Fighting Childhood Obesity in American Schools: A Critique of Jamie Oliver's Food Revolution - Desiree Otenti

Introduction

Childhood obesity has become an alarming trend in America. Obesity rates have more than tripled since 1980 in children ages two to nineteen (1), and approximately 32 percent of American children are currently overweight or obese (2). The detrimental health effects of obesity on children are abundant and include increased cardiovascular risk, elevated blood pressure and cholesterol, joint problems, type 2 diabetes, gallbladder disease, asthma, depression, anxiety, peer isolation, low self-esteem and eating disorders (3,4). Combating the "epidemic" of childhood obesity will require a multi-level approach ranging from interventions targeting individual families to governmental policy; however, one intervention that has already shown positive results in preventing and reducing childhood obesity is school-based programs (3,4,5). One school-based intervention that has been capturing the nation's attention is a new reality television series, "Jamie Oliver's Food Revolution," on ABC. Jamie Oliver, a British celebrity chef, has made it his mission to improve nutrition in American schools by cutting out processed foods and re-introducing homemade, from-scratch, recipes into American school cafeterias (6). As benevolent as this mission might sound, Mr.Oliver surprisingly faced ample hostility and multiple road-blocks when trying to change the school menus in an elementary school and high school in Huntington, West Virginia. The issues that Mr.Oliver confronted developed from three basic flaws in his initial approach: first, Mr.Oliver used inappropriate and ineffective behavioral theories upon which to base his interventions; second, Mr. Oliver's marketing angle was based on poor formative research and did not satisfy the demand of his target audience; and third, Mr.Oliver did not look far enough upstream to address the barriers to change the local school systems faced. After a few episodes, realizing that his program methods were failing, Mr. Oliver completely changed his tactics to appropriately include interventions based on diffusion theory and the theory of social ecology. He also changed is marketing strategy to meet the needs of his target audience and started to look upstream by involving local policy makers. The "Food Revolution" television series shows the spectrum of traditional to modern social behavioral theory through Mr.Oliver's trial-and-error approach and ultimately demonstrates that the most important quality of a public health intervention is adaptability.

Critique 1

Although statistics help to prove a point, often they are not enough to change minds. This principle could not be any clearer than in the first two episodes of "Jamie Oliver's Food Revolution." Mr. Oliver chose to start his mission in Huntington, West Virginia because of a CDC morbidity and mortality report that sited Huntington as the most obese county in the nation (6, 7). He uses the data from this report repeatedly to explain why he started the food revolution and why people should change their eating habits (6). For example, Mr.Oliver meets with a local radio DJ, Rod Willis and tells him about the CDC report. Mr.Willis asks "Why would you say that we are [the most obese county] because there's other cities that have the same problems that we have?" Mr.Oliver replies "Because this is a government statistic based on death." To which Dr.Willis replies "I just don't think that you should come in here and tell us what to do. I mean, who made you the king?" (6). This reaction by Mr.Willis is surprising. However, when looking more closely at the problems with how Mr.Oliver has framed his intervention, Mr.Willis' resistance to change starts to make more sense.

The show does not make clear if Mr.Oliver has been trained in public health behavioral theory; however, Mr.Oliver uses social behavioral health theories throughout his show, whether or not he is aware of this. In the first two episodes, Mr. Oliver is basing his approach to behavior change on the health belief model which states that once people are made aware of the disease severity and their susceptibility to the disease, they will be more likely to change their behavior as long as there are few barriers and they are confident they can change (8). Using the CDC report and other statistics, Mr.Oliver tries to increase people's knowledge about the high morbidity and mortality rates related to obesity (6). He also tries to increase their awareness of their susceptibility to becoming obese based on prevalence studies (6).

This approach is flawed for a few reasons. First, simply educating people about their health risks does not address the social and environmental factors that impede behavioral change (9). Social factors play a very important role in the spread of obesity (10). One 2007 study looked at the spread of obesity over 32 years in a large social network in Framingham, Massachusetts (10). This study concluded that obesity can be spread through social ties and social norms that make obesity acceptable (10). For Huntington, West Virginia to become the most obese city in the nation, that means there are multiple, strong social ties between obese groups and that the society views obesity as acceptable. The health belief model is directed at the behavior of individuals; therefore, when Mr. Oliver comes into town telling individual people that they need to combat obesity, he is potentially taking them out of their social network and telling them that their previously held cultural acceptance of obesity is wrong.

Second, this approach relies on fear and guilt, very negative emotions, to motivate behavior change and places blame on the individuals who cannot change despite their intentions (11). For example, Mr.Oliver goes into the home of a family in which every member, the mother, father, two sons and daughter are obese. Their eleven-year-old-son weighs over 200 pounds (6). To visually demonstrate the amount of unhealthy food that the family consumes in one week, Mr.Oliver literally cooks an entire week's worth of their usual meals: pizza, fried chips, doubly fried doughnuts, corn dogs, heaps of processed foods, no fresh fruits or vegetables whatsoever (6). He then piles all the food into the kitchen and says to the mother "I need you to know that this is going to kill your children early" (6). The mother then starts crying and says "I'm feeling really sad and depressed right now" (6). Mr. Oliver then teaches the mother how to cook a healthy meal, gives her a grocery list, and hands her a list of recipes to cook over the next week (6). When he returns one week later, he is surprised to find that the mother changed almost nothing in her previous eating habits (6).

To the television viewer, it appears that this mother has learned nothing and that she does not care about the health of her family. This is a major flaw in perception when behavior change is viewed solely through the health belief model (11). The health belief model implies that once the mother was taught that her eating habits were unhealthy, and after she was showed how to prepare a healthy meal, she should have changed her behavior to start cooking healthy meals, which is what Mr.Oliver was expecting (8). This expectation takes the mother out of the context of her daily life and away from the social, cultural, and economic factors that created her initial behavior (11). The mother clearly understood the health consequences of her lifestyle, felt badly about this and had the skills to prepare healthier meals (6). However she still lived in a social group that accepted obesity as normal, had multiple time restraints preventing her from spending more time in the kitchen, had to convince her husband and children to eat the new meals and likely had multiple other unseen barriers to changing the family meal structure (6). Mr.Oliver's intervention, based on the health belief model, did nothing to address anything other than the mother's knowledge of healthy eating.

Critique 2

Marketing theory is based on the principles of exchange, self-interest, behavior change, competition, audience orientation and segmentation, the social marking mix, and building relationships (12). When creating a marketing strategy, in order to follow these principles, the first step is to conduct formative research to fully understand the perceived costs and benefits of the target audience (12). If Mr.Oliver's team conducted any formative research on the perceptions of the people in Huntington, West Virginia, it certainly does not show in the first two episodes. This is demonstrated by how Mr.Oliver packaged his social intervention and the initial rejection of his ideas by the cafeteria workers.

Mr. Oliver started his food revolution by going into one elementary school in Huntington, West Virginia. When he walked into the school cafeteria, it appeared to be for the first time, and he was surprised by the attitudes and values of the cafeteria workers and the system they worked under. First he makes the mistake of calling the women who worked in the cafeteria "lunch ladies," to which they very clearly took offense (6). Then he talks about changing the entire lunch preparing system, a system that the cafeteria workers previously had taken pride in as evidenced by one women's comment, "I don't understand why he is here to change our system which is working good" (6). Finally, Mr.Oliver points out the ingredient labels to the cafeteria workers, expecting them to be alarmed by the long list of additives and expecting this intervention to inspire change (6). The women merely shrugged (6).

This marketing approach violated many of the basic marketing principles. The exchange Mr.Oliver proposed was the processed lunch items for the from-scratch recipes. This took into account the health needs of the children but did not address the self-interests of the cafeteria workers. The concept of self-interest states that the only perceived costs and benefits that matter are those of the customer, and in this intervention, the cafeteria workers are the customers (12). In Mr.Oliver's proposed exchange, the cafeteria workers incurred all of the costs such as increased preparation time, increased dishes to clean, learning new recipes, and giving up their previously held values that they were taking good care of the children. Only the children would benefit, but this would be in the long-term. In social marketing, the benefits are often difficult to measure and are not seen until far in the future which is one of the difficulties in applying marketing to social interventions (13).

In addition, Mr.Oliver was not adequately orienting his intervention to his specific audience. His additive-revealing tactic might have worked on an audience segment that shops at whole foods or buys farm shares, but the cafeteria workers did not identify with his message and told Mr.Oliver they saw nothing wrong with the food they served (6). This shows that Mr.Oliver did not conduct adequate formative research to understand the opinions of his targeted audience. Also, Mr.Oliver did a very poor job of building good relationships with the cafeteria workers. He insults them by calling them lunch ladies, again, an avoidable mistake with formative research (6, 12). He looks horrified by the food he encounters, which is insulting to the women, and he tells them the system they had been using for the past twenty years is wrong (6).

The mistake of bluntly telling the women their system is wrong builds poor relations because it violates their feelings of ownership and forces them out of their status quo bias (14,15). Each of the women who worked in that school had been working there for at least ten years (6). They felt a sense of ownership for their system, as shown by their reluctance to change and their positive feelings toward the status quo (14,15). By pointing out the flaws of the system and telling the women they were making the children unhealthy, Mr. Oliver is taking away their sense of ownership for what they felt was good and is replacing it with the knowledge that they have been harming children for the past decade (14,15). Many of the women rejected this exchange and remained hostile toward Mr.Oliver (6).

Critique 3

The food that is served in American public schools is regulated by the United States Department of Agriculture (USDA) through the National School Lunch Program (NSLP) (16). This program is administered at the state level, and in return for providing meals that meet the federal nutritional requirement, schools are given cash subsidies and donated commodities from the USDA (16). Before Mr.Oliver arrived at the schools in West Virginia, they were meeting the federal nutritional requirement even though the foods were all highly processed and generally unhealthy (6). The current system does not ensure that healthy meals will be provided, and when they are provided it is often as a choice (17,18). For example, the breakfast being served on Mr.Oliver's first day in the elementary school was pizza with sausage topping along with cereal, a choice of strawberry, chocolate or plain milk, and apple juice (6). If the children ate everything on their plate, they would have consumed approximately 727 calories (estimate based on 1 average slice pizza, one cup chocolate milk, one cup apple juice, and 3/4 cup golden grahams). The 2005 Dietary Guidelines for Americans recommends that children ages four to eight eat 1,200 to 2,000 calories based on how active they are (19). Therefore, for sedentary children, that breakfast accounted for over half of their recommended daily caloric intake and still met the USDA requirements of a reimbursable meal (17, 18, 19). There are two problems with these facts, and Mr.Oliver addresses only one of them. First, the school system has the option of serving a healthier breakfast but chooses not to, and this is the problem that Mr.Oliver is trying to change (6). Second, federal school meal nutrition standards do not represent current nutritional science and are based on the outdated 1995 Dietary Guidelines for Americans (17, 18).

When Mr.Oliver first met with the cafeteria workers in the elementary school he pointed out many of the nutritional flaws in the current food regulation system (6). One of the women responded "I think you're taking it up with us when you should be taking it up with the one that is over us," and she has a good point (6). Although the school she works in has a choice of what to serve, there are two strong barriers to changing the current system: cost and meeting federal nutritional standards. Schools have to work within a specified budget for food, and processed foods are cheaper than fresh foods (20). Changing policy to prioritize food services in school budgets would enable more schools to have the means to improve the nutrition of what they serve. Also processed foods are already classified by the manufacturer as to what nutritional and serving size standards they meet under federal guidelines (16). This classification is called Child Nutrition (CN) labeling and makes school meals easier to plan (16). If a school wanted to create a new recipe based on fresh foods, in order to show the recipe meets federal guidelines, the school has to fill out lengthy paperwork showing the exact amounts of specific ingredients such as wheat, milk, eggs (17). Then these ingredients have to be reported in specific measurement quantities that requires an entire chapter, full of math equations, in the federal meal planner guide to figure out (17). Therefore the lunch lady has the choice of opening a package with no added work versus creating a recipe from scratch and then having to fill out pages upon pages of paperwork to make sure the school can be reimbursed by the government (16,17). If Mr.Oliver wants to motivate schools to try new, from scratch recipes, he needs to address the system that creates barriers to trying new foods.

Proposed Intervention

One of the strengths of Mr.Oliver's food revolution is that it does not rely on one approach to behavior change. In the first two episodes, Mr.Oliver used the health belief model and marketing theory to try to change the behavior of a radio DJ, an elementary school, and an obese family. Even though these interventions were mostly unsuccessful, Mr.Oliver obtained a clearer picture of what does not work. This picture was an important platform to create new interventions.

The health belief model interventions did not work because of resistance to Mr.Oliver's message, social networks accepting obesity, and environmental barriers to change. Realizing at least that his tactics were not working, Mr. Oliver changed his intervention. In the high school, Mr.Oliver used peer groups and social networks to promote healthy eating based on diffusion theory. Overall, Mr.Oliver changed his focus to address each of the levels of influence from the theory of social ecology: intrapersonal, interpersonal, institutional, community and policy (21).

In the first two episodes, Mr.Oliver's marketing strategy involved going on Rod Willis's local radio show and telling people why they should believe in his revolution. Clearly, as seen in critique one, Mr.Willis did not agree with Mr.Oliver's position and used his influence to discredit what Mr.Oliver was trying to accomplish (6). This is because Mr.Oliver was trying to change Mr.Willis's opinion based on statistics and the CDC report. In the next three episodes, Mr. Oliver changes his tactics and tailors his marketing pitch specifically to his target audience, Mr. Willis. In addition, Mr.Oliver changes his overall marketing strategy based on the perceived costs and benefits of the Huntington community through the use of community events, such as a cook-a-thon.

On a policy level, Mr.Oliver starts to address upstream issues instead of just intervening in the public schools. He involves the governor of West Virginia, the mayor of Huntington and a state senator in local events (6). In addition, Mr.Oliver visits the local food distributor to the schools of Huntington to see if they have enough fresh foods to meet the demand should every school in the district adopt Mr.Oliver's policies. Mr.Oliver also alludes to a plan to visit federal officials in Washington DC to help promote his cause. These up-stream interventions are crucial to removing barriers to better nutrition in American public schools. As an additional intervention, Mr.Oliver should write a cookbook with recipes specifically for schools that include all the CN information that processed food manufacturers supply. This cookbook would give schools healthier recipes to work with, reduce the amount of paperwork needed to comply with federal standards, and empower cafeteria workers to speak-up in favor of fresh foods instead of processed foods.

Defense of Intervention 1

Mr.Oliver's use of the health belief model was unsuccessful because it increased reactance to his interventions. In general, social influence can threaten people's sense of freedom and autonomy, and they respond by rejecting this pressure which is known as reactance (22). However, reactance can be decreased when the message is provided by someone similar to the message recipient (22). Mr.Oliver could not seem more different from the inhabitants of Huntington, West Virginia. He's British, he holds frequently voiced, different values from the community and he dresses differently (6). In this proposed intervention diffusion theory can help to decrease reactance.

Diffusion theory is an important tool to decrease reactance by increasing the similarities between the target audience and the person sending the message (21,22). In diffusion theory, change takes place within a social group or through contact with a change agent (21). Change agents are influential figures within the social system (21). In the high school, Mr.Oliver creates a peer group of six students to spread his message of change (6). The students appear to be from different social groups and grades within the school thereby increasing the number of groups that can be influenced by these students (6). According to diffusion theory, social groups are more likely to change their behavior when the information is presented from someone similar inside the community(21). This concept is demonstrated by the fact that in the high school, once the message of change was spread, not a single person went into the junk-food line, and all the kids lined up to try Mr.Oliver's food (6). This intervention was so successful that Mr.Oliver was given permission to take full control of all high school kitchen and cut out all junk food (6).

The theory of social ecology can also be seen throughout all of the food revolution episodes. Mr.Oliver had originally only addressed the intrapersonal level of influence by teaching healthy eating to individuals outside of their peer groups using the health belief model (8,21). Mr.Oliver addresses the interpersonal level of influence through his use of peer groups which addresses relationships within primary social groups (21). He also changes his tactics for the obese family mentioned in critique one on this interpersonal level. Although the mother of the family may not have as much time to cook, the eleven-year-old son has time and has an interest in cooking. Mr.Oliver takes this child to his kitchen and gives him a few lessons on cooking (6). In this way, Mr.Oliver has influenced the obese family on the intrapersonal level through teaching the mother and son separately, but also on the interpersonal level by changing the family dynamic and the family view on healthy eating (21). When hearing the message for social change from her son, the mother’s reactance is decreased, and she will be more likely to change (22).

Defense of Intervention 2

Mr.Oliver's second intervention change was to redirect his marketing strategy. In critique two, Mr.Oliver tried to create a demand for change in the school cafeterias by influencing the cafeteria workers. As discussed previously, cafeteria workers have little incentive to want to change as they incur all of the costs but few of the benefits. In episodes three through five, Mr.Oliver changed his target audience to multiple different groups and created a product specifically for each group. These outside groups have the potential to create pressure to change from the community and by adopting new menus for the children, the cafeteria workers would have a new benefit of the community’s respect. This paper will only focus on how Mr.Oliver changed his marketing strategy toward Mr.Willis.

With Mr.Willis, the initial marketing exchange was status quo for change based on statistics. Mr.Willis rejected this exchange. Mr.Oliver then changed his strategy to exchange status quo for change based on the law of small numbers. The law of small numbers states that people have erroneous intuitions about random sampling being highly representative of the population (23). This leads to overinference which is an exageration of information based on small signals from multiple sources (24). For example, Mr.Oliver takes Mr.Willis on a field trip to different places in Huntington to meet various people (6). They visit a funeral home that sells coffins for obese people (6). Mr.Willis is struck by the size of the coffin and the story of the funeral home owner that sales of these coffins are rising (6). No statistical data is given to Mr.Willis proving that sales actually were rising, and he trusts in the account of one man in one funeral home. Then Mr.Willis meets a girl whose father died of complications from obesity when she was in high school (6). Her story was tragic and Mr.Willis starts to become emotional (6). After meeting a few other people, Mr.Willis meets an obese high school girl who was recently told by her doctor that she has only five to seven years left to live because of projected complications from her obesity (6). She would have a chance at a longer life, if only she could get her obesity in control, which causes Mr.Willis to tear-up (6). At the end of that field trip, Mr.Willis is completely won over.

Each of these encounters was a small signal that added up and caused Mr.Willis to dramatically change his position, likely due to overinference from these few examples to the larger population, and likely due to how emotionally charged each of these experiences were (23,24). This transformation process was shown on television and broad-casted on the local radio in Huntington as part of Mr.Oliver's new marketing strategy. Other skeptics of Mr.Oliver's program probably could identify with Mr.Willis if they listened to his radio show. Again because of diffusion theory using similarities to decrease reactance, Mr.Willis' transformation and his position as a local celebrity changed the community's attitude toward Mr. Oliver (6,21, 22). In one of the first episodes, Mr.Willis bets Mr.Oliver that he can not get 1,000 people to come into his kitchen. At first no one comes to Mr.Oliver's kitchen; however during Mr.Willis's transformation, news catches on and suddenly people are responding to Mr.Oliver through cook-a-thons, work-sponsored events and finally through a local television show (6).

Defense of Intervention 3

Federal policy regarding school lunches has improved over the past five years, but it still has a long way to go (18). Currently states can create policies that affect school nutrition programs, but school districts are allowed to decide if they will follow these policies which is known as local control (18). States can create incentives to adhere to policy such as further funding, but ultimately the school districts decide exactly what food will be served in the end (18). By going into the school systems, Mr.Oliver is showing individual schools how they can comply with federal and state regulations and serve healthy meals at the same time (6). This increase in knowledge for the cafeteria workers empowers them to change their role within a faulty system, but does nothing to change the system itself.

Currently, nineteen states have set higher standards for nutrition in school meals than the 1995 USDA standard, compared to four states only five years ago (18). However most states operate on outdated guidelines to the detriment of the children being served unhealthy meals on a daily basis (18). Every state should be mandated on a federal level to update to the 2005 USDA standards (18, 19), and these states should not need to create stricter standards if the USDA guidelines were up to date in the first place (18).

Schools also have to cope with rising food prices and USDA reimbursements do not cover this increase in cost or the increase in labor costs (25). Because foods such as wholegrain breads, fresh fruits and fresh vegetables are more expensive, schools are often forced to buy cheaper processed foods to cut back on costs (26). Subsidies and USDA reimbursements should be rewritten so that meals higher in nutrient value and using fresher ingredients get reimbursed at higher rates than processed foods. This would create an incentive for schools to value healthier foods because they bring in more revenue.

Mr.Oliver alludes to a possible Washington DC visit in future episodes (6). When he goes to Washington, he should focus on updating federal and state guidelines to reflect current nutritional science, he should lobby for higher USDA reimbursements for healthy meals, and he should lobby for meal requirement guidelines to be re-written so that schools can create from-scratch recipes more easily without having to fill out mountains of paperwork. In the meantime, before Mr.Oliver goes to Washington, he should create an intervention that kills two birds with one stone. He should write a recipe book for schools based on the from-scratch, nutritious recipes he is using in each episode that have come in on budget. The recipes in this book should be calculated to show CN values for each meal and how much fresh meat and produce needs to be purchased. In this way, the recipe book competes with processed food for ease of use and cost and creates a foundation upon which new USDA nutrition guidelines can be written.

Conclusion

Overall, Mr.Oliver's food revolution used multiple social behavioral theories in the public health intervention of decreasing childhood obesity by improving the nutrition of school lunches. This can be summarized well through the theory of social ecology. Intrapersonal influences were based on the health belief model and focused in increasing individual awareness (21). Interpersonal influences were based on targeting key members in primary social groups such as peer leaders in the high school through diffusion theory (21). Institutional influences were not highlighted as much in this paper, but Mr.Oliver went to various corporations to raise awareness and support for his initiative, and Mr.Oliver had multiple meetings with the woman who ran the school nutrition program for the county (6,21). Community influences were targeted through specific marketing messages such as the transformation of Mr.Willis leading to a 1,000 person cook-a-thon over one week (21). Finally, policy influences were addressed through meeting with the mayor, governor and state senator, and Mr.Oliver plans to speak with more representatives in Washington, DC (21). There are two key strengths in Mr.Oliver's intervention. First, he does not rely on one model to change behaviors. He uses as many models as he appropriately can which increases the number of people who hear his message and increases the likelihood that they might identify with an intervention and change their behavior. Second, he is incredibly flexible. If the intervention does not work, he drops it and tries something new. Adaptability is the cornerstone of the food revolution and will hopefully lead to the changes our schools and our children desperately need.

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