Saturday, May 8, 2010

Why Assuming That Individual’s Are Rational Decision Makers Leads To Failure of A Public Health Intervention: A Critique of The Transtheoretical Mode

The growing rates of overweight and obesity in the United States are alarming. Over the last 10 years, many states have gone from <10% of its population classified obese to more than 30%. In 2008, Colorado was the only state to have a prevalence of obesity less than 20% (1). Thirty-two states had a prevalence equal to or greater than 25%, with six of these higher than 30% (1). The drastic increase in these numbers is absolutely shocking, and demonstrates the need for change on a large-scale level. Weight loss programs and techniques such as Jenny Craig, Nutrisystem, and the Atkins diet have boomed over the last 20 years in response to these trends. However, these systems are very strict and limiting with specific diet requirements that can be too much for individuals who are trying to make a life long behavior change. The Transtheoretical Model has been proven to be a useful technique in helping to understand why and how people motivate themselves to make a change. Weight Watchers, a popular commercial weight loss program, uses the model as the basis for its plan but altered many areas to fit its goals. Both the TTM and Weight Watchers have aspects that are flawed and therefore limit success when used in a public health intervention. However, addressing the flaws and creating new techniques can make Weight Watchers, with the basis of the TTM, a successful intervention to decrease growing obesity rates in the United States.

Argument 1: The TTM and Weight Watchers possess many flaws that prevent success in a public health intervention.

The Transtheoretical Model (TTM) analyzes behavior change through a series of stages and processes. This model discusses the idea of decision making on an individual level; specifically how an individual decides to and acts to modify a problem behavior and acquire a positive one (2). Prochaska et al created this model on the preface that individuals can be characterized as belonging to one of five stages: precontemplation, contemplation, preparation, action, and maintenance. “Precontemplation is the stage at which the individual has no intention to change behavior in the near future. Many individuals in this stage are unaware or under-aware of their problems. Contemplation is the stage in which individual’s are aware that a problem exists and are seriously thinking about overcoming it, but have not yet made a commitment to take action. Preparation is when individuals are intending to take action in the next month and have taken some action in the past year. Action is the stage in which individuals modify their behavior, experiences, or environment in order to overcome their problems. Action involves performing the behavioral changes and requires commitment of time and energy. Maintenance is when individuals work to prevent relapse and maintain their progress after six months” (2). The different stages help to diagnose an individual’s status and to determine where he/she is in the behavioral change process. Though there are five sequential stages, the model accounts for the fact that not all individuals are at the same step at the same time, some may not go through all the stages based on their past experiences, and some may never reach full maintenance. For example, for individual’s who are attempting to lose weight, some may have made it to the action stage after thinking about beginning a diet, choosing one to use, and actively trying it out. However, they may not have seen results, and gave up because it was too difficult, brining them back to the contemplation or preparation stage. Another component of the model is the time frame for each stage. Each time frame is very specific; categorizing people based on how many days they are in a stage. One issue with this is that some individual’s may not be in a stage for exactly 30 days or 6 months, which could alter which group they are placed in and potentially accurate documentation of their progress. As a result, this model focuses on the idea that interventions to promote change, such as weight loss programs, should be designed so that they are appropriate to the individual’s current stage (3). Prochaska et al believe that moving an individual from one stage to another is promising because it increases the likelihood that the person will ultimately reach the termination stage.
Weight Watchers is a commercial weight-loss program based on the idea of the Transtheoretical Model. Weight Watchers is a system that motivates individual’s to lose weight by presenting them with a specific diet to help them reach their goals (4). The program is focused on the idea that, with the mapped out plan, support, and guidance the program provides, all individuals will succeed. Though Weight Watchers is based on the idea of the TTM, the model does not conform completely to the goals of the program. The TTM has drawbacks that can lead to the potential of failure in light of a public health intervention like Weight Watchers. For example, the TTM focuses on change only at the individual level (2). The TTM believes that all individuals possess self-efficacy, the belief that he/she has the ability to perform and act in a certain manner to attain goals and make changes, and that this is the key to successful behavior change (2). It does not take into account that group level support can have a positive effect on an individual when used in combination with self-efficacy. It also does not acknowledge that the five stages of change are limiting; creating labels and time frames can be frustrating for individuals who may not complete the stage in a specific amount of time. Therefore, Weight Watchers devised their own behavioral change process with the belief that the program will have higher success rates than the TTM itself.
Though Weight Watchers altered the TTM to fit its goals, the program also has many flaws of its own. Weight Watchers does not specify every stage of an individual’s behavior change. Rather, it assumes that those who come to the program have already conquered the precontemplation and contemplation stage and are prepared to take action. Weight Watchers begins the program immediately, setting individual weight loss and exercise goals and initiating the action stage. This can be problematic because the individual may come to Weight Watchers with full confidence that he/she is fully prepared to begin the program; however his/her level of self-efficacy may be low or temporarily high due to advertising promoting the success of Weight Watchers. It is important for the individual and for Weight Watchers to be in tune with each other as to the individual’s past experiences and current goals. Most times, Weight Watchers looks at an individual just like every other member, someone who is there solely to lose weight and look and feel better about themselves. However, this may not always be the case. The TTM takes into account that a change is being made to benefit the person’s health status, where Weight Watchers is based on helping individuals lose weight while making a profit. The goals of WW are naturally going to be much different because it is not a clinical based program; it focuses more on seeing physical effects and numbers on a scale. Similarly, the main focus of Weight Watchers is to help an individual lose weight through group support and guidance (4). Though there are some individual meetings for “weigh ins”, the members are advised to attend group meetings where they can seek support and motivation, and share stories, questions, comments, and concerns with others in the program. According to the Article “Enhancing social support in weight loss groups,” (5) social support has been linked with lasting weight loss because it enhances feelings of control and confidence. Similarly, in the article “Weight loss with self-help compared with a structured commercial program,” (6) there was a direct connection between attendance at Weight Watchers meetings and weight-loss results. Weight Watchers uses group support to make up for a person’s low self-efficacy, which in the case of making weight loss, healthy eating, and exercise a life long behavior change, can be a huge setback. Long-term group therapy has been found to inhibit the development of self-reliance and self-discipline, which could pose problems when the individual is on his/her own (6). The action stage is the focus of Weight Watchers; once the individual hits their target weight, Weight Watchers declares that the individual has completed the program and has acquired habits and knowledge that will allow them to maintain his/her progress. This assumption is a large issue for Weight Watchers; not everyone is in the maintenance stage once they have reached their target weight. This is a main reason as to why many people struggle when on their own and why many return to Weight Watchers a second time. Therefore, both the TTM and Weight Watchers have flaws that would prevent complete success when used in a public health intervention.

Argument 2: Weight Watchers assumes that individuals are rational thinkers

Weight Watchers focuses heavily on the role of diet on weight loss. Rather than focusing on specific foods to eat and not to eat and setting calorie limitations, Weight Watchers does not limit food choices by using the idea of “points.” Each person enrolled in Weight Watchers is given a weight loss goal that is analyzed and altered as time progresses. Most individuals start off with a 5-10% weight loss reduction goal that is expected to be met within a certain time period (4). From here, the Points allowance is determined based on how many calories are needed to assist weight loss. Weight Watchers provides its members with a list of foods and the number of points each contains, along with guidance on how to choose foods that will meet dietary recommendations and will foster healthy weight loss (4). However, the individual is allowed to plan the diet on his/her own, incorporating foods they like without feeling limited. Naturally, Weight Watchers assumes that an individual who is actively trying to lose weight will follow the point system as accurately as possible in order to achieve weight loss. The program expects that the individual will fill themselves up with zero point foods like vegetables, salad, some fruits, and save the remaining points for nutrient dense foods like whole grains, meat, poultry, fish, and dairy. However this may not always be the case, due to many factors. Some of the point values can be deceiving; for example, an average serving of peanut butter is 1 tablespoon, but for Weight Watchers, a one-point serving is a teaspoon. The points can quickly add up if the individual consumes a peanut butter and jelly sandwich for lunch. People may struggle at first with trying to understand the point system and getting used to the portions; this could cause problems with underestimating calories (points), especially if eating out at restaurants when the person does not have control over everything on the plate.
Another major issue with Weight Watchers is that it assumes that individuals will spread points out throughout the day as to control their appetite and keep their metabolism in check. However, due to schedules, errands, and appointments, some people may not have time to balance out 3 meals and two snacks a day. This could lead to someone choosing quick, unhealthy options on the go or consuming all of their points at one sitting. Some may even plan it out so that they can use all of the points on a treat like a banana split, or a pizza. Finally, some individuals may not be able to follow the program as specifically as necessary. For example, to make weight at weigh-in time, a person may not eat or drink for the entire say to show that they lost the two pounds required of them so that they do not seem like a failure.
The belief that all individuals in Weight Watchers are rational thinkers is a large fault of the program. The reality is that people are irrational thinkers; humans often believe they are acting rational, but are unaware of flaws in reasoning or a misunderstanding of their intentions and interests (7). This irrationality is a reason as to how and why humans make decisions that are not always considered the “best” by society, though it may be right in their eyes. Similarly, irrationality is often a contributor weight gain and ultimately joining Weight Watchers; people can explain eating ice cream because of a rough day at work, or having a burger because everyone else is. It is counterproductive that Weight Watchers does not address this irrationality; if people are not aware that their decision-making is irrational, it will prevent them from succeeding in the program and thereafter.

Argument 3: Weight Watchers is confident that the program will set members up for a lifetime of sustained weight loss and healthy lifestyles.

Weight Watchers prides itself in the idea that the program provides healthy weight loss through an approach that is realistic, practical, and livable (4). They believe that helping people set weight loss goals and providing them with information on what to eat is a successful way for them to see results and to form habits that are sustainable long-term. Weight Watchers has proven in many studies to be a program that provides safe, substantial weight loss program. The New England Journal of Medicine found that individuals who cut calories by 750 but did not eat less than 1200 per day, and who attended weekly group sessions for the first 6 months, showed the most weight loss (8). These persons experienced and average weight loss of twenty pounds versus nine pounds in those following just a calorie restricted diet. However, there is little evidence that these results are retained after the individual leaves the program. In the same study, after one year, all of the individuals involved in the study began to gain weight back, just at a slower rate (8). The same study also indicated that successful eating plans should be “tailored to individual order to have the best chance for long-term success” (8). As mentioned, Weight Watchers focuses on the idea of group support to help individuals’ motivate themselves through the program. The main issue with this form of support is that when a person leaves the program, others who are in the same situation will not surround them. If the person does not have another form of support, he/she may have trouble staying on track and motivated. This is due to a lack of focus on self-efficacy, a key factor in individual motivation and success. In addition, one reason for large success while in the program is that the individual has something to work toward each week: achieving the set weight loss goal at weigh-in time. When weekly weigh-ins with a supervisor are non existent, the individual may not have the same drive to succeed as they did when they were required to step onto a scale. As a result, many individuals may not follow the diet as carefully if they know that they wont be pressured and defined by a number.
Another issue in the program is the Points system. While it is beneficial for short-term weight loss because it provides the person with guideline of how much food to eat, it disguises a real understanding of calories, nutrients, and portion sizes. For example, if an individual learns how to eat based on single numbers, he/she may not understand the science behind the reasoning. This can lead to issues in food choices; for example if a serving of almonds and slice of cake both have 4 points, someone might justify that they are the same amount of calories, and choosing the cake must be an equal alternative. It can also lead to issues with portion sizes; one fillet haddock or flounder is worth four points, but the actual weight is not specified. A fillet to someone could mean anywhere from 3 to 8 ounces and could cause overeating without knowing it. Providing people with information as to how to look beyond food as a number is extremely important for success in the real world. An understanding of calories, fats, proteins, and nutrients and how the body metabolizes them is crucial. Without this, people will continue to think irrationally and make choices based on irrational and insufficient information.

Intervention Goal: Incorporate some important aspects from both the TTM and Weight Watchers and create a more dynamic program

Both the TTM and Weight Watchers possess key ideas and components for a successful public health intervention. The key to a successful intervention is understanding the target population and addressing the needs of that specific group of people. In a weight loss intervention like Weight Watchers, the target group is overweight or obese men and women who are looking for a diet and support plan. These individuals are in search of a program that will help them change poor habits and lifestyles into positive and healthy ones. For an intervention to be successful, it must target this specific population at both a group and individual level.
The Transtheoretical model is based on the idea that an individual can successfully make a behavior change through a series of stages and processes. The stages are very time specific and classify people according to their emotions, cognitions, and behaviors. For example, an individual is labeled in the precontemplation stage if he/she is planning to make a change in the next six months or is in the action stage if he/she has been modifying habits for six months. However, some people may want to make a change soon but are unsure of when they will do it, and others may need longer than six months to make a successful, long-term behavior change. Similarly, this model focuses on change at the individual level, claiming that self-efficacy is the key to change. Weight Watchers is also based on behavior change through a series of steps including weight loss goals, diet change, attending group meetings, and weekly weigh-ins. The main focus of this program is targeting individuals at the group level, using support systems to help individuals motivate themselves to succeed. My idea to make these two models more successful in a public health intervention is to use ideas from both and combine them. A person looking to make a behavior change should incorporate both self-efficacy and group influence into the process. If an individual possesses self-efficacy, he/she will have a constant voice in their head motivating and encouraging them. However, if he/she encounters obstacles or setbacks and feels discouraged, group support will come into play, when the individual needs that extra push.
The first part of my intervention is to revamp the Weight Watchers program techniques. The main focus should be on the individual, with group support as a contributor. The individual who signs up should be assigned a specific counselor who will monitor his/her progress throughout the program. The client should work with the counselor to set reachable goals that are individualized and that are edited as necessary. With the focus on the individual, the counselor will be able to see how the client is feeling throughout the process and can track them more effectively than in a group setting. Group meetings should be in addition to individual meetings and be a place for people to be open about how they are feeling, and the struggles they face. Goals should not be created in group meetings, rather they should be a support system to an individual plan. In this way, the individual will feel that they are more than just a face in the crowd; they have a specific, individualized plan but have an open, supportive ear along the way. Similarly, it will strengthen the person’s self-efficacy in the short and long term if he/she is the main support system and influence during the change.
The second part of my intervention is for Weight Watchers to acknowledge that individuals are irrational. To admit that individuals are irrational will allow the program to be more effective in really impacting the person making the behavior change. Currently, Weight Watchers is focused on weight loss, and reaching a target reduction each week at weigh-in time. As a result, people become obsessed with numbers rather than focusing on the positive changes they are making physically and mentally. It is important to educate the client that the number on the scale is only a byproduct of the hard work and changes he/she is making. This will help to take some of the pressure off, and will help individuals to stay on a healthy track to weight loss. Similarly, to deal with irrationality, Weight Watchers should be focused more on teaching individuals about a healthy well balanced diet and gradual weight loss. There is no need to rush through the program to reach a goal weight; it is more important to implement changes slowly and accurately. Through the point system, individuals are given a sheet of foods and beverages and their point values. With a limit as to how many points to each, the person is to use his/her best judgment in choosing what to eat. As discussed earlier some individuals may not make the healthiest choices when given the option. The diet plan should still use the idea of points, but education should be provided about the theory behind the numbers and how the points translate into calories. In this way, the person will be able to fit Weight Watchers into everyday life, versus looking at foods solely as a number. If they think of foods for their actual nutritional worth and the benefits that they are providing to the body, the individual is more likely, though still not guaranteed, to make healthier decisions.
Similarly, Weight Watchers should teach portion control and ingredient importance. A person should be able to balance the amount of food they consume by knowing what to eat and how much of it, no matter what the circumstance. This will teach people how to follow a well balanced diet, and how to deal with challenges like a work buffet lunch or a child’s birthday party, without getting feeling like they cant eat anything because they don’t know how many points the food is worth. Different ways to teach portion control include demonstrations of portion sizes, like how much a serving of chicken is, and how to rationalize a portion size when out at restaurants. In addition, knowing the ingredients in foods is crucial to weight loss. For example, a slice of pizza may be 6 points, but a slice of pizza on whole wheat crust with low fat cheese and extra vegetables is much different than a slice of pepperoni on normal crust. These are skills that every person should know, especially those who are looking to make life long behavior changes that will not only help them manage their weight, but also improve their quality of life.
Finally, Weight Watchers should provide individual’s with useful pointers on how to be successful once out of the program. As mentioned earlier, it is important for the individual to strengthen his/her self-efficacy while also using group meetings for support and motivation. However, once out of the program, the support system will be gone. Weight Watchers should involve the individual’s family into the process to make the transition easier. People value having others around them that support their goals and motivate them to succeed. It would be useful to have sessions for family and friends so they know why the individual was at Weight Watchers, what he/she did while in the program, and how they can help make the transition easier for them. If they are involved in the program, they will be more motivating and may even be willing to make positive changes themselves.
In conclusion, both the Transtheoretical Model and the current Weight Watchers programs have positive and negative aspects. There are flaws in each that have the potential for failure in the light of a public health intervention. The TTM affects the ability of an individual to make a behavior change because it classifies him/her according to thoughts, behaviors, and emotions, and limits the amount of time allotted for each stage. This can be limiting, especially if an individual fails at getting through all the stages successfully. Similarly, it only considers change at the individual level, and focuses on self-efficacy as the key to change. In Weight Watchers, the main focus is change through group level techniques, with little focus on self-efficacy. The focus of the program is quick weight loss without the stress of a diet plan, but rather the implementation of a points system. Though they recommend eating low point foods like fruits and vegetables, there is little mention about the benefit of a well-balanced diet on weight loss and the many benefits it has on overall health and wellness. In addition, there is little focus on portion control except for how many points a food has.
Encouraging an individual to join to a program like Weight Watchers is the easy part; helping them to find the courage and motivation to participate in the plan and to create changes that are life long is the more challenging part. The program must teach the individual the importance of self-efficacy and group and family/friend support, and the impact they can have on making a change successful. By teaching habits that can be implemented in everyday life and used in the long term will help a person stay on track and find the motivation to continue on the plan. Removing labels and limitations through stages will also improve the program. For an individual to make a successful behavior change, the focus must be on change at the individual level, but incorporating group support for motivation and encouragement when self-efficacy is not enough. The points system is a good way for an individual to learn to control eating habits, but there should be more focus on. Finally, the TTM has a good approach with the use of stages; however they are too specific. Using ideas like preparation, action, and maintenance are good reference points; rather than being forced to change in a specific amount of time, the person should be encouraged to keep going and trying no matter how long it takes. With these improvements and the combination of the improved Weight Watchers and TTM ideas, Weight Watchers will prove itself to be more successful and make a bigger and more positive impact in the a large scale public health intervention.


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