Be Informed, Be Healthy? A Critique of the Nation’s Approach to A Healthier Lifestyle – Emily Simmons

Introduction

Obesity is one of the most significant public health concerns of today. The obesity epidemic in the United States is often a top long term priority for many local public health organizations around the country as well as larger national organizations such as the Centers for Disease Control and Prevention (CDC). In 2007-2008, the prevalence of obesity was 32.2% among adult men, 35.5% among adult women, which is defined as having a BMI of 30 or higher (1). Similarly, from 2007-2008 among children and adolescents from two to nineteen years of age, 11.9% were at or above the 97^th percentile of the BMI-for-age growth chart, and 31.7% were at or above the 85^th percentile (2). There are many causes of obesity, but the two arguments lie in the lack of physical activity and the lack of proper nutrition. According to the CDC, less than 25% of adolescents eat the daily recommended servings of fruits and vegetables and few get regular physical activity, certainly less regular than the recommended thirty minutes per day.

All of these factors combined result in an increasing number of overweight and obese children, adolescents, and adults in the United States. This is most certainly not anything that we did not already know. Government agencies have been rolling out public health campaigns for decades that try to convince the general public that eating five fruits and vegetables a day and following the food pyramid and exercising regularly will drastically reduce your chances of being obese, and subsequently reduce your risk of heart disease, diabetes, and stroke (just to name a few). So, what are we doing wrong? How is it that we have been fighting the obesity epidemic for so long, and yet we have failed so miserably? Below, I offer three arguments for why these campaigns have not worked, and three changes that could be made to existing programs (or new programs), according to social science theory, that could achieve better results and a healthier population.

Critique 1: Current Interventions Assume Individuals Make Rational Decisions - Use of the Health Belief Model

The King County public health department in Seattle, Washington rolled out a new campaign in early 2009 that targets the obesity (3). This campaign is aimed at “getting chain restaurant customers to read menu labels and make healthier choices” (3). The King County public health officials placed posters in subways and around town in general that consisted of images of a regular fast food meal with 1310 calories printed beside the picture and the same image except with a smaller portion off fries and a diet soda with 740 calories printed next to it. Clearly, there are multiple concerns with this intervention. First, it relays to the public that you can eat fast food meals, as long as they are with a diet soda and a smaller serving of French fries. The public health department of King County is suggesting that, by cutting back on the fries and incorporating a diet soda into your meal, you will be informed and healthy. Secondly, it suggests that counting your calories is all that you need to do in order to be healthy. And most importantly, it is relying on the fundamental belief that individuals make rational decisions.

The New York City Department of Public Health and Mental Hygiene began a campaign in 2009 that was targeted at reducing consumption of soda and other sugary drinks. The “Pouring On the Pounds” campaign consists of a signature image in which a bottle of soda, sports drink, or sweetened iced tea turns into a blob of fat as it reaches the glass followed by the slogan, “Don’t Drink Yourself Fat.” According to the New York City Department of Public Health, these images are “a stark reminder of how these products can lead to obesity and related health problems” (4). While it is true that drinks such as soda or sweetened iced tea are high in sugar, and thus usually high in empty calories that could easily be avoided with a glass of water, this campaign is still relying heavily on the notion that once people see this poster or commercial, they will immediately make the rational decision to put down their Coca-Cola Classic and reach for that glass of low-fat milk instead. Despite campaigns such as this, all signs point to the fact that soft drink consumption is on the rise, with the average daily consumption of soft drinks doubling from adolescent females and tripling among adolescent males form 1978 to 1998 (5).

These two recent campaigns are just two examples of countless that try to change the public’s behaviors by appealing to the rationality of those behaviors. Health departments and government agencies across the nation have somehow decided that by engaging the rational and intellectual part of individuals change will ensue. However, with obvious facts of increased risk of disease and shock-filled images, the general population continues to consume the fatty foods, soft drinks, and other unhealthy drinks and foods thereby neglecting all reason and rationality for the more pleasurable experience.

Critique 2: Current Interventions Do Not Address Self-Efficacy

Just because the information is available, does not guarantee that the warning will be heeded. Likewise, just because instructions and guidelines are provided to an individual on how to achieve weight loss, does not inherently imply that he or she will be successful. Current interventions provide plentiful recommendations and guidelines for losing weight. There are countless diet plans and schools of thought on which exercise regimen is the most effective (6). The American population is essentially led on a wild goose chase for the golden ticket to weight loss. Public health interventions are no exception. Many current interventions to increase awareness of the caloric value of fast foods rely on the use of nutrition labels such as the King County intervention described earlier (3). Simply putting nutrition labels in fast food restaurants will not guarantee that individuals who enter those establishments in the first place (which is not a healthy decision in and of itself) will make the “healthy” decision to opt out of the super sized meal, nor will it guarantee that individuals who enter these establishments will have the willpower to pass of the French fries and opt for the side salad.

Self-efficacy is an integral part of any major lifestyle change that an individual decides to make. This concept, first presented by Albert Bandura (7), simply refers to whether or not an individual believes that he or she can complete a task set before him or her. Bandura believed that a strong sense of self-efficacy would enhance “human accomplishments and personal well-being” (7). This concept has subsequently been applied to many social science theories, but unfortunately is not utilized in many public health campaigns that target obesity. For instance, New York’s “Pouring On The Pounds” campaign described earlier (4), provides only startling images of soda turning into fat, but fails to give New Yorkers the confidence that they can give up soda and replace it with a healthier option such as water or low-fat milk on any given day.

Similarly, the concept of weight report cards used in school-aged children to stimulate weight loss in the children by increasing awareness of the problem in their parents, provide parents with the knowledge that their children are overweight or obese but fail to give children the confidence that they need to believe that they can stick to a healthier lifestyle (8). BMI report cards were first introduced in 2003 when the state of Arkansas initiated and implemented a statewide BMI screening and surveillance program and other states have since followed, (Illinois, Maine, New York, Pennsylvania, Tennessee and West Virginia) (9,10). Under the program, schools inform parents of students they have determined either have or are at risk of developing weight problems, by sending home BMI report cards with the student’s BMI. While these interventions provide information, they do not provide the obese population with the tools necessary to build confidence and encourage self-efficacy, which is the key to success as anyone who has every tried to complete any challenging task such as quit smoking or losing weight. Instead these interventions label individuals negatively and simulate feelings of failure or negative body image.

Critique 3: Interventions Are Focused on the Individual Rather Than the Population

Traditional approaches to the obesity crisis in America have largely targeted the individual citizen and impressed upon him or her that importance of maintaining a healthy lifestyle of a balanced diet and daily exercise. Beginning in 1952, the American Heart Association has identified obesity as a risk factor associated with adverse cardiac events (11). After linking obesity with cardiac problems, many Federal agencies and organizations issued guidelines to encourage Americans to reduce energy intake, raise energy expenditure, or both to maintain a healthy lifestyle (11). In an onslaught of reports generated by Federal agencies from 1952 to the present day, including the 1977 National Institutes of Health “Obesity in America” and the 1996 American Heart Association’s “Dietary Guidelines for Health American Adults” and the 2005 U.S. Department of Health and Human Services’ “Finding Your Way to and Healthier You,” the target for initiating behavior changes was the individual (12).

Another example of an individual-level intervention that targets obesity in American children is demonstrated in an article that was published earlier this year. In this article, the authors report that a Federal panel of experts has issued new recommendations that encourage “U.S. doctors to screen children aged six and older for obesity, and to offer them a referral to intensive weight management programs when necessary” (13). These recommendations come from the U.S. Preventative Services Task Force and are updates to a 2005 report that failed to find critical evidence in support of routine obesity screenings in children; however, due to a series of randomized clinical trials that found appropriate therapy for obese children, the task force modified the recommendations.

Despite these efforts to reduce the percentage of obese children, which would subsequently reduce the percentage of obese adults in theory, it is clear that these Federal-level efforts to inform the public of the risks of obesity and being overweight in hopes of inspiring behavior changes at the individual level have failed. This is indicated by the glaring statistics that the obesity rates in America have continued to rise for the past five decades, as King et al. (2009) found that from 1988 to 2006, the percent of adults with a body mass index greater than or equal to 30 kg/m3 has increased from 28% to 36% and physical activity twelve times a month or more has decreased from 53% to 43% (14). Until we are united in our approach to tackling the obesity epidemic across all aspects of the problem on a population level, we will not be able to successfully achieve positive results.

Proposals for an Alternative Intervention

1. Make the Decision to Become Healthy Easy by Appealing to the Irrationality of People

Rather than targeting the individual and assuming that they will always make rational, weighted decisions, a more successful way to target the obesity epidemic is to address groups of individuals by appealing to their deepest desires and wishes, no matter who irrational they may be. If we, as the general population, know that eating fast food and drinking soft drinks and other sugary drinks are unhealthy habits, then why do we insist on polluting our bodies with these high calorie, fat-filled foods and drinks? The simple answer is that our wants and desires often outweigh and rational and practical decision to make the healthier choice. Likewise, watching television and staying home are significantly more appealing options than going to the gym on a weeknight.

So how should public health professionals steer their audience away from the easy, convenient choice of unhealthy habits and toward the more seemingly-difficult healthy habits? The solution can be found in similar campaigns that have targeted smoking cessation in young adults and teenagers. The Truth Campaign, a widely successful anti-smoking campaign, is a prime example that obesity campaigns should follow since it appeals to the deepest desires to young people to fight big business making decisions for you (15). Public health campaigns could just as easily empower adults and teenagers alike to fight big companies putting unknown or unhealthy products in our food just so they can last longer on the shelves, and consumers would begin to demand fresh, healthy foods.

Another possible solution is to make the connection between a high calorie, high fat diet immediate health impacts more direct. This could be accomplished by putting on nutrition labels, in addition to the number of calories in the product being consumed, the effects that a ten percent increase in an individual’s caloric intake or fat intake can have on the heart. By making a direct connection between consumption of unhealthy foods with empty calories and adverse health effects, the consumer would have the convenient knowledge of the consequences of their actions at their disposal at the time of consumption. This would help to take the challenge out of the decision making process.

2. Promote Self-Efficacy in Interventions

Many successful social science models used in public health have incorporated the self-efficacy component (16). Studies have shown that self-efficacy is needed to ensure the success of weight loss and healthy lifestyle programs (17). Creating a positive self image and self-efficacy among children and adults who could potentially be at risk for obesity is a critical component that any intervention that aims to reduce the number of obese individuals in a population should include because it is the foundation required to motivate and change behavior (17). With self-efficacy established in the population, individuals will feel more confident about making decisions to improve their dietary intake and physical fitness routines (17).

There are a few programs that are currently implementing the concept of fostering self-efficacy in their campaigns. One example is Small Steps Program. This program provides easy “small steps” that one can take toward a healthier lifestyle including things such as “portion out your snack on a plate, not a bag” and “take the stairs instead of the escalator” and “eat before grocery shopping” (18). By providing the American population with easy steps that they can take to become healthier people, the Small Steps program is empowering people by helping them realize that they can achieve a healthy lifestyle and that it is not as hard as they might have once believed. The Small Steps program, while not perfect, better illustrates a successful public health campaign that targets the obesity epidemic that can be applied to future campaigns on a national level.

3. Create Population-Based Interventions for Target Populations

It is critical that we consider the multiple aspects of American culture that can and do impact the obesity rates, from fast food consumption to the sodas in schools to the millions of dollars dumped into fast food marketing that children are exposed to from the age at which they can first watch television. Policy makers and public health officials must band together to form universal, multifaceted public policy approach that targets groups of individuals and the population as a whole if we hope to reverse the obesity epidemic that were are currently faced with.

There are several target populations that are at a higher risk for obesity than others. The prevalence of obesity is known to be highest among people with fewer years of education (19), therefore community-based health education campaigns targeted toward the undereducated population. These interventions could include weekly group exercise activity organized by local organizations and held in areas that are densely populated by people with less than a high school diploma. Also, physicians, community health centers, and other sources of medical care could organize free clinics for physicals and counseling of target populations to educate them on the risk factors for obesity as well as offer them group guidance on physical activity and nutrition, since this method was successful in a smoking cessation study (20). Overall, community-based health education campaigns tailored to cultural background, gender, education, and age group and health messages widely distributed in the entertainment and news media can help correct misperceptions that contribute to obesity and promote healthy behaviors.

Another potential solution to the obesity epidemic could be to approach the issue from a policy standpoint. By passing laws and bills that ban vending machines from school properties that sell sugary drinks and snacks such as sodas and candy and laws that mandate school lunch programs to incorporate a higher percentage of fresh fruits and vegetables and less preservatives into meals served on campus, policymakers could effectively change the nutritional value of the types of foods that American children consume while at school. By targeting America’s youth, the hopes are that healthy habits could be instilled at an early enough age to decrease the prevalence of obesity in future adult populations.

Conclusion

It is clear that simply providing passive information on nutrition labels or in public service announcements is not an effective way to convince the public that they should opt for a healthier lifestyle as seen by the persistent increase in obesity in the United States (1,2). It is critical that public health campaigns and programs learn from previous campaigns that have been successful such as the Truth Campaign for anti-smoking and apply similar tactics to the problem of obesity.

Here, three problems with the current public health approach to targeting obesity are identified: the heavy reliance on the Health Belief Model, a lack of self-efficacy in campaigns, and reliance on individual-level models. In response to these critiques, three proposed solutions are offered and include, appealing to the irrational hopes and dreams of the population, fostering deep-seeded confidence in the ability to adhere to a healthy lifestyle, and focusing on targeting populations instead of just individuals. While these proposed strategies for intervention are not exclusive, they do provide a reasonable start to successfully fighting the obesity in America.

References

1. Flegal, Katherine, et al (2010). “Prevalence and Trends in Obesity Among US Adults, 1999-2008.” JAMA 303(3):235-241.

2. Odgen, Cynthia, et al (2010). “Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008.” JAMA 303(3):242-249.

3. King County Public Health Department. (2009). “Be Informed Be Healthy.” http://www.kingcounty.gov/healthservices/health/nutrition/healthyeating/menu/campaign.aspx. Last Updated November 2009. Accessed April 3, 2010.

4. New York City Department of Public Health and Mental Hygiene. (2009). “New Campaign Asks New Yorkers If They’re Pouring On the Pounds.” http://www.nyc.gov/html/doh/html/pr2009/pr057-09.shtml. Accessed April 3, 2010.

5. Centers for Disease Control and Prevention. (2008). “Nutrition and the Health of Young People.” U.S. Department of Health and Human Services. November 2008. http://www.cdc.gov/HealthyYouth/nutrition/pdf/facts.pdf.

6. Tsai, AG, et al. (2005). “Systemic Review: An Evaluation of Major Commercial Weight Loss Programs in the United States.” Annals of Internal Medicine 142(1):56-66.

7. Bandura, Albert. (1994). “Self-Efficacy.” In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71-81). New York: Academic Press. (Reprinted in H. Friedman [Ed.], Encyclopedia of mental health. San Diego: Academic Press, 1998).

8. Chomitz, VR, et al. (2003). “Promoting Healthy Weight Among Elementary School Children Via a Health Report Card Approach.” Archives in Pediatric and Adolescent Medicine 157(8):765-72.

9. Justus MB, Ryan, KW, Rockenbach J, Katterapalli C, Card-Higginson P. Lessons Learned While Implementing a Legislated School Policy: Body Mass Index Assessments Among Arkansas’s Public School Students. Journal of School Health, Dec. 2007, Vol 77, No.10.

10. Levi J, Juliano C, Segal L. F as in Fat: How Obesity Policies are Failing in America 2006. Washington, DC: Trust for Americas Health; 2006.

11.Nestle, M. and M.F. Jackson. (2000). “Halting the Obesity Epidemic: A Public Health Policy Approach.” Public Health Reports 115(1):12-24.

12. U.S. Department of Health and Human Services, U.S. Department of Agriculture. (2005). “Finding Your Way to a Healthier You: Based on the Dietary Guidelines for Americans.” http://www.health.gov/dietaryguidelines/dga2005/document/pdf/brochure.pdf

13. Klein, Jonathan D., et al. (2010). “Adoption of Body Mass Index Guidelines for Screening and Counseling in Pediatric Practice.” Pediatrics 125(2):265-272.

14. King, Dana E., et al. (2009). “Adherence to Healthy Lifestyle Habits in US Adults, 1988-2006.” The American Journal of Medicine 122:528-534.

15.The Truth Campaign. www.thetruth.com. Accessed April 25, 2010.

16. Edberg, Mark Cameron. Essentials of Health Behavior : Social and Behavioral Theory in Public Health. New York: Jones & Bartlett, Incorporated, 2007.

17. Clark, M.M., Abrams, D.B., Niaura, R.S., Eaton, C.A. and Rossi, J.S., 1991. Self-efficacy in weight management.Journal of Consulting and Clinical Psychology 59, pp. 739–744.

18. U.S Department of Health and Human Services. “Small Steps.” http://www.smallstep.gov/. Accessed April 27, 2010.

19. Blumenthal, Susan J. and Jennifer M. Hendi. (2002). “A Public Health Approach to Decreasing Obesity.” JAMA 288:2178.

20. Pisinger, Charlotte, et al. (2005). “Smoking Cessation Intervention in a Large Randomised Population-Based Study. The Inter99 Study.” Preventative Medicine 40(3):285-292.