magazine spreads will feature a young, attractive woman. She will be doing something as simple as posing on a beach. A fresh fruit or vegetable will appear in her hand or beside her, but not as the focus of the advertisement. The slogan will read “You are what you eat.” The promise of being beautiful and carefree will resonate with youths and young mothers alike. The slogan will brand the program by associating it with physical attractiveness. In a sizeable portion of the advertisements certain celebrities such as musicians and actors will be used to tie the program in with mainstream values. These advertisements will promise consumers that they can look and feel attractive if they eat nutritious fruits and vegetables.

One criticism of this solution highlights the issue of finances. Instead of being funded by the government, these media advertisements will have to be paid for with money from the program’s contributors – more specifically, the industry groups that have deeper pockets than the non-profit or government organizations. Although they will be expensive, these advertisements represent a significant component of the program.

Conclusion
The Fruits and Veggies: More Matters program should be structured around the Social Marketing Theory and include elements from the Advertising Theory and Social Expectations Theory. Implementing policy change is an effective and efficient way to create behavior change on the population level. Modeling advertisements after successful tactics used in conventional product promotion will help the program appeal to the emotional side of the predictably irrational population. Incorporation of all the changes discussed in this paper will help the Fruits and Veggies: More Matters program become a strong public health intervention that will improve the health and wellness of our current population as well as of future generations.

REFERENCES
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3. Panagiotakos DB, Pitsavos C, Kokkions P. Consumption of fruits and vegetables in relation to the risk of developing acute coronary syndromes; the CARDIO2000 case-control study. Nutrition Journal 2003;2:1-6.
4. Veer P, Jansen M, Klerk M. Fruits and Vegetables in the Prevention of Cancer and Cardiovascular Disease. Public Health Nutrition 1999;3:103-107.
5. Wang Y, Beydoun M. The Obesity Epidemic in the United States—Gender, Age, Socioeconomic, Racial/Ethnic, and Geographic Characteristics: A Systematic Review and Meta-Regression Analysis. Epidemiologic Reviews 2007;29:6-28.
6. Dehghan M, Akhtar-Danesh N, Merchant A. Childhood Obesity, Prevalence and Prevention. Nutrition Journal 2005;4:24-31.
7. Fruits and Veggies Matter. Q&A. Atlanta, GA: Centers for Disease Control and Prevention. http://www.fruitsandveggiesmatter.gov
8. Dietary Guidelines for Americans, 2005. Food Groups to Encourage. Washington, D.C.: U.S. Department of Health and Human Services. http://www.health.gov/DietaryGuidelines/dga2005/document/default.htm
9. 5 A Day For Better Health Program USA. Origin of 5 A Day Program. Geneva, Switzerland: World Health Organization. http://www.who.int/hpr/NPH/fruit_and_vegetables/lorelei.pdf
10. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
11. Cassady D, Jetter K, Culp J. Is Price a Barrier to Eating More Fruits and Vegetables for Low-Income Families. Journal of the American Dietetic Association 2007;107:1909-1915.
12. Moore LV, Roux A. Associations of Neighborhood Characteristics with the Location and Type of Food Stores. American Journal of Public Health 2006;96:325-331.
13. Powell LM, Slater S, Mirtcheva D. Food Store Availability and Neighborhood Characteristics in the United States. Preventive Medicine 2007;44:189-195.
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17. Douglas L. Children’s Food Choice. Nutrition and Food Science 1998;98:14-18.
18. Chronic Disease Prevention and Health Promotion. Heart Disease and Stroke Prevention. Atlanta, GA: Centers for Disease Control and Prevention.http://www.cdc.gov/NCCDPHP/publications/AAG/dhdsp.htm.
19. Glanz K, Basil M, Maibach E, et. al. Why Americans Eat What They Do: Taste, Nutrition, Cost, Convenience, and Weight Control Concerns as Influences on Food Consumption. Journal of the American Dietetic Association 1998;98:1118-1126.
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Why the Shape up Somerville community intervention to decrease childhood obesity is flawed - Andrea Crete

A Massachusetts, community-based, environmental change intervention called “Shape up Somerville” (SUS) intended to prevent obesity in culturally diverse, early elementary school children. This program was designed by researchers from the Friedman School of Nutrition Science and Policy at Tufts University and the Tufts University School of Medicine in collaboration with the Somerville community(1).

This program used a range of initiatives designed to provide and promote healthy eating options at local restaurants and in the elementary school cafeteria, and physical activity among the elementary school-aged children in Somerville, MA. The elementary school cafeteria offered healthier foods, developed more healthful recipes, and promoted the consumption of new foods through interactive education programs. New after school curriculum involved creative cooking classes, yoga, games, and field trips to farms to teach the children how food is grown and to appreciate where it comes from. New in class curriculum included daily “cool moves” sessions, weekly nutrition and physical activity lessons, and fun and healthy giveaways. Not only was the elementary school intimately involved in the program, but the parents of the children and Somerville community participated as well. Parents were encouraged to get involved in the after school and community events. Forums were made and sent to the different language communities in Somerville along with news letters containing healthy tips, fitness contests, and coupons for healthy foods. The local restaurants also collaborated with the program by developing an “SUS” stamp of approval indicating that the restaurant offers healthy menu options (1).

A BMI-z-score was used as a measure to report weight gain or loss during this one year program. The results of this program were a one pound reduction in weight gain on average over eight months for an eight year old child (1).

This paper will provide three arguments as to why this intervention is flawed.

Argument 1. BMI-z-score cards lower self esteem, label children, and increase BMI.

It is believed that childhood obesity is strongly associated with psychosocial morbidity. Psychosocial effects of obese children can include social isolation, discrimination, and peer problems. This can lead to increased rates of sadness, lower self esteem, loneliness, and nervousness by adolescence (2). A stronger association between body fat and self esteem is generally reported when body esteem or body image is the primary aspect of self esteem being measured (2).

This may be the case with using BMI-z-scores in the elementary children. The scores place children in categories of normal (non overweight), overweight or obese. Longitudinal studies have shown greater decreases in self esteem for obese children than non obese (2).

In the study done by Hesketh et.al, a temporal relationship was shown between self esteem and BMI in a cohort of young children tracked for three years from early to late elementary school. At the beginning of the study and at the end, children’s height and weight were measured. BMI was calculated and transformed to z-scores. Parents of the children completed a self esteem scale at the beginning and end of the study for the children. Low self esteem scores were defined as those falling below the 15^th percentile (2).

Results of the self esteem scores and BMI indicated that higher BMI scores (at the beginning of the study) predicted poorer self esteem scores at the end of the study. Children classified as overweight or obese in the beginning had lower self esteem scores at the end of the study. Self esteem and BMI are clearly related. BMI may play an important role in the development of lower self esteem experienced by many overweight and obese elementary school children placing them at risk for psychosocial effects.

According to the Stigma or “labeling” theory in public health, if these elementary school children are labeled as obese or overweight according to their BMI z-scores, the children will actually change their behavior to fit their label. This stigma becomes a barrier to behavior change thereby increasing BMI and contributing to the childhood obesity epidemic.

Argument 2. Other causes of childhood obesity are ignored.

Using the health belief model by providing and promoting these two environmental and community changes it is assumed the children will make the decision to eat healthy and exercise. Especially when their BMI z-score indicates they are overweight or obese. This gives the child a perceived susceptibility that they are at risk and the decision to make a healthful change will follow. The health belief model has proved ineffective in many public health interventions.

The Shape up Somerville intervention only incorporates diet and physical activity as a means to lower BMI among the elementary school children in the community. According to Robinson, most prevention programs that specifically aim to reduce fat and energy intake and increase physical activity have been ineffective at changing body fatness (3).

Television viewing has been speculated to be one of the causes of obesity among children. American children spend more hours watching television and playing video games than they do anything else besides sleep. This may lead to reduced physical activity and increased dietary energy intake either as a result of television food advertisements or during viewing (3).

Robinson developed an intervention designed to decrease media use alone without promoting active behaviors as replacements. The intervention, based on Bandura’s social cognitive theory, incorporated self monitoring lessons for the elementary children to report on regarding total television, and video game use to reduce the time spent in these activities. Lessons were followed by a television turnoff, where the children were challenged to watch no television, video tapes, or video games for ten days. The children were also asked to report the amount of food they ate during the day, and while watching television. BMI was measured at the beginning of the study and at the end to determine body fat loss or gain from the intervention (3).

Robinson found that compared with controls, children in the intervention group significantly reduced the number of meals they reportedly ate in front of the television. Compared with controls, the children in the intervention also had statistically significant decreases in BMI, triceps skinfold thickness, waist circumference, and waist to hip ratio. Robinson concluded that reducing television, video tape and video game use may be a promising, population based approach to prevent childhood obesity (3).

If SUS changes the environment the children live in by promoting physical activity and healthful food options, other factors including behavioral changes (tv viewing and video games) need to change as well. Children’s BMI may still increase if television watching and video games are not reduced.

Argument 3. Social Inequalities of obese children and their families in the community are ignored.

The Institute of Medicine reported that on assessing progress in childhood obesity prevention, some risk factors are relatively everywhere across all settings, but more concentrated in low-income communities of color (4). In schools, participation among female, racial/ethnic minority and lower income students are low for varsity and intramural sports. School SES and racial/ethnic composition are inversely correlated with BMI even after controlling for individual race/ethnicity and SES (4).

Crime rates and perceptions of danger are higher in low income neighborhoods. Unsafe neighborhoods do not attract walking to school and playing outdoors after school, at home, or in parks. This not only displaces physical activity among children, but also promotes increases in television viewing and video games. Lower income families with a high cost for housing and other living expenses may have little money left over to buy healthful foods thereby relying on inexpensive, but high calorie foods. Isolated environmental changes cannot be expected to break longstanding eating and physical activity patterns among populations undergoing ecologic stress who have adapted to their circumstances (4). The African American ethnicity for example incorporates high fat and high calorie “soul foods” into their diet as a positive connotation to help define their culture. Health advice coming from the majority culture may not be met with trust, generalizing from past experiences with discrimination (4). The SUS intervention may not reach the lower SES families of some obese children. Nothing in the intervention addressed how these families would be integrated into the program. The intervention to improve diet and increase physical activity in Somerville may be too weak or insufficiently focused to have an affect on the obesity epidemic in African American, Latino or Native American children.

In conclusion, the Shape up Somerville intervention to decrease childhood obesity by promoting a healthful diet and physical activity rich environment fails to address issues that may be contributing to the obesity epidemic of children. Using BMI z-scores have shown to cause low self esteem among some children who are labeled as obese or overweight, and have increased their BMI as a result.

Behavioral/life style changes such as watching less television and playing less video games have shown to decrease BMI and also decrease food consumption. The SUS intervention only strives to increase healthful food consumption and physical activity, failing to address these other causes of obesity including the lower SES families and how to incorporate them into the intervention.

Counter Proposals for the Shape Up Somerville Community Intervention –

Andrea Crete

The Shape Up Somerville intervention to decrease childhood obesity by promoting a healthful diet and increasing physical activity fails to address other issues that may be contributing to the obesity epidemic of children. Using BMI scores to label children as obese or non obese; solely focusing on diet and exercise; and failing to incorporate lower SES families; are some of the flaws that are addressed in this paper. This paper will discuss a new intervention that improves upon the Shape Up Somerville Intervention by developing counter proposals for the flaws mentioned in the previous paper.

Counter Proposal for Argument 1.

Studies have shown that children’s BMI can actually increase based on their scores. A BMI that labels a child as obese lowers that child’s self esteem which can eventually lead to an increase in BMI over the years to come. Self esteem and BMI are clearly related. BMI may play an important role in the development of lower self esteem experienced by many overweight and obese children, placing them at risk for psychosocial effects (2). Although BMI is a measurement currently used for assessing the growth of children, it is only a rough estimate of risk for overweight. For an individual child, BMI is likely to change over time in regards to changes in height and weight as the child’s muscle mass and stage of puberty change accordingly. There are also some children who have a high BMI that are actually not at risk of having too much body fat, while others with lower BMI have more body fat and are at risk. BMI can also give a false positive reading for obesity for some children with a high BMI that do not have high body fat (6). These are some of the inaccuracies of BMI scores.

I propose that the Somerville intervention dismiss the idea of using BMI to label a child as obese or non obese, putting them in a category that is subjected to lowering self esteem and hence defeating the purpose of lowering BMI. Developing an intervention that focuses on the importance of physical activity and healthy eating to lose weight and be healthier will be more effective in lowering BMI. Instead of using BMI as a means to measure weight loss and program effectiveness, I suggest that children’s weight be measured using a scale in the nurses’ office. The child’s weight can be measured twice a month for the length of the intervention. The weight loss or gained can be reported to the parents. Rewards are given for child participation in the program, not whether they lost weight or not.

This improvement avoids stigma or “labeling” theory commonly used in public health and in the Somerville intervention by using BMI scores and categories.

Counter Proposal for Argument 2.

The Shape up Somerville Intervention only incorporates diet and physical activity as a means to lower BMI among the elementary school children in the community. Programs and interventions that primarily aim to reduce fat and energy intake and increase physical activity have been ineffective at changing body fatness (3). Due to the fact that American children spend many hours watching television and playing video games, this may lead to reduced physical activity and increased dietary energy intake either as a result of television food advertisements or during viewing (3). I propose that parents of the children in the Shape Up Somerville intervention monitor and reduce the amount of television used (tv watched and video games played) to further increase the effectiveness of the intervention. Community and after school activities would aim to increase children and parent participation to limit the time children spend home with the television.

Interventions have been developed to decrease media use alone without promoting physical activity as a replacement. These studies have shown that reducing television, video tape, and video game use may be a promising, population based approach to prevent childhood obesity (3).

Counter Proposal for Argument 3.

The Shape Up Somerville intervention may not be effective in reaching the lower SES families in some obese children. Nothing in the intervention addressed how these families would be integrated into the program. Studies have shown that crime rates and individual perceptions of danger are higher in low income neighborhoods. Families that have a lower SES and a higher cost of living tend to buy less healthful foods which are lower in cost. Unsafe neighborhoods deter walking to school and playing outdoors or in parks. This increases television viewing and video games among children (4). Numerous studies have associated lower SES with poorer health. Neighborhood stressors such as exposure to violence and the physical condition of the neighborhood are also linked to SES and may affect physical health (5). Social networks in a neighborhood may define the level of trust and norms of cooperation and behavior thus also relating to both SES and health. Childhood health problems such as obesity have been documented as related to low SES (5).

I propose neighborhood activities be designed to get the different neighborhoods involved including the lower SES and work together. A feeling of being part of the community may increase moral in lower SES neighborhoods. I would develop a program that would make unsafe neighborhoods safer by setting up neighborhood committee’s that would work together in assessing their neighborhoods’ needs and improvements. Residents in the neighborhoods can collaborate to make improvements, do some landscaping/gardening to make the appearance better, help those in need with fixing up homes and yards, and developing activities for the children to do outdoors to increase physical fitness.

This would ideally change the perceptions of the neighborhoods being unsafe and promote activities outdoors, potentially decreasing child obesity among lower SES families.

Conclusion

Using a scale to measure children’s weight bi-monthly is a more effective way of lowering BMI in children as opposed to using BMI z scores which can lead to lowered self esteem and an actual increase in BMI. Decreasing the amount of television viewed and video games played along with increasing physical fitness and healthful eating can also decrease body fat in children. Lower SES families and neighborhoods need to be involved in community events and activities. Making neighborhoods safer, cleaner and unified may help change some of the negative perspectives residents have about their neighborhoods and increase child outdoor activities in those neighborhoods. An intervention that incorporates the above would be a more effective approach to decreasing childhood obesity.

References:

1) Fennelly, Christine. Childhood Obesity Intervention Shows Promising Results. Tufts University, Health Sciences. May 10, 2007.

2) Hesketh et.al. Body mass index and parent-reported self esteem in elementary school children: evidence for a causal relationship. International Journal of Obesity (2004) 28, 1233-1237.

3) Robinson, N. Thomas. Reducing Children’s Television Viewing to Prevent Obesity. JAMA, October 27, 1999-vol 282. No. 16, 1561-1566.

4) Yancey, K. Antronette et.al. Bridging the Gap: Understanding the Structure of Social Inequalities in Childhood Obesity. American Journal of Preventive Medicine (2007); 33 (4S) S172-S174.

5) Chen, Edith and Peterson, Laurel. Neighborhood, Family, and Subjective Socioeconomic Status: How Do They Relate to Adolescent Health? Healthy Psychology (2006); vol. 25 No. 6, 704-714

6) Crawford et.al. Weighing the Risks and Benefits of BMI Reporting in the School Setting. Center for Weight and Health. http://nature.berkeley.edu/cwh/PDFs/BMI_report_cards.pdf

The 5-A-Day Campaign Backfires: A Critique of the Health Belief Model in Action – Leigh Friguglietti

A diet high in fruits and vegetables has been associated with a decreased risk of certain cancers, reduced morbidity and mortality from heart disease, decreased risk from chronic conditions and enhanced weight management (1-5).  Yet, most of the US population does not consume the recommended amount of fruits and vegetables.  The 5-A-Day campaign, initiated in 1991, is a nutrition intervention whose purpose is to increase fruit and vegetable consumption for improved public health.  The 5-A-Day program is a collaborative effort comprised of government agencies, private companies, state coordinators, and educators, to strengthen fruit and vegetable intake to at least 5 servings per day for 75% of Americans by 2010 (6).  Despite all the television commercials, websites and billboards that were created to raise awareness about the importance of fruit and vegetable consumption, research revealed that fruit and vegetable intake rates were not improved by the 5-A-Day campaign (7).  In fact, according to Serdula, from 1994 to 2000, the mean frequency of consumption of fruits and vegetables declined, from 3.44 times per day in 1994 to 3.37 times per day in 2000 (8).  The campaign backfired on public health practitioners and had a negative effect on fruit and vegetable intake.

Introduction

For many public health promoters it appears that those for whom the information is most relevant are often the least persuaded.  Thus, people fail to respond positively to potentially vital campaigns.  Such is the case for the 5-A-Day nutrition intervention.   This approach is based on the Health Belief Model.  Furthermore, the intervention holds that there will be an increase in fruit and vegetable consumption if people believe that they are susceptible to cancer and heart disease (perceived susceptibility), that cancer and heart disease are serious (perceived severity), that increasing fruit and vegetable consumption will reduce the risk (benefits), and that the barriers to the change, like cost and access, are not unreasonable (barriers to change) (9).  This paper presents at least three reasons why this rationale is not effective.

Furthermore, the intervention failed to encourage its target audience and has been an ineffective public health intervention to increase fruit and vegetable consumption in the US population.  The campaign did not succeed at changing individuals’ behavior for several important reasons.  First, awareness messages about the benefits of consuming fruits and vegetables are not enough to change a persons’ behavior.  Second, the 5-A-Day campaign neglects individuals’ need for self-efficacy to change behavior.  And lastly, this intervention does not recognize the importance of social norms and their effect on eating fruits and vegetables.

1.  Benefits and barriers; how awareness is not enough to change behavior

The 5-A-Day campaign offers people information through a variety of avenues about the benefits of consuming at least five servings of fruit and vegetables each day, while providing the risks of not receiving the recommended daily allowance of fruits and vegetables.  However, awareness messages about the benefits of consuming fruits and vegetables are not enough to change a person’s behavior.  Steptoe informs us that there is no association between beliefs in health benefits of eating fruits and vegetables and consumption (10).  In fact, many individuals recognize the benefits of consuming fruits and vegetables and intend to consume more, but intention does not always lead to behavior. 

Cost and accessibility, rather than awareness, are the most significant predictors of consumption of fruits and vegetables.  Steptoe says that peoples’ dietary choices are influenced by cost of produce and the availability of food stores (10).  Furthermore, the campaign does not mitigate barriers that impede people from consuming five or more servings of fruits and vegetables a day. Even if people are aware of potential benefits, how can people change behavior if fruits and vegetables are not affordable or accessible?  If people do not have the means to obtain fruits and vegetables, then increasing consumption is not a viable behavior change. 

For example, in a study that examined barriers to fruit and vegetable consumption, a focus group of African Americans reported limited access to fresh produce which consequently inhibited their fruit and vegetable intake.  Predominantly minority and racially mixed neighborhoods had significantly less supermarkets and grocery stores than Caucasian neighborhoods, thus limiting fruit and vegetable intake among low income populations.  Furthermore, the lack of super markets in low-income areas forces residents to depend on small stores with very limited selection of fruits and vegetables (4).  Though people may want to change, barriers thwart some from consuming produce. 

It is important that behavioral interventions incorporate and reflect the realities of peoples daily lives and that interventions reduce these barriers that otherwise impede people from getting the recommended servings of fruits and vegetables.  The 5-A-Day initiative does not improve access to fresh fruits and vegetables nor does it make them more affordable.  A broader contextual model that examines these issues is needed to ensure that first and foremost, all individuals have access to fresh fruit and vegetables.  Behavior cannot change if people do not have the ability to afford fruits and vegetables, or if there is no outlet to purchase them even if they intend to. 

2.  No self-efficacy leads to no change in behavior

            Albert Bandura has defined self-efficacy as our belief in our ability to succeed in situations.  Self-efficacy can play a major role in how an individual approaches goals, tasks, and challenges.  Bandura’s Social Cognitive Theory is centered on self-efficacy, which believes that people will be more inclined to take on a task if they believe they can succeed (9). 

            Researchers have seen the application of self-efficacy in nutrition interventions.  Sorensen reports, that higher levels of self-efficacy are associated with increased consumption of fruit and vegetables (11).  Luszczynska found that self-efficacy is among the factors most strongly and consistently associated with higher levels of consumption.  In addition, an intervention targeting self-efficacy, those who had self-efficacy action plans, compared to those who did not, resulted in an increase of fruit and vegetable consumption.  Self-efficacy enabled participants to change their consumption and consume more servings of fruit and vegetables (12).  Furthermore, Epton found that in a randomized trial, participants that were self-affirmed and encouraged to consume more fruits and vegetables reported consuming significantly more portions of fruit and vegetables over a seven day period than the non-affirmed participants (13).  In conclusion, enhancing self-efficacy results in nutrition change.

            The 5-A-Day campaign does not enhance self-efficacy as a means to change behavior.  In turn, lack of self-efficacy discourages nutrition change.  If people feel that they do not have the capacity to eat five servings of fruit and vegetables a day, then they will not attempt to eat five servings of fruit and vegetables a day.  Individuals need to believe that they can consume five servings prior to embarking on this beneficial behavior change.  Thus, incorporating self-efficacy is absolutely necessary to promote an increase in fruit and vegetable intake.  Furthermore, a self-efficacy intervention would mediate effects of an intervention on health behavior.

3.  5-A-Day campaign ignores the importance of social norms and consumption of fruits and vegetables

            Social norms are behavioral expectations and cues within a society or group.  Generally, they are the rules that a group uses for appropriate and inappropriate values, beliefs, attitudes and behaviors.  Social Expectation Theory boasts the importance of social norms and their influence on behavior (9).  Unlike Social Expectation Theory models, the Health Belief Model is an individual level model that does not consider social context or the role social norms play in health behavior.  A major limitation of the 5-A-Day campaign is that it does not consider or target psychosocial factors and behavioral outcomes.  By not targeting social factors, the 5-A-Day campaign limits its effectiveness, and fails to succeed at changing behavior.

Social context matters in health behavior change.  Social and physical surroundings directly affect individual’s health behaviors (15).  Furthermore, the presence of strong social norms that support fruit and vegetable consumption are pivotal to the behavior change process.  For example, in study that looks at social context on changes in fruit and vegetable consumption, Sorensen reports that change in fruit and vegetable consumption is strongly associated with two social contextual factors; social networks and supportive social norms (11).  Yet, the 5-A-Day campaign does not aim at social norms that support fruit and vegetable consumption, as a result, this campaign failed.   

Research has demonstrated that positive social norms regarding fruit and vegetable intake result in increased consumption (11, 14).  Therefore, rather than focusing interventions on individual attitudes it is important to consider the influence of social norms in human behavior.  There is a need to build strong social norms around fruit and vegetable intake and implement them into interventions for effective health behavior changes.  Perhaps community based approaches (16) rather than individual level models, offer a way of changing overall community norms about nutrition problems, which could be beneficial for influencing individual level improvements in health behavior.    

Conclusions

            The 5-A-Day campaign was unsuccessful at increasing fruit and vegetable intake (7).  Since, the campaign is based on the Health Belief Model, by nature, the campaign is doomed to fail.  The intervention relied on awareness, and awareness of a problem will not lead to behavior change, especially when barriers are high.  The campaign did assert self-efficacy, which is crucial to changing an individual’s behavior. Lastly, the effort did not consider the importance of social norms. 

Thus far, nutrition interventions have focused on heightening public awareness and increasing the populations’ knowledge about the importance of consuming fruits and vegetables.  Although knowledge is an important factor in predicting fruit and vegetable consumption, knowledge alone has not been sufficient to change diet.  Eating fruits and vegetables is influenced by processes at a number of levels, from social norms to practical issues of food distribution and accessibility and individual attitudes, like self-efficacy.  The 5-A-Day campaign does not focus on the previously mentioned factors that clearly affect individuals’ fruit and vegetable intake.  As a result, this campaign has been ineffective at increasing fruit and vegetable intake among the US population.

            There is need to broaden the traditional approach of planning interventions beyond increasing awareness and education.  Developing interventions that consider the environment, social norms and social context on behavior change are necessary.  Interventions that enhance cues to action of health benefits of fruit and vegetable consumption together with increasing self-efficacy and decreasing perceived barriers will have a positive impact on the entire population.

 Proposed Intervention: ‘Something Fresh’

The following intervention was designed with the 5-A-Day campaign failures in mind.  The Something Fresh intervention encourages and makes it easy for all individuals to consume more fruits and vegetables.  This campaign not only improves access to produce, it creates an environment in which people feel like they can consume more fruits and vegetables, and understands the pivotal role family plays in fruit and vegetable consumption. 

Something Fresh distributes fruit and vegetables to areas where they are not available and makes produce more affordable for everyone.  If individuals do not have access to a grocery store or do not live in an area with fresh fruit and vegetables available, the ‘fresh van’ delivers produce, including seasonal fruits and vegetables to your home.  Delivery is free of charge for individuals and produce is affordable through the Something Fresh subsidy.  This program also provides incentives for individuals that already have access to grocery stores with adequate produce.  The Something Fresh program discounts the price of produce when individuals’ grocery bills are at least a 30% produce.  The slogan eat something fresh, promotes eating fresh produce and different advertisements encourage people to take advantage of them in order to increase fruit and vegetable intake.  The campaign works through media messages to encourage everyone to eat something fresh.  In addition, the intervention makes suggestions for how to increase consumption that promote self efficacy.  Ultimately the intervention makes people feel that it is possible to eat something fresh thereby consume more fruits and vegetables.  Lastly, the campaign supports family meals and provides serving suggestions in addition to menu ideas for families so as to incorporate produce into family meals.

Reconciliation 1

Most people are aware of the benefits of consuming five fruits and vegetables each day (10).  However, awareness is not enough to change behavior and barriers like accessibility and cost inhibit individuals from consuming fruits and vegetables (4, 10).  Rather than boring consumers with the risks and benefits of fruit consumption like the 5-A-Day campaign, this intervention removes obstacles that individuals face when trying to access fruits and vegetables.  The Something Fresh intervention eases barriers like access and cost, by delivering produce to peoples’ homes and making fruits and vegetables more affordable through discounts.  With this intervention in place, people that want to be healthy, but did not have the means to obtain fruits and vegetables, now have two advantageous options to get more produce in to their homes and ultimately their meals. 

Since perceived barriers proved to be most consistently associated with poor fruit and vegetable intake (10), this campaign removes barriers, so that behavior can change.  Choices people make about eating fruits and vegetables are no longer limited by the produce available to them.  This intervention created a way for people to afford and access fruits and vegetables.  Without barriers that impede behavior change, increasing fruit and vegetable consumption is realistic and attainable behavior. 

Reconciliation 2

Self-efficacy is required for behavior change.  The 5-A-Day campaign does not use self-efficacy, and as a result does not succeed in increasing fruit and vegetable intake.  In the 5-A-Day campaign, if people feel that they do not have the capacity to eat five servings of fruit and vegetables a day, then they will not attempt to eat five servings of fruit and vegetables a day.  Something Fresh utilizes Albert Bandura’s Social Cognitive Theory, which is rooted in self-efficacy, the belief that people will be more inclined to take on a task if they believe they can succeed (9).  This new campaign does not put a number on the servings of fruit and vegetables individuals should get; rather, it encourages individuals to eat fresh fruits and vegetables.  In addition to encouraging consumption the campaign offers materials to people with simple ways to eat fresh.  These materials will help initiate cues to action and will help people plan their behavior change.   

Studies have shown that self-efficacy mediates behavior change (11-13).  The key to the Something Fresh campaign is to make eating more fruits and vegetables attainable, which leads to the belief that people can achieve this healthy behavior, in turn increasing fruit and vegetable consumption. 

Reconciliation 3

Social context and strong social norms supporting fruit and vegetable consumption are pivotal to the behavior change process.  Furthermore, both upbringing and family have a paramount impact on fruit and vegetable consumption (11).  The 5-A-Day campaign does not lend itself to the role social norms play in behavior change.  For this reason, Something Fresh focuses on the social context of families and changing family norms about fruit and vegetable consumption.  One of the goals of the campaign is to increase nutrition knowledge in parents and to make them aware of the importance of fruits and vegetables in a child’s diet.  Increasing Knowledge in parents positively influences the quality of the children’s diet (4, 12, 14).  Furthermore, when children grow up eating fruits and vegetables and they are able to develop a taste for produce that stays with them forever.  In addition, having family meals is positively associated with fruit and vegetable intake (4).  For this reason, Something Fresh targets families because of their important role in the consumption of fruits and vegetables. 

Conclusions

       The 5-A-Day campaign was unsuccessful at increasing fruit and vegetable intake (7) by in large because it is based on the Health Belief Model.  This intervention does not realize that consumption of fruit and vegetables is influenced by processes at a number of levels, food distribution and accessibility, individual attitudes, like self-efficacy and social norms.  The Something Fresh campaign improves on the 5-A-Day campaign because it addresses all of the significant processes that facilitate fruit and vegetable intake.  Something Fresh addresses and eases practical barriers that inhibit people from accessing fruits and vegetables.  In addition, this campaign uses Social Cognitive Theory and self efficacy to encourage people to participate in this beneficial health behavior.  Lastly, this campaign uses Social Expectations Theory because of the importance of social norms in behavior change.  This intervention considers an individuals environment, attitudes and their social context and as a result is a more effective public health intervention.
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2. Ness A., Powles J. Fruit and vegetables, and cardiovascular disease: A review. International Journal of Epidemiology 1997; 26: 1-13.

 

3. Peto J. Cancer epidemiology in the last century and the next decade. Nature 2001; 411: 390-395.

 

4. Yeh M., Ickes S., Lowenstein L., Shuval K., Ammerman A., Farris R., Katz D.  Understanding barriers and facilitators of fruit and vegetable consumption among a diverse multi-ethnic population in the USA. Health Promotion International 2008; 23: 42-51.

 

5. Hung H., Joshipura K.,Jiang R.  Fruit and vegetable intake and risk of major chronic disease.  Journal of the National Cancer Institute 2004; 96: 1577-1584.

 

6. Aronson D. Fruits and Veggies-More Matters: Bringing New Life to an Old Nutritional Message. Today's Dietician 2007; 9: 30-34.

 

7. Pivonka E., Hoy K., Boyce B. Development of the Fruits and Veggies-More Matters Brand: The next stage of increasing fruit and vegetable consumption. FASEB J 2007; 21: 671-683.

 

8. Serdula M., Gillespie C., Kettel-Khan L., Farris R., Seymour J., Denny C. Trends in Fruit and Vegetable Consumption Among Adults in the United States: Behavioral Risk Factor Surveillance System, 1994-2000. American Journal of Public Health 2004; 1014-1018.

 

9. Edberg M. Essentials of Public Health Behavior: Social and Behavioral Theory in Public Health.  Sudbury, MA: Jones and Bartlett Publishers Inc., 2007.

 

10. Steptoe A., Porras L., McKay C., Rink E., Hilton S., Cappuccio F. Psychological Factors Associated With Fruit and Vegetable Intake and With Biomarkers in Adults From a Low-Income Neighborhood. Health Psychology 2003; 22: 148-155.

 

11. Sorensen G., Stoddard A., Dubowitz T., Barbeau E., Bigby J., Emmons K., Berkman L., Peterson K. The Influence of Social Context on Changes in Fruit and Vegetable Consumption: Results of the Healthy Directions Studies. Framing Health Matters 2007; 97: 1216-1227.

 

12. Luszczynska A., Tryburcy M., Schwarzer R. Improving fruit and vegetable consumption: a self-efficacy and planning intervention. Health Education Research 2007; 22: 630-638.

 

13. Epton T., Harris P. Self-Affirmation Promotes Health Behavior Change. Health Psychology 2008; 27: 746-752.

 

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“Small Steps” Against a Big Problem: Failure of the Health Belief Model to Successfully Combat Obesity – Jiayang Chien

Introduction

            The US Department of Health and Human Services, in an attempt to combat the ever-growing obesity epidemic, launched the “Healthy Lifestyles and Disease Prevention Media Campaign”, abbreviated the “Small Step” campaign (www.smallstep.gov), in March of 2004 (1). Based on the idea that obesity prevention should not require “extreme” measures such as “joining the gym or taking part in the latest diet plan” (2), “Small Step” is centered around over 100 tips that promote healthier eating and physical activity, designed to be easily incorporated into one’s lifestyle. At first glance, this campaign looks promising. Its homepage acknowledges the structural barriers that prevent Americans from staying in shape, including living in neighborhoods without sidewalks, over-reliance on automobiles for transportation, and being surrounded by foods high in calories and fat (3). The tips are intended to empower people by showing them how to make small, easily achievable changes to their existing routines that will eventually add up to a healthier overall lifestyle. In the long run, these changes will presumably prevent obesity in spite of existing barriers to health.

            Careful research went into the production of this campaign. According to the HHS campaign report, the theoretical framework for this campaign included the Consumer Information Processing model, Social Marketing, Social Learning Theory, and the Transtheoretical (Stages of Change) model (1). Using these, the HHS, in collaboration with the Ad Council, designed a series of print advertisements and public service announcements (PSAs) intended to be attention-grabbing, promote self-efficacy, and steer individuals through the stages of behavioral change by giving them incremental steps to work with. The advertisement materials underwent extensive focus group testing with both clinicians and target audience members drawn from high-risk population subgroups, such as African-Americans and Hispanics.

            Despite positive feedback from target audience focus groups (1), this campaign has been criticized for being ineffective and disappointing (4). The reasons for this stem from the theoretical underpinnings of the campaign. Although “Small Step” was intended to be modeled on Social Learning Theory, principles of Social Marketing, and other group-based models of behavior, its core components, the 100-plus “steps”, actually stem from the Health Belief Model. Perhaps because the HBM was not intentionally used, its application is incomplete and leaves parts of the model unaddressed. Additionally, “Small Step” suffers from the inherent limitations of the HBM—specifically, that it ignores environmental factors affecting behavior, and assumes that people act in rational ways. Finally, despite best intentions, this campaign is poorly designed to accommodate the broad diversity of the American population, and instead tries to use a “one size fits all” approach to behavior modification. These three factors together make the “Small Step” campaign ultimately ineffectual at combating the obesity epidemic.

 

1. The Health Belief Model is incomplete and poorly applied.

            Upon close inspection, “Small Step” may be more accurately described as a campaign based on the Health Belief Model (HBM) rather than the ones listed by the HHS. The HBM posits that a rational weighing of benefits and barriers determines one’s intention and, ultimately, behavior (5). The target audience of “Small Step”, as described by Ad Council, consists of “Jaded Can’t Doers” who “need to be convinced that a healthier lifestyle is attainable” (1). Based on this, it is clear that the campaign’s focus is decreasing one’s perceived barriers against healthy eating and engaging in physical activity. “Small Step” does not, however, use the complete HBM; it only addresses a few of the barriers that prevent people from adopting healthier behavior, and ignores the benefits of obesity prevention—perhaps assuming that people are already aware of them.

            The website mentions alarming statistics on the prevalence of obesity (2 out of 3 Americans are overweight or obese), as well as the health effects thereof (diabetes, heart disease, hypertension), sending the message that every American is susceptible to becoming obese, and that the consequences are severe. Logically, therefore, the primary benefit of weight management is the prevention of these health consequences; yet, these benefits are not explicitly mentioned. The campaign’s PSAs, in an attempt to use humor as an attention grabber, all follow a storyline where some characters find a flesh-colored mass lying on the ground that turns out to be an extraneous body mass (e.g. double chin) that was shed in the course of following one of the “Small Step” tips. There is certainly shock value in this approach, but these commercials do not show any positive effects of following the “Small Step” tips. In fact, one might argue that by focusing on body parts, the campaign is inappropriately emphasizing the aesthetic aspects of weight management, which, if taken to an extreme, could ultimately lead to another type of unhealthy behavior: eating disorders (6). Furthermore, the unappealing visual imagery of disembodied parts may cause audiences to want to change the channel rather than learn more about obesity prevention.

            The entire “Small Step” approach is based around the idea of overcoming barriers to achieve healthy behaviors; it is an unfortunate irony, therefore, that many of these “simple and free” tips ignore the two largest barriers that prevent individuals from making good lifestyle choices in general: money, and time. For example, “instead of eating out, bring a healthy, low calorie lunch to work” requires that the person has time to prepare said meal ahead of time, which is not always a realistic expectation. Telling people to “order smaller sizes” when eating out ignores the economic incentive to super-size. Even physical barriers to healthy behavior are often ignored. “Use a snow shovel instead of a snow blower” or “wash the car by hand” may be an option for younger adults who are already in good physical shape, but such un-ergonomic strenuous labor could injure others. Tips like “walk kids to school” or “get off a stop early and walk” assume that most people live in towns where schools are located close to residences, where there are sufficient sidewalks, and where there is public transportation. Unfortunately, due to prevailing land zoning practices, such walkable areas are scarce in the US (7), which is the real barrier. Furthermore, in order to substitute more active modes of transportation for driving, people must budget more commuting time into their daily routines, which adds rather than subtracts barriers to increasing physical activity.

            In failing to acknowledge these additional barriers to effective prevention of obesity, the “Small Step” campaign conveys the message that people make poor lifestyle choices simply because they do not know any better. As a result, many of the tips presented on the website or in the PSAs come across as patronizing, much like a disapproving teacher chastising students for failing to follow the rules. Such an approach is likely to alienate rather than engage people, so that they are turned off not only by the campaign, but the message that it promotes (4). Then, even tips that may be of real help (e.g. “Be sensible. Enjoy the foods you eat, just don’t overdo it”) fail to reach their intended audience.

 

2. Limitations inherent to HBM mean limitations for “Small Step”.

            Even when correctly and comprehensively applied, the HBM suffers from several major limitations that make it a less-than-ideal model for many public health campaigns. The “Small Step” campaign, being based on an incomplete rendition of the HBM, therefore also suffers from these constraints, making it ultimately ineffective.

            One of the limitations of the HBM is that it assumes human behavior to be based on rational decision-making; this goes along with the aforementioned assumption that people do not make healthy choices because they do not know how to. “Small Step” bases the entire campaign on knowledge: “We are bombarded every day with conflicting information about our health…  It's no wonder that many of us throw up our hands and give up. But if we want to live long and fulfilling lives, it's essential that we learn the real facts about health, nutrition, and physical activity” (3). The campaign neglects the psychological and emotional components of behavior, which may actually be more influential than the rational. People have a tendency to crave food—especially high-calorie, high-fat, high-sugar foods that are most likely to cause obesity—when under stress. Issues of body image and self-esteem, which, as previously mentioned, may be exacerbated by the “Small Step” PSAs, play a major role in preventing overweight individuals from becoming more active. Indeed, in failing to recognize that emotions are strongly tied to behaviors, “Small Step” has made the mistake of using visually gross images of disembodied body parts in their PSAs, thereby inadvertently associating obesity prevention behavior with feelings of disgust.

            Another criticism of the HBM is that it assumes people are in full control of their behavior, and that intention necessarily leads to behavior. “Small Step” does recognize that many individuals struggle with self-control when it comes to food, but does not provide lasting solutions to this problem. For example, tips such as “store especially tempting foods, like cookies, chips, or ice cream, out of immediate eyesight, like on a high shelf or at the back of a freezer” or “eat off smaller plates” are ways for people to trick themselves into better portion control. However, food storage habits need to be maintained over long periods of time to be effective, and smaller plates may be compensated for by second servings—which is addressed separately in another tip: “Before going back for seconds, wait 10 or 15 minutes”.

Another prevalent recommendation in the campaign is that people substitute low-fat, low-calorie ingredients for what they may normally use or eat. For example: vegetable oil instead of shortening, low-fat milk instead of cream in coffee, and diet sodas for regular sodas. While this does make obesity prevention appear less threatening and, therefore, easier to accomplish (since people are not forced to give up their preferred foods), in the long run, this approach may backfire. Ingredient substitutions often alter a food’s taste or texture, making them difficult to maintain. Additionally, simply attempting to create low-fat versions of inherently high-fat foods does not address the larger problem, which is that people crave these high-fat foods in the first place. Rather than relying on psychological tricks to deal with the self-control issue, it may be more effective to acknowledge it and tackle it head-on.

            Finally, the HBM ignores many of the external factors influencing individuals’ behavior. As already mentioned, several of these factors (e.g. money, time) are out of the individual’s control and therefore are significant barriers to obesity prevention. But what is often overlooked is the fact that the external environment can also be a valuable resource to promote healthy behaviors. For example, social networks can provide a source of encouragement and support for someone having difficulty managing his or her weight, and in fact, socialization can help motivate an individual to begin or maintain a healthy behavior. Rather than suggesting this, however, “Small Step” recommends some behaviors that are likely to be perceived as strange or eccentric. For example, “skat[ing] to work instead of driving” may negatively affect one’s professional image. Other suggestions, such as “when eating out, ask your server to put half of your entrée in a to-go bag” may conflict with established social norms of the area; in such a case, this request would only annoy the server, give the customer a bad reputation, and perhaps create awkwardness and embarrassment, thereby ensuring that this behavior will not be repeated again. Whether as an obstacle or a resource, external factors do matter and cannot be ignored if one hopes to successfully alter behavior.

 

3. One size does not fit all of America.

            The third and final criticism of the “Small Step” campaign is that it fails to account for the broad socioeconomic, ethnic/cultural, and geographic diversity of the American population. These factors impact not just the individual’s risk of becoming obese, but also the availability of resources with which to prevent it or mitigate its effects.

            Socioeconomic status has been shown to correlate highly with poor health outcomes even after controlling for other variables (8). Though the exact mechanisms by which this occurs is not known, the fact that lack of economic resources greatly constrains choice plays a part. Some of the economic barriers previously mentioned (e.g. incentive to super-size meals) are but superficial examples of a much broader issue. Individuals in low SES strata are often employed in high-stress jobs with long hours, or live in neighborhoods where walking may not be safe, and that are avoided by businesses such as supermarkets. Though there are over 100 “Small Step” tips, most of them are not applicable in situations such as these.

            Though “Small Step” was launched with the intention of reaching racial/ethnic groups at high risk of becoming obese, such as African-Americans and Hispanics, the cultural diversity of the campaign does not extend any further than including ethnic minority actors and models in the PSAs and print advertisements. Some tips encourage individuals to “try new fruits and vegetables” and “eat ethnic foods”, but the nutritional guidelines and cooking information make no mention of these foods. For someone whose dietary patterns vary from that of the “typical” American, then, it may difficult to see how they fit into the healthy eating picture, and conversely, how obesity prevention applies to them. Additionally, the campaign focuses exclusively on the rational basis for food choices when in reality, eating is a social activity in many cultures. Social and cultural values may factor into which restaurant someone chooses when meeting with friends, or what dishes they cook when having company in their homes. For example, in many Asian cultures, a higher value is placed on meat compared to vegetable dishes.

            Geographic diversity is yet another feature of the American population that is often ignored by public health campaigns. Urban and suburban living environments are drastically different in design, with the former being more pedestrian-friendly than the latter. Tips like “walk to work” are simply not feasible in many suburbs where roads have no sidewalks and cars travel at speeds that would make vehicle-pedestrian collisions fatal, and where public transportation is simply unavailable. In terms of food, the different regional cuisines of the country do not always lend themselves easily to obesity prevention. The south, in particular, is known for its high-calorie dishes that heavily rely on creams, butters, and oils. Simply telling people to make ingredient substitutions—which may alter the taste of traditional foods—will not be sufficient to promote healthier eating. Instead, a successful obesity prevention campaign will have to specifically target different regions of the country and think of ways to promote exercise and healthy eating keeping in mind both the physical and cultural geography of where they live.

 

Suggested Solutions

            Fundamentally, the “Small Step” campaign suffers from what one critic calls “small vision” (4). That this campaign fails to acknowledge the larger social, practical, psychological, and emotional influences on behavior has already been discussed. In choosing to focus on individual level behaviors for this campaign, the HHS intended to empower individuals and give them things that they can do in the scope of their own lives in spite of existing obstacles beyond their control (1). But by completely ignoring these obstacles, the campaign’s tips for change become impractical and unrealistic. Furthermore, in failing to account for the diversity of the American population, the “Small Step” campaign alienates the high-risk groups it needs to reach the most: those minority groups with higher risk of obesity, people with lower socioeconomic status, and those who live in areas built for cars, not pedestrians.

            These problems can be remedied to a certain extent, with the following recommendations. First, “Small Step” can make its campaign message more appealing and palatable to its audience by emphasizing the benefits of healthy eating and exercise. The current advertisements only address barriers to healthy behaviors, and the imagery used in the PSAs is unappealing. In terms of applying the HBM, the current campaign has only done half the job, which can only be remedied by shifting the focus of the advertisements to the beneficial aspects of healthy behavior. Changing the imagery used in promotional materials to connote positive ideals of health, beauty, and energy will provide viewers with positive motivational cues for healthy behaviors, making the campaign more effective.

            Second, “Small Step” should turn the scattered, poorly organized tips that comprise the core of its campaign into a comprehensive, progressive program. This can be achieved by getting rid of tips that are unrealistic or repetitive, reorganizing the remaining tips into categories targeted toward people in specific situations, and expanding certain sections to encompass a wider range of living situations. In this way, the campaign can better serve the needs of a diverse population, including people in different socioeconomic strata, from various ethnic and cultural backgrounds, and who live in diverse geographic landscapes. Instead of a one-size-fits-all approach, the website can allow users to better access tips custom-tailored to their specific needs.

            Finally, and perhaps most importantly, “Small Step” must be integrated with broader initiatives at the population level. Behavioral changes can help to prevent or mitigate the effects of obesity, but if the environmental causes are not addressed, then results are likely to be very limited. It is important, therefore, for “Small Step” to present itself not as a catch-all solution to the problem of obesity, but rather, as a part of a larger effort aimed at addressing the fundamental causes thereof. A more detailed discussion of these three suggestions follows.

 

1. Focus on positive aspects of healthy behaviors.

            Imagery is key to marketing any product; indeed, many advertising campaigns are able to successfully sell consumer products by using beautiful models and scripted scenes to associate products with ideals, such as beauty, youth, happiness, and of course, sex. The current “Small Step” PSAs, in an attempt at humor, use images of discarded body parts, which may evoke feelings of disgust among audience members and lead to rejection of the campaign. A better strategy would be to imitate the aforementioned successful advertising campaigns and use positive images to “sell” the “product” of healthy behaviors. “Small Step” could create advertisements in which attractive, healthy-looking people promote the benefits of following some of the tips on the campaign, such as having more energy, feeling better about their appearance, and worrying less about developing certain health problems. By associating healthy eating and physical activity with positive ideals such as health, beauty, and vitality, the advertisements become more palatable and easily accepted by viewers. Moreover, explicitly showing the benefits of healthy behaviors would allow people to more easily visualize the goals of the program, which could provide motivation to stick with it.

            “Small Step” PSAs should also send a positive message of empowerment to its viewers. The previous discussion of the campaign criticizes its failure to directly address the issue of self-control, which is a major barrier to adopting or maintaining healthy eating and exercise behaviors. To directly confront this issue, “Small Step” must step beyond the rational basis for behaviors and acknowledge the complex psychological and emotional components of eating and exercise behaviors; in other words, shift from simply telling people what to do and why, to making them feel good about doing it. For example, advertisements can depict people in various situations overcoming the temptation to eat unhealthily or shirk out of physical activity. One or two motivational slogans could be repeated throughout the campaign to further emphasis self-empowerment.

            In adopting these strategies strategy, “Small Step” should take care to portray people in realistic situations. Empowerment messages should limit their scope to address only the barriers that can be overcome by individual behaviors (for example, the temptation to take the elevator). Portrayals of unrealistic outcomes of behavior changes may cause the audience to reject the campaign altogether. In some cases, unhealthy food behaviors that lead to obesity may be linked to psychiatric disorders (9, 10). The “Small Step” website should acknowledge this and provide links to resources for these individuals. In a related vein, promotional materials should feature actors who are of normal weight. Currently, media advertising is filled with images of models who glamorize thinness to such an extent that may, many health professionals argue, encourage people to engage in unhealthy, self-destructive behaviors (6, 11). To counteract this alarming trend, “Small Step” advertisements should glamorize people who are healthy and who represent a wide range of body types, to combat not just overweight, but underweight as well. Audiences will more readily identify with images of regular people portrayed in realistic situations, and the overall message of the campaign will thus become more readily accepted.

 

2. Turn scattered tips into a comprehensive, targeted program.

            The 100-plus tips that comprise the core of the “Small Step” campaign are far from perfect. As mentioned previously, many of these tips make assumptions about the socioeconomic, geographic, and cultural situations in which people live, and are therefore unfeasible. Furthermore, these tips are organized in a haphazard way on the website, so that the effort involved in going through the entire list and sorting out which tips are applicable to them may completely offset the convenience of having small, manageable tips to follow in the first place.

            To address this problem, “Small Step” should first condense their list of tips down to a more manageable size. Tips that can potentially cause harm or injury (“Use a snow shovel instead of a snow blower”), are generally beyond one’s control (“Choose a checkout line without a candy display”), tend to add stress to situations (“Take wheels off luggage”), or just miss the point (“Get a dog and walk it”) should simply be deleted. Slight variations on the same tip (“Snack on fruits and vegetables” and “Keep a bowl of cut-up vegetables in the refrigerator for snacks”) can be combined to reduce repetition. A shorter list of good tips that can be applied in a large number of situations will make the entire campaign appear more manageable.

            Next, the “Small Step” campaign should organize the remaining tips and present them in a way turns these scattered pieces of advice into a cohesive program. For example, the tips can be categorized based on how easy they can be followed and how intrusive they are to an established routine. “Take the stairs instead of the elevators” would therefore be considered an easy tip, while “Don’t skip breakfast” would be considered harder, because it may require a readjustment of one’s morning routine. The categorized tips should be accompanied by directions; people should begin by incorporating the easier tips into their lives before progressing to more difficult ones, with the eventual goal of adjusting to a healthier overall lifestyle. Providing these directions will allow people to more easily keep track of their progress, and clearly stating the objectives and goals of the program may provide people with additional motivation to stick with it.

            Some of the tips can also be categorized based on the specific situations to which they apply, so that people can more easily find tips that are of use to them. For example, tips such as “Play with your kids 30 minutes a day” or “Walk kids to school” could be presented in a special section for parents, along with links to information pertinent to children. Tips targeted towards people who live in the city and take public transportation can be separated from those aimed at people who live in suburban environments. Cooking advice and recipes can be organized according to ingredients or region. These organizational changes would spare people the frustration of wading through all 100-plus tips to find ones that are useful to them, and improve the accessibility of the program.

            Partitioning the tips this way will not only make it easier for people to find helpful advice, but also suggest areas that need to be expanded and/or improved. Examples given above illustrate how the current campaign fails to account for the socioeconomic, ethnic, and geographic diversity of the American population. Adding tips targeted toward specific sub-populations would allow the campaign to reach much wider audiences. Examples include: expanding the cooking section to include region-specific recipes and providing nutritional information for ethnic foods; suggesting creative ways to increase walking when the design of the neighborhood is not pedestrian-friendly; adding exercises that can be done by older people without leading to injury. If these tips are presented in clearly-labeled, well-organized categories, then each visitor can quickly find his or her specific niche, and the website will avoid giving the impression of making false assumptions about the way people live. By simultaneously pruning tips that are unfeasible while adding new tips to target special populations, “Small Step” can become more effective without having to expand in size.

 

3. Incorporate “Small Steps” into larger initiatives.

            Small steps for change may have some results, but ultimately, the obesity battle must be fought by group forces rather than individuals. Success stories in the battle against obesity have typically involved population-level initiatives that are brought about by the collective efforts of community coalitions and municipal officials. For example, Michigan’s Building Healthy Communities initiative brought together local transportation officials, zoning and planning departments, universities, hospitals, residents, and farmers to build and improve walking trails, add new equipment to parks, open new farmers’ markets, and distribute coupons to low income families for fresh fruits and vegetables (12). Similar programs are gaining momentum across the country as people are beginning to recognize the environmental factors that affect overweight and obesity.

            To be fully effective, “Small Step” must be integrated with such population-level anti-obesity programs, because the fundamental causes of obesity are environmental factors, not individual ones. The current campaign acknowledges the structural contributors to obesity, but fallaciously implies that small individual-level behavioral changes can overcome those factors. The website feebly attempts to integrate with other programs by providing links to other government agencies as well as to local “Steps” programs, but these links are haphazardly organized and sometimes uninformative. Instead, the “Small Step” website could replace those pages with a new section that specifically discusses the importance of population-level initiatives, with better-organized links to local programs and resources, accompanied by brief summaries of the program components. The site could also acknowledge the limitations of individual-level behavioral changes (without implying that they should be abandoned), and suggest ways for citizens to get involved in population-level programs.

 

Conclusion

            While the HHS should be commended for tackling the ever-growing problem of obesity, the current “Small Step” media campaign suffers from its narrow focus. The incomplete application of models of health behavior, use of negative imagery, and failure to acknowledge the structural causes of obesity all contribute to make “Small Step” ineffective. Furthermore, because many of the campaign tips implicitly assume that all Americans live in a homogeneous manner, their applicability is severely limited.

            Improving the program would entail an overhaul of the existing advertisements and the website. Promotional materials need to adopt positive imagery. The tips featured on the website must undergo extensive revision. Implementing these changes will allow “Small Step” to be more readily accepted by people of all backgrounds and situations, and result in a more effective campaign.

            Most importantly, however, the HHS must recognize that the “Small Step” campaign, while valuable in its own right, is insufficient to combat obesity by itself. Individual behaviors can prevent obesity to a certain extent, but environmental factors that promote physical activity and healthy eating can yield more significant long-term results. Therefore, greater steps must be taken to integrate “Small Step” with broader, population-level initiatives to change the environment so that the US population as whole can lead healthier lives.

 

 

References

 

1. U.S. Department of Health and Human Services and The Advertising Council. Healthy Lifestyles and Disease Prevention Media Campaign: Take a Small Step to Get Healthy. Washington, D.C.: U.S. Department of Health and Human Services, March 2004. http://www.adcouncil.org/download.aspx?id=426

 

2. Longley R. Obesity Target of Renewed HHS Attack: Estimates 64 Percent of Americans are Overweight or Worse. About.com: US Government Info, April 3, 2008. http://usgovinfo.about.com/cs/healthmedical/a/hhsobesity.htm

 

3. U.S. Department of Health and Human Services. Smallstep Adult and Teen. Washington, D.C.: U.S. Department of Health and Human Services. http://www.smallstep.gov/index.htm

 

4. Stein K. Obesity PSAs: Are They Working as a Public Service? Journal of the American Dietetic Association, 2008; 108(1):25-28.

 

5. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

 

6. Keita GP. Letter to the U.S. Department of Health and Human Services. Washington, D.C.: American Psychological Association, July 3, 2007.

 

7. Frank LD, Andersen MA, Schmid TL. Obesity Relationships with Community Design, Physical Activity, and Time Spent in Cars. American Journal of Preventive Medicine, 2004; 27(2):87-96.

 

8. Raphael D. Health Inequities in the United States: Prospects and Solutions. Journal of Public Health Policy, 2000; 21:392-425.

 

9. Seamoore D, Buckroyd J, Stott D. Changes in Eating Behaviour Following Group Therapy for Women Who Binge Eat: A Pilot Study. Journal of Psychiatric and Mental Health Nursing, 2006; 13(3):337-346.

 

10. Barnes ME. Compulsive Eating Disorders (comment). Archives of Family Medicine, 1993; 2(8):813-814.

 

11. Hawkins N, Richards PS, Granley HM, Stein DM. The Impact of Exposure to the Thin-Ideal Media Image on Women. Eating Disorders, 2004; 12(1):35-50.

 

12. The Centers for Disease Control and Prevention and the U.S. Department of Health and Human Services. Obesity: Successes and Opportunities for Population-Level Prevention and Control. Atlanta, GA: Centers for Disease Control and Prevention, February 24, 2009. www.cdc.gov/NCCDPHP/publications/AAG/pdf/obesity_success.pdf