Chancellor Promotes Unwholesome Foods & Hinders Children’s Development & Empowerment: NYC Ban of Homemade Goods at School Bake Sales– Annabelle Ho

Introduction

Kellog’s frosted brown sugar cinnamon Pop-Tarts are allowed to be sold at school bake sales while homemade banana bread and Greek spanakopitas are not? In New York City’s Public Schools, this is the case. This past February, New York City’s Department of Education (DOE) revised Regulation A-812, Competitive Foods, “to improve the quality and nutritional value of foods and beverages that are available for children” (1). According to this revision, students may only sell food items at school that are in the DOE’s approved list between the time school begins and 6:00 pm, with one exception for PA/PTA fundraising sales. This exception allows PTAs to hold a fundraiser once a month with non-approved foods during the school day after the last lunch period, as long as the sales occur outside the cafeteria. The DOE’s list of approved foods to sell during the school day currently includes all fresh fruits and vegetables and around forty or so packaged items, including low-fat Cool Ranch Doritos, brown sugar cinnamon Pop-Tarts, and blackberry Nutri-Grain cereal bars (2). These packaged items all meet the DOE’s Food and Snack Guidelines, which, among other specifications, state that the products are each in single serve packages and meet a specific nutritional profile.

According to the Child Nutrition and WIC Reauthorization Act of 2004, an act which is to be renewed this year, school districts that participate in federally funded meal programs are required to develop and institute a wellness policy (3). According to this act, schools’ wellness policies need to incorporate goals for nutrition education and physical activity, and guidelines that promote student health and reduce childhood obesity (4). The DOE’s regulations regarding Competitive Foods will become a part of the DOE’s 2010 Wellness Policy, which is currently still under revision. The wellness policy addresses the obesity epidemic in the United States, which has become a growing problem, especially over the past few years. In 2003-2004, the National Health and Nutrition Examination Survey (NHANES) estimated that 17.1% of U.S. children who were between 2-19 years of age were overweight (5). This shows a significant increase in overweight children from previous years, as the percentage of overweight children of 2-19 years of age were 13.9%, 15.4%, and 17.1% in 1999-2000, 2001-2002, and 2003-2004, respectively.

Although the revision of A-812 was meant to promote student health and reduce obesity, there are many problems with this intervention. A-812 allows approved foods that meet “healthy food guidelines.” However, the food that is in the DOE’s approved list can be of much lower nutritional quality than fresh, homemade goods. In addition, preventing students and parents from selling homemade goods at bake sales during the school day inhibits children’s development as evidenced by the Ecological Systems Theory, and disempowers children according to the Empowerment Theory.

A-812 Does Not Promote Nutritious Foods

Although regulation A-812 was meant to promote student health and reduce obesity as part of New York City’s 2010 School Wellness Policy, the regulation and approved food list promote unwholesome foods. The Food and Snack Guidelines state that products must meet a specific nutritional profile. For example, each product must contain 200 calories or less, 200 mg of sodium or less, less than .5 g of trans fat per serving, and at least 2 g of fiber per serving if the snack is a grain-based product (2). However, even if a food meets the specified nutritional profile, this does not mean that the food is nutritious. For example, the main ingredients of Stacy’s Cinnamon Sugar Pita Chips, which are in the DOE’s approved list, are enriched wheat flour, sunflower and/or canola oil, and sugar (6). Stacy’s Cinnamon Sugar Pita Chips contains less than 2% of whole wheat flour, organic sugar, brown sugar, cinnamon, sea salt, active yeast, oat fiber, compressed yeast, malted barley flour, and inactive yeast. While Stacy’s Cinnamon Sugar Pita Chips do meet the nutritional guidelines set forth by the DOE, the main ingredients of these pita chips are not nutrient-rich. Regular consumption of whole grains and whole grain products, as opposed to refined grain products, has been associated with reduced risks of various types of cardiovascular diseases (7). Whole grains naturally contain phytochemicals and antioxidants that work synergistically to create health benefits, and these synergistic effects cannot be replicated or recreated by simply enriching refined grains with the vitamins that are known to be lost during the grain-refining process.

Many homemade baked goods can be very nutritious. While many of the approved snacks on the DOE’s list contain a combination of whole and refined grains, children cannot sell homemade 100% whole wheat bread or rolls under A-812, even if the whole wheat bread or whole wheat rolls did meet the DOE’s required nutritional profile. Homemade banana bread is also not permitted, even if whole wheat flour, healthy oils, such as olive oil, and bananas, a fruit that naturally contains protective antioxidants and phytochemicals, are used. Many health benefits have been attributed to olive oil. Olive oil is said to reduce risk factors of coronary heart disease, have protective effects against various cancers, modify immune and inflammatory responses, and contain many healthy phytochemicals including polyphenolic compounds (8). In addition, bananas and fresh fruits and vegetables naturally contain antioxidants and phytochemicals, and it has been found that the total antioxidant activity from these foods comes from the combination of phytochemicals (9). One antioxidant cannot replace the combination of phytochemicals naturally found in fruits and vegetables to produce health benefits, because it is the additive synergistic effects of phytochemical activity that are responsible for these antioxidant and anticancer activities. The collaborative effects of phytochemicals naturally found in foods cannot be replicated by simply enriching or fortifying snacks, because there are many compounds in food that remain to be identified. The health benefits found in foods naturally high in antioxidants and phytochemicals cannot be found in processed food products that do not contain these nutritious ingredients, even if the Brown Sugar Cinnamon Pop-Tarts are fortified with niacin, thiamin, iron, riboflavin, folic acid, vitamin A, and vitamin B6 (10). Although an individual may believe a packaged snack contains fruit, the actual amount of fruit in the product may be considerably less than he or she may have initially believed. For example, even though an individual might expect to have some fruit from a Nutri-Grains Blackberry Cereal Bar, a product which is approved by the NYC’s DOE, blackberries are actually the fourth ingredient in the cereal bar filling (11). The first three ingredients of the cereal bar filling in order are high fructose corn syrup, corn syrup, and glycerin. While any fresh fruits and vegetables are allowed to be sold during bake sales, teaching students and parents learning how to incorporate these healthy foods into baked goods, rather than letting the manufacturers do the work, is important and can be very educational.

A-812 Hinders Proximal Processes and Child Development

A-812 hinders proximal processes and child development according to the Ecological Systems Theory. Two main propositions define the Ecological Systems Theory. Proposition I states that human development takes place throughout life through processes of increasingly more complex reciprocal interactions between active, evolving human organisms and the persons, objects, and symbols in its immediate environment (12). For interactions to be effective, they need to be mostly on a regular basis over long periods of time. These continual forms of interactions in the immediate environment are known as proximal processes. A corollary to Proposition I is that the developmental power of proximal processes is enhanced during circumstances in which the persons involved have developed strong emotional attachments to one other. Meanwhile, Proposition II states that the form, power, content, and direction of the proximal processes affecting development vary steadily as a combined function of the characteristics of the developing person, the immediate and remote environment, and the nature of the developmental outcomes under consideration.

In the ecological model, the developing individual is also influenced by five successive systems, with each system contained within the next (13). The microsystem includes the setting in which an individual lives, while the mesosystem involves connections between two or more settings which both involve the developing individual. The exosystem includes two or more contexts, at least one of which does not contain the developing individual but which influences the individual. Macrosystems involve the culture in which the developing individual lives, and the chronosystem involves change or consistency in the developing individual and their environment over time.

Child development can thus be hindered if only packaged snacks are typically allowed at school bake sales. As indicated by the Ecological Systems Model, children are most affected by proximal processes, close relationships, and factors in their immediate environment (13). This has implications in school bake sales, especially if children are baking homemade goods with their parents. Cooking is becoming a lost art in the United States, and children increase their development, cooking ability, and ability to interact with others if they have more complex interactions with other people, such as by cooking with their parents. Furthermore, as indicated in Proposition I, these interactions are enhanced when these interactions occur regularly. If PTA bake sales with non-approved goods can only occur once a month, the interaction and experience of the child cooking with his or her parent is rather infrequent, particularly if a parent is busy at one month and cannot cook with the child until the next month. This infrequency decreases the amount of interaction the child has with the parent and can thus hinder a child’s development.
Foods that children make with their parents are more meaningful than packaged food items. For instance, home-baking is important in relation to a child’s culture, a part of the macrosystem (13). A student may get more from a cooking experience with a parent if the food that they are making has a familial and cultural background. Helen Martineau-Kraus, a parent from New York City, used to make mini-spanakopitas, a pastry characteristic of Greece, with her two daughters for their school bake sales (17). Under A-812, homemade spanakopitas can only be sold at the exceptional PTA bake sale once a month. According to the Ecological Systems Theory, a child would learn much more from making and selling a homemade treat that is characteristic of their family and culture, which has much more meaning as compared to a retail packaged item. Meanwhile, the corollary to Proposition I notes the importance of strong emotional attachments in relation to proximal processes and individual development (12). While a child’s relationship to a General Mills Strawberry Team Cheerios Cereal Bar may involve a television commercial, the emotional attachment between a child and parent is much stronger and more meaningful. In effect, learning how to cook a healthful, homemade baked good with a parent increases a child’s development much more than reselling a packaged food item provided by a manufacturer. In addition to hindering proximal processes and child development, A-812 is disempowering.

A-812 Disempowers Children

Regulation A-812 disempowers children by preventing them to sell homemade goods at school bake sales during the school day. Empowerment is “the process of gaining influence over events and outcomes of importance to an individual or group” (14). At the individual level, empowerment refers to a process in which individuals gain control and mastery over their lives, and a critical understanding of their environment (15). The empowerment theory predicts that participating in decision making can enhance an individual’s feeling of empowerment, and that empowered individuals are more likely to participate in community organizations and activities (16).

Various studies explore the Empowerment Theory in more depth. In a study performed by Prestby and colleagues, it was found that organization empowerment may be linked to person-environment fit through their research of the connection between incentive management and organization activity (16). Organizations that have shared decision making, open leadership, and communal projects may be empowered by individuals motivated by factors including social ties, skill building, and helping others (16). In 1990, Chavis and Wandersman proposed that the sense of community is important in the development of personal control and participation, and found that a sense of community had a direct effect on an individual’s level of involvement in a neighborhood association (16). Chavis and Wandersman also suggested a reciprocal relationship between “a sense of community and participation and a sense of personal power and participation” (16).

The DOE’s restriction of only being able to sell foods from their approved list disempowers children from being able to decide what goes into the foods sold at school bake sales. Yes, students can submit a retail package with a nutritional label, ingredient list, and allergen list if they want the proposed, packaged food to be reviewed by a chef and nutritionist to be added onto the approved list (2). However, limiting children to only selling foods that they did not make themselves removes is disempowering, decreases their sense of control, and leads to decreased feelings of community and motivation.

Experiences from several parents emphasize the importance of community and empowering children through school bake sales. By contributing homemade goods to bake sales in the past, students and parents felt a sense of community. Helen Martineau-Kraus, a parent in East Village, New York, stated “Everybody contributes, everybody feels more like they are part of the school community. They try things that other people have baked. In such a big city it’s really nice to have that small community feeling” (17). In addition, these bake sales are often used as fundraisers. Geraldine Neary, a parent at the Renaissance Charter School in Jackson Heights, Queens, NY, said her school’s weekly bake sales, which made around $200-$300, made enough money to send eleven students to Mexico last year (17). School bake sales are important in bringing students, parents, and the school staff together. Again, allowing children to sell only foods that appear in an approved food list restricts their feeling of empowerment, feelings of organization responsibility, and likelihood to participate in community activities.

Conclusion

There are better ways to promote health and reduce obesity in school and school bake sales than by preventing children from selling homemade goods at school bake sales. Homemade goods should be allowed in school bake sales during the school day, because they can provide nutritious options that processed foods do not offer. Baking homemade goods fosters the development of the child. In addition, allowing children to sell homemade goods at school bake sales empowers the children and promotes the feeling of community.

The New York City 2010 Draft Wellness Policy does include goals for nutrition education and promotion (4). For example, SchoolFood is a program that will work with and partner with the New York City Public Schools and the community. Partnership meetings will include discussions of nutrition-related topics and the school food service program, and invited participants can include students, a school administrator, a parent coordinator, the school nurse, and the SchoolFood manager (4). Meanwhile, the Office of Fitness and Health Education will address “nutrition education in professional development trainings for the Department’s recommended comprehensive health curricula, HealthTeacher (for grades K-5) and HealthSmart (for grades 6-12)” (4). The DOE encourages schools to promote parents’ efforts to provide a healthy diet and regular physical activity for their children as well. According to the 2010 Draft Wellness Policy, schools can offer healthy-eating seminars for parents, send home nutrition information, post nutrition advice on school websites, and provide nutrition analyses of school menus (4).

Although the 2010 Draft Wellness Policy does address nutrition education and promotion by educating staff and promoting parental awareness of nutritional food choices, selling homemade goods at school bake sales during the school day should be viewed as an educational opportunity for the children, parents, and school staff in regards to nutrition. Instead of preventing children from selling homemade goods at bake sales, children and parents should be educated about ways to incorporate healthy ingredients into their cooking and homemade treats, such as by substituting shortening, which may contain trans fats, with healthier options, such as olive oil. Instead of using refined white flour, students and parents can be taught that whole wheat flour is more wholesome and contains more health benefits than white flour, and that whole wheat flour can be a complete or partial substitute for white flour in recipes. When educating parents and children about the importance of fruits and vegetables in the diet, recipes and creative ideas to incorporate fruits and vegetables in baked goods can be recommended, such as by incorporating raisins in baked cookies or breads.

Homemade goods can meet specified nutritional guidelines as much as manufactured food can. For a food to be accepted on the approved foods list, the food item must be available in single serve packages and meet a specific nutritional profile (2). Instead of disempowering students by preventing them from selling homemade goods, students and parents should instead be given the resources to not only learn how to make food that is more nutritionally sound, but also be given the resources that will help them to evaluate whether their foods meet recommended dietary guidelines. There are even free recipe analyzers online, such as CalorieCount.com’s Recipe Analyzer, where individuals can enter the ingredients in a recipe to create a nutrition label of the food. After generating a nutrition label, students can revise the recipe if necessary, or keep the recipe if it meets the nutrition standards set forth by the DOE. Subsequently, children can divide the homemade goods into individual portions, and provide ingredient lists and nutrition labels when selling homemade goods at bake sales.

The new nutritional standards set forth for products sold in New York City schools should can seen as a way to educate the students and parents about what they eat and make at home, and not as a way to disempower children and by restricting them to sell retail and processed products at school. Children and parents are able to make nutritionally sound food just as well as any manufacturer can. After all, what’s life without a little dessert?



References
1. Regulation of the Chancellor. Competitive Foods - A-812. New York City, NY: New York City Department of Education, 2010.
2. Office of SchoolFood. Nutritional Guidelines for Products Sold in Schools. New York City, NY: New York City Department of Education, 2010.
3. New York City Department of Education. General Programs/Services and Other Information – Wellness Policy. New York City, NY: New York City Department of Education, 2010. http://schools.nyc.gov/Offices/Health/GenProgServ/Wellness. htm.
4. The New York City Department of Education. Draft: The New York City Department of Education Wellness Policies on Physical Activity and Nutrition - January 2010. New York City, NY: New York City Department of Education, 2010.
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6. Stacy's Pita Chips. Our Products. Dallas, TX: Stacy’s Pita Chips. http://www. stacyssnacks.com/#/?page=products.
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8. Stark, A. and Madar, Z. Olive Oil as a Functional Food: Epidemiology and Nutritional Approaches. Nutrition Reviews 2002; 60(6):170-176.
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10. Kellogg’s. Kellogg's Pop-Tarts 20% DV Fiber Frosted Brown Sugar Cinnamon toaster pastries. Battle Creek, MI: Kellog’s. http://www2.kelloggs.com/Product/ ProductDetail.aspx?brand=202&product=11011&cat=poptarts.
11. Kellogg's. Kellogg's Nutri-Grain Cereal Bars Blackberry. Battle Creek, MI: Kellog’s. http://www.nutri-grain.com/ProductDetail.aspx?product=12270.
12. Bronfenbrenner, U. Ecological Systems Theory (pp. 129-133). In: Kazdin, A, ed. Encyclopedia of Psychology, Volume 3. Washington, D.C.: American Psychological Association, 2000.
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14. Foster-Fishman, P., et al. Empirical support for the critical assumptions of empowerment theory. American Journal of Community Psychology 1998; 26(4):507-536.
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16. Zimmerman, M., et al. Taking aim on Empowerment research: on the distinction between individual and psychological conceptions. American Journal of Community Psychology 1990; 18(1):169-176.
17. Kershaw, S. Taking the Bake out of Bake Sale. NY: The New York Times. http:// www.nytimes.com/2010/03/17/dining/17bakesale.html

Why the Soda Free Summer Campaign’s Reliance on the Health Belief Model Limits Its Efficacy in America’s Fight Against Obesity

The Added Sugar That’s Making Us Fat

Obesity in the United States has reached epidemic levels. 32.2% of adult men and 34.5% of adult women can be classified as obese (with a body mass index of 30 or more) (1) and many see sugar-sweetened beverages as a major contributor to the fattening of America. The Nurse’s Health Study II found that consumption of sugar-sweetened soft drinks was positively correlated with caloric intake, weight gain, and incidence of diabetes (2). A prospective observational study found that for each additional serving of sugar-sweetened drink consumed, body mass index and frequency of obesity both increased after adjusting for anthropometric, demographic, dietary, and lifestyle factors (3). Soda consumption in particular, has also been negatively associated with children’s nutrient intake, specifically vitamin A in all age strata, calcium in children under 12, and magnesium in children 6 years and older (4). The American Association of Pediatrics recommends that doctors suggest limiting intake of sugar-sweetened beverages to all children but those below a 5% body mass index (5).

The Soda Free Summer Campaign aims to reduce obesity and obesity-related diseases by inspiring individuals to abstain from drinking soda and other sugar-sweetened beverages for a 10-week period during the summer. The campaign, first implemented in the San Francisco Bay Area, recruits people to sign a pledge card to commit to a soda free summer and log their progress. To support the campaign they distribute informational pamphlets and promotional materials such as wrist bands, conduct Be Sugar Savvy workshops showcasing sugar content of beverages, and spread their campaign messages via local media outlets (6).

This critique of the Soda Free Summer Campaign postulates that the campaign’s reliance on the health belief model (7, 8) limits its efficacy through its focus on the individual, assumptions of rationality and unfaltering self-control, its lack of environmental and policy considerations, and its failure to provide compelling visuals or appeal to core values.

If Only Our Behavior Was Truly Individual, Rational, and Subservient to Our Long-Term Health Goals

The view that lifestyle is determined simply by the sum of behavioral choices and some intrinsic personality characteristics is antiquated at best. No consumer ever entered a restaurant demanding a bottle filled with high fructose corn syrup; consumer choices are made based on which products are produced and promoted by corporations whose goal is profit maximization (9). The idea that this consumer should be the sole target of a campaign to reduce obesity is a predictable, individualistic, and simplistic western response (10) especially given that there is little evidence that individual level interventions have had much success at the population level (11). Dietary behavioral change is not always as easy as simply deciding to make a change but is instead a complex interplay between availability and cost of alternatives, social supports, and consistent positive feedback that outweighs the barriers to making the change (12). After all, if it were as simple as deciding to make a positive change we would all stick to our New Year’s Resolutions, strictly adhere to our diets, and exercise regularly.

We humans are deeply irrational beings (13). The world in which we rationally weigh the costs and benefits of each possible choice and do only that which we intend, while remaining uninfluenced by those around us or by the environment around us, is called an economic model. In reality, we judge people’s personalities differently if we’ve been exposed to different temperatures (14), we start diets and then decide to have one more piece of chocolate cake (15), and we fail to adhere to healthy behaviors even after we’ve actually experienced a negative health outcome like cardiovascular disease, hypertension, or diabetes (16).

Rather than being isolated and independent actors, we are deeply affected by the behavior of others (17-19). Teenage girls who see other teenage girls having children are more likely to have children themselves and the GPA of a college freshman’s randomly assigned roommate can essentially predict her GPA (20). Quantitative analysis done using data from the Framingham Heart Study demonstrated that over a 32 year period individuals connected by social ties gained weight and quit smoking in concert. A person’s chance of becoming obese increased if she had a friend, spouse, or sibling who became obese in a given interval but was not affected by a neighbor becoming obese (21). In the same vein, smoking cessation of a spouse, friend, sibling, or co-worker at a small firm considerably reduced a person’s chances of smoking (22).

Consumption of sugar-sweetened beverages in particular, has been associated with other dietary patterns (23), clustered with TV viewing among teens (24), and influenced by parental consumption among Latinos (25). The focus on individual and isolated behavior ignores social influence and our current understanding of human irrationality.

Left to Our Own Devices: Why Environmental and Policy Changes Shouldn’t Be Ignored

While the 2009 Soda Free Summer Campaign gauged public support for policy changes (26), its failure to incorporate any environmental or policy nudges as part of the intervention weakened its efficacy. This decision, in keeping with the simplistic view of the health belief model, relies heavily on an individual’s self-control and fails to take advantage of the power of a small environmental nudge in the right direction.

Recent research showing the degree to which we underestimate context and overestimate our ability to behave in accordance with our good intentions has underscored the usefulness of policy and environmental interventions. It turns out that different parts of the brain are involved with planning and doing: the planner part looks out for our long-term welfare while the doer easily succumbs to temptation; a man on a diet might agree to go out with colleagues thinking that he can resist the wine and desert options but immediately orders wine once at the restaurant (27). The farther removed we are from a temptation the more self-control we have and the more self-control we believe we will have when tempted. This is why so many pregnant women say they will refuse drugs during labor but so often change their minds once actually experiencing the pain of childbirth (28) and why when given the choice of $100 in 30 days or $110 in 31 days nearly everyone chooses $110 in 31 days but when given the choice of $100 today or $110 tomorrow nearly everyone chooses the instant $100 (29).

Small environmental and policy changes can help steer us toward healthier choices without mandating or controlling our behavior. Smaller portion sizes can nudge us to eat less (30-31), musical stairs can coax us off the escalator (32), and greater access to physical activity resources encourages us to be physically active without telling us to be (33). Taxing unhealthy products is another social disincentive policy at our disposal. Cigarette taxes are seen as a useful way of reducing smoking and increasing state revenues (34) and some states have begun to implement soda taxes (35) in the same vein. Some also call for a ban on food advertising to children (36) citing studies like one published in Health Psychology showing that children consumed 45% more when exposed to food advertising (37).

In the case of sugar-sweetened beverages, a randomized, controlled pilot study almost completely eliminated sugar-sweetened beverage consumption in a diverse group of adolescents and showed a beneficial effect on body weight through delivering beverages with no added sugar to the homes of adolescents (38).

Environmental interventions and policy changes can be effectively used to incentivize healthier behaviors, discourage unhealthy behaviors, improve availability of healthy alternatives, restrict access to unhealthy foods, control marketing and advertising, and create communities that support healthy lifestyles (39). With such potential to influence behavior at the population level, they should not be ignored.

Selling Health and Statistics: No Match for the Coke & Pepsi Promise

The Soda Free Summer Campaign promises a reduction in weight gain, a reduced risk of diabetes and heart disease (40,41) and the chance at a few raffled prizes in exchange for giving up soda (42). The health promises are backed up by statistics about sugar consumption and obesity-related diseases. The campaign also created a video that reiterates the same statistics on their website and fails to provide compelling visuals or appeal to core values like independence and control.

While the Soda Free Summer Campaign sells health benefits, Coke and Pepsi make grand promises and appeal to consumers’ core values. Coke promises its consumers happiness with its “Open Happiness” advertising campaign (43) and “Share Happiness” slogan for its new 2 liter bottle and backs up its promise with images showcasing beautiful, young people looking incredibly happy (44). Pepsi makes similarly grand promises: if you drink Pepsi you will belong to a larger movement of youthful change makers (45) appealing to American values of community and positive social change. Both Coke and Pepsi have recently launched “movements”, further capitalizing on Americans’ hunger for positive change, with the Pepsi Refresh Project which awards grants to “refreshing” ideas (46) and Coke’s Live Positively Campaign which supports environmentalism, active lifestyles, and volunteerism (47).

If indeed Americans saw health as a core value, the Soda Free Summer Campaign and other health promotion campaigns who promise health would be more effective and we might see fitness facilities marketing health benefits rather than attractiveness. Time and time again, health does not motivate our behavior (48). The 5 A Day Campaign is largely considered a failure (49, 50), nutritional knowledge has been shown to have only a peripheral impact on children’s food preferences (51), and smokers who overestimate the prevalence of heart disease and cancer in smokers continue to smoke (52). This is only magnified by the fact that we have an incredibly strong optimistic bias, so that even if we know and understand the health risks and statistics related to diseases like obesity and diabetes we think our own susceptibility is below average (53, 54).

While the Soda Free Summer Campaign utilizes promotional materials, reaches out to local media, and contains a short video, it fails to be an effective social marketing campaign. An effective campaign must have a unified core position, evoke desired visual images, employ recognizable catch phrases, suggest appropriate metaphors, showcase its program as the solution, and must not attribute the problem to the individual (55). The Soda Free Summer Campaign fails to suggest any appropriate metaphors or use compelling visual images and attributes responsibility solely to the individual.

The Soda Free Summer Campaign also runs the risk of inciting reactance through its negative messaging. The campaign tells you that soda and other sugar-sweetened beverages should be completely given up, essentially a “just say no” campaign. Between the request to give up something that for many may be a daily habit and the adults in the video barraging you with facts and statistics, the campaign may elicit psychological reactance. In a study done with heavy drinkers, those exposed to “Don’t Drink” messages drank significantly more directly after exposure to messaging than those exposed to a “Drink Moderately” message (56). A video on youtube in response to New York City’s Pouring on the Pounds Campaign (57) is a concrete example of this kind of response, showcasing New Yorkers who feel angry and rebellious toward a campaign which they see as the government telling them what to do (58).

An effective social marketing campaign could go a long way in the fight to reduce American consumption of sugar-sweetened beverages but we won’t get there by putting seemingly far-off health promises up against happiness.

A Different Approach: How Using the Social Ecological Model and Advertising Theory Could Nudge People Toward Healthier Drinks And Create a Social Movement

The social ecological model with a strong social marketing component modeled on the Truth Campaign’s success has the potential to effectively reduce sugar-sweetened beverage consumption, obesity, and obesity-related diseases at the population level. The social ecological model has many advantages over other public health models as it provides an effective framework for real people living in complex environments (59). Prominent agencies like the U.S. Centers for Disease Control have used this framework to assess and coordinate school health services (60) due to its comprehensive structure that addresses the macrosystem (laws, history, culture, economic system, social conditions), exosystem (extended family, community centers, neighborhoods, mass media), and microsystem (family, peers, siblings) components that surround each individual (61).

Policy initiatives that eliminate corn subsidies, tax sugar-sweetened drinks, or even ban high fructose corn syrup, mandate 0 sugar-added drinks in schools, government buildings, and government funded community centers, and ban sugar-sweetened beverage advertising to children could significantly alter the demand and availability of sugar-sweetened beverages and nudge people to make healthier choices. A broad-based social marketing campaign modeled on the Truth Campaign’s use of advertising theory (62) could include a series of ads that promise unity and social change with desired visual images. The campaign could also harness reactance to create positive behavioral change by appealing to people’s distrust of government and corporations and inspire a Tea Party-esque outrage about corporate profit margins and institutionalized racism (63) and the government’s subsidization of the high fructose corn syrup that’s making our country fat.

Beyond Door-to-Door: How We Can Effectively Target the Population

The social ecological model and advertising theory are both group-level models. For these models we need not assume that humans make decisions in rational vacuums and we avoid the typical western trap of blaming the individual; we actually take advantage of the social influence we have on one another instead of ignoring it. Corporations like Coca-Cola and Pepsi who produce and promote sugar-sweetened beverages have always successfully aimed their promotion efforts at the population, so why should we go door-to-door?

The ecological model allows us to target the population and see population level results. Shape Up Somerville is an ecological wellness intervention that has successfully reduced body mass index of elementary-aged children at the population level (64). Its initiatives have encouraged an entire city’s children to become more active not by targeting individual children but by creating an environment that supports activity for all.

Effective social marketing like the Truth Campaign also have an essential role in modern public health promotion (65). They successfully target a wide range of groups in an array of settings (66) and address the population as a whole (67). Successful campaigns have increased demand for everything from condoms in Zambia (68) to syphilis testing among gay and bisexual men in San Francisco (69).

Nudged: How Environmental and Policy Changes Can Help Us Make Healthier Choices

Policy and environmental changes give the planner in us a chance to follow-through on our good intentions by creating an environment that supports healthier options. We have seen these interventions work to combat smoking (70) and increase healthy behavior in schools (71).

Getting rid of corn subsidies would eliminate the artificially low price of high fructose corn syrup, a base ingredient in the most popular sugar-sweetened drinks. A sugar-sweetened beverage tax would further increase the price and a ban on high fructose corn syrup might be considered given its other negative health effects (72-74). The American Public Health Association supports a soda tax citing that it is just as appropriate as a cigarette tax and could help pay for the $47.5 billion a year that the government spends on medical care related to obesity through Medicaid and Medicare (75). Economists estimate that a 58% soft drink tax would result in a small but real decrease in body mass index (a reduction of 0.16 points) (76) so just think what a broader sugar-sweetened beverage tax could do.

Mandating 0 sugar-added drinks in schools, government buildings, and government funded community centers and a ban on sugar-sweetened beverage advertising to children would improve environmental support for healthy choices and allow for mindless choosing of healthier options in schools and other public institutions. This could improve health and change social norms in much the same way as cigarette bans have (77, 78).

A New Truth: High Fructose Corn Syrup, Sugar-Sweetened Beverages and Obesity

Public Health campaigns have an enormous opportunity to learn from commercial branding and marketing strategy. We need to cultivate brand recognition, promise core values, and deliver on those promises (79). If we strategically reframe the issue of sugar-sweetened beverages we can affect population consumption by selling core values, harnessing reactance, and starting a social movement.

The VERB Campaign and the Truth Campaign were highly successful social marketing campaigns that used advertising theory to begin positive social movements and significantly increased physical activity (80, 81) and reduced smoking respectively. The VERB Campaign and associated advertisements promised community and opportunity. The campaign sent yellow balls all over the country and put kids in charge. VERB challenged kids to invent new games that could be played with the ball and then pass the ball on to someone else giving kids an opportunity to feel in control (82). The Truth Campaign appealed to adolescent values of rebellion and independence (83) and created a counter-industry movement that significantly reduced the prevalence of smoking in Florida teens (84-88).

The issues surrounding sugar-sweetened beverages, high fructose corn syrup, and obesity are rife with material that would make an excellent Truth Campaign. Instead of selling abstinence of sugar-added beverages, a social marketing campaign could sell freedom, independence, control, and rebellion. It could inspire a movement that stood for community and rebellion against the corporations and government subsidies that conspire to make Americans fat. The “product” being sold would be identity as a fit and attractive person in charge of her appearance and rebellion against the feelings of unattractiveness and lack of control over her appearance (89).

Uniting Against Obesity: Conclusion and Call to Action

The Soda Free Summer Campaign has severe limitations due to its reliance on the health belief model, its focus on isolated and rational behavior, its failure to address policy and environmental change, its weak promise backed up by statistics, and its failure to provide compelling visual imagery. The campaign could be improved by addressing any one of these failures.

Obesity is arguably the most serious health issue in America today. The public health community needs to incorporate best practices from successful public health marketing campaigns and ecological model approaches in order to target the population and stop blaming the individual, nudge us toward healthier choices with smart policy and environmental supports, and inspire us to join a movement where we stand up against government subsidies and corporate agendas and say enough is enough.

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Hyperlinks:

Soda Free Summer Campaign Video:

http://www.sodafreesummer.org/news.html

Coca-Cola Commercials:

http://www.youtube.com/watch?v=3hj0JMCHZpI

http://www.youtube.com/watch?v=nlpZRK2Yfd0

Coca-Cola Live Positively Project:

http://www.livepositively.com/#/home

Pepsi Commercial:

http://www.youtube.com/watch?v=-Ob2HGQtQWo

Pepsi Refresh Project:

http://www.youtube.com/pepsi?utm_source=pepsi&utm_medium=banner&utm_content=panel&utm_campaign=refresh#p/u/17/2fS39FitsoQ

Sprite Commercial:

http://www.youtube.com/watch?v=KtJ6bXnoQxE

The Truth Campaign Commercials:

http://www.thetruth.com/videos/

NYC’s Pouring on the Pounds Campaign:

http://www.youtube.com/watch?v=-F4t8zL6F0c

ABA’s Response to NYC’s Pouring on the Pounds Campaign:

http://www.youtube.com/watch?v=K65TAi_siCo

The Fun Theory:

http://www.youtube.com/watch?v=2lXh2n0aPyw

People get fat in groups:

http://content.nejm.org/cgi/content/full/357/4/370/DC2

People quick smoking in groups:

http://content.nejm.org/cgi/content/full/358/21/2249/DC1

Drinking Life Away in New York City: A Critique of the Pouring on the Pounds Campaign

In the past 20 years the incidence of obesity has been continuously rising in the U.S. and most recently around the world (1). The prevalence of obesity is a serious public health concern because it is a major risk factor for cardiovascular disease, certain types of cancer, type 2 diabetes, and lifetime morbidity (2). According to the Centers for Disease Control and Prevention (CDC), in 2007-2008 around 33% of Americans were obese and nearly 68% were overweight, ranking the U.S. as the number one country in the world with the highest rate of obesity (1). If current trends continue, it is estimated that 75% of Americans will be overweight or obese by 2015 (3). Research has stated that the rising trend of obesity in the U.S. has been consequent to the suboptimal eating habits and sedentary lifestyles of Americans (2). This unfavorable lifestyle leads to the lack of energy balance, which is the precise cause of overweight and obesity (4). Consequently, obesity and overweight occur over time when you take in more energy or calories than you use.


To combat this trend, many intervention programs have been designed to encourage consumption of healthier foods along with heightened physical activity. In 2009, the New York City Department of Health and Mental Hygiene implemented the Pouring on the Pounds public communications campaign in order to highlight the health impact of sweetened drinks (5). The campaign was designed in lieu of the proposed, but highly debated, 18% “obesity tax” on sugary sodas and juice drinks (6). Instead, the Health Department decided to target drinking habits to combat obesity by designing a public awareness campaign. Sugary drink consumption was chosen as the area of focus for this campaign because research has shown that more than 2 million New Yorkers drink at least one sugar-sweetened beverage a day, adding as many as 250 empty calories to their diets, which puts the human body at increased risk for a multitude of diseases (5). The campaign urges people to drink lower-calorie alternatives or limit their portions.

The message of the campaign is disseminated through public ads in city subways, educational brochures, the campaign website and most recently through a viral Internet video. The main component of the ad is a poster of disgusting, unadulterated, gelatinous fat substituting for soda as it pours into a cup. The video, titled Man Drinking Fat, shows a man pouring fat out of a soda can and drinking it as it drips out of his mouth. It ends by exhorting the audience to choose healthier alternatives like water, seltzer or low-fat milk. The ads work to demonstrate that we are literally pouring on the pounds and drinking ourselves fat by consuming soda and other sugary beverages. According to the Health Department, the video was produced to playfully send out the message that sugar-sweetened beverages are fueling the obesity epidemic and disabling millions of New Yorkers (5). The goal of the campaign is to shift drinking habits even slightly by gruesomely depicting the health impact of sweetened drinks.

Although the campaign was recently launched, it has had successful exposure due to the mediums of communication used. Not only has the Health Department chosen to place their ads in highly trafficked city subways, but also set up and placed ads in social media networks such as youtube.com/drinkingfat and facebook.com/DrinkingFat. Together, these networks have had over half a million hits in the past few months and word-of-mouth exposure is becoming viral. However, aspects of the campaign are flawed and susceptible to scrutiny.


The Campaign Does Not Account for Behavior Influenced by Context
The goal of the Pouring on the Pounds campaign is to change human behavior by embedding nauseating images of the health impact of sugary drinks. The first assumption of the campaign is that behavior is planned and rational. It is assumed that by viewing the gruesome ads, people will be disgusted and decide to eliminate or reduce sugary drinks from their diet. This concept is partly correct. In a hot state, during exposure, people might discard their beverages or avoid drinking for a few hours (7). However, the objective of the campaign disregards the concept that human behavior is dynamic and that it is influenced by context (7). It is visceral drives, or instinctive unreasoning, that control people’s behavior (7,8). Visceral factors refers to a wide range of drive states, including hunger, thirst, and sexual desire. According to a research studying the effects of emotions on economics, visceral factors can alter desires rapidly because they are affected by changing internal bodily states and external stimuli (7). The emergence of a new situation generally alters the present course of action and alters behavior (7). For example, a person purchasing a drink at Starbucks will transition to an alternative hot state to accommodate their environmental context. Exposure to images and menu options at the store or restaurant will now influence their purchasing behavior. Their decision is based on situational awareness defined by the context of their environment. This concept further suggests that the environmental context has a greater impact on unfavorable eating habits. This could be demonstrated by the considerable gap in the prevalence of obesity found among neighborhoods or cities with differing socioeconomic levels.

East Harlem, a low-income minority community, has the highest rates of obesity in New York City (9). According to a report by the Health Department published in 2006, one third of East Harlem adults are overweight or obese (9). The demographic profile of the neighborhood consists of predominantly African-American and Hispanic residents. Over 38% of the population in the community is below the national poverty level, which is nearly twice as high as in Manhattan and NYC overall (9). Similar to other low socioeconomic communities, the built environment of the neighborhood is comprised of fast food restaurants, bodegas and affordable energy-dense food grocers (10). The area also has 18 schools with fast-food restaurants within one-tenth of a mile (10). This is not surprising since researchers in New Orleans recently discovered that fast-food restaurants are geographically associated with low income, and in particular African-American, neighborhoods (11). These neighborhoods average twice as many fast-food restaurants per capita as white neighborhoods, making fast food a more likely choice for their residents (11).

High rates of obesity in low-income neighborhoods demonstrate that a stronger correlation exists between eating habits and the neighborhood residential context (12). A recent report stated that studies have not been able to link a uniform change in perceived control of health, but instead suggest that environmental and social factors can affect one’s sense of control over one’s own health (12). Therefore, public service announcements that seek to modify human behavior will only work if risk factors are modified or reduced within the context of the built environment.


The Perceived Cost Undermines the Perceived Benefit
Motivating people to modify behavior remains a critical and unmet challenge in the U.S.(13). This is especially true with modifying eating habits and physical activity. Research suggests that there are four motivational factors that are modifiable and may be influenced by education, experience and coaching: 1) Perceived chances of success, 2) Perceived benefit of the goal, 3) Perceived cost, and 4) Inclination to keep old habit (13). The most pertinent factors for this campaign are perceived costs and perceived benefits of giving up sugary beverages. This is so because people ultimately decide whether to adopt or reject behavior based on the balance of the appraisal of these factors.

Applicable to the Pouring on the Pounds campaign, the perceived benefit of modifying behavior is losing 10 pounds a year by not drinking one can of soda a day. Although it is not mentioned in the ads, it is implied that this change will ultimately reduce the risk of obesity as well. Conversely, the perceived cost of the campaign is eliminating or reducing sugary drinks from their diets. Instead of deciding to drink sugary drinks, the ad encourages consumer to drink water, seltzer or low-fat milk. The perceived cost in this equation, however, has a high significance in the U.S. due to the embedded traditions of sugary, not healthy drink, consumption (14). Events such as happy hours, bar-b-ques, sports outings, etc., have accustomed Americans to a drinking habit that often promotes sugary drinks. These habits have given significant social value to the context around sugary drink consumption. Although the campaign aims at changing life-long habits, if fails to connect healthy habits to the rhythm of life. Stating alternative drinks as bland and boring options does not strengthen the proposal to change drinking habits. Expecting people to change lifelong sugary beverage consumption needs to be supported by a strong promise to the consumer (15). Instead, stating that only a 10 pound weight gain could be prevented weakens the perceived benefit of giving up sugary beverages and associated social norms. To a portion of the population, especially those who are overweight, a 10 pound difference might not be worth the cost of giving up their drink of choice. To these people, the perceived chance of successfully modifying habits involves more than just giving up sugary drinks. This is especially true when linking behavioral risk factors, aside from social norms, to drinking habits. Instead, perceived capability and confidence has a stronger influence on initiation and self-efficacy (16). To this effect, the campaign fails to frame the issue in a way that gives strength to a change in social norms and ultimately a rippling effect on individual behavior. The intention to modify behavior is focal and crucial, yet the content of the campaign dominates the message instead of the outcome. Moreover, the campaign also uses the unadjusted approach that one sugary beverage is consumed every day. Therefore, those who consume less sugary beverages will consider the ad irrelevant instead of incorporating the overall message.

To overcome the common obstacles of modifying behavior, framing the issue in a way that gives people control and a broad sense of choices must be used (17). If the goal of the intervention is to get a high level of reactance, a program that implies a change in social norms will be more influential than targeting individual behavior (18).


The Campaign Reinforces Negative Social Stigma Towards Unhealthy Weight
Obesity has had in increasing trend for the past two decades. Yet as Americans are becoming more overweight, the standard for attractiveness remains thin and fit while overweight people are widely stereotyped as lazy, unattractive, and lacking self-discipline (19). The constant exposure to the idea of beauty as slim and proportioned has created a negative and stigmatized perception towards the overweight and obese. Not only has this created a pool of isolation, but numerous studies have examined a variety of social stressors, including discrimination, stigma and low socioeconomic status, all of which have been linked to poor health outcomes (20).

Weight-based stigmatization is defined as “negative weight-related attitudes and beliefs that are manifested through stereotypes, bias, rejection, and prejudice towards people because they are overweight or obese” (20). Acknowledging this perception, it is assumed that most obese people would like to become more fit. However, for so many leading a healthy lifestyle is a very difficult undertaking. They may give much energy towards trying to change their personal behaviors to acquire attractiveness, but their attempts continually fail.

The message of the Pouring on the Pounds Campaign reinforces this social stigma by producing a disgusting reaction of fat, which reflects a negative view of unhealthy weight. This is opposed to a good or proactive view of healthy weight. The message only serves to further internalize negative association of unhealthy eating habits. Studies that have examined the relationship between weight-based stigmatization and psychosocial functioning, state that in addition to affecting emotional well-being and social functioning in obese people, stigmatization can also negatively impact health behaviors (20). Stigmatization or the perceived threat, as the campaign message indirectly implies, has been associated with increased weight concerns, dieting, binge eating and unhealthy weight control and bulimic behaviors (21-23). This suggests that the objective of the message could be counterproductive and ineffective to prevalent cases of obesity.


Addressing and Implementing an Obesity Intervention in New York City: A Cultural Approach
The demographic profile of New York City is unique in its level of diversity. According to the U.S. Census Bureau, in 2006 over 3 million or 36.7% of the population in New York City was foreign-born (24). A recent report by the Department of City Planning states that the Newest New Yorkers, or immigrants, tend to live in enclaves of highly dense low-income neighborhoods (25). Intertwined with socio-economic disadvantage, obesity is also largely prevalent in these neighborhoods of the city (11). These neighborhoods are mostly comprised of minority or immigrant families who have assimilated to some degree to U.S. eating habits. This is evident by contrast of the Latino Paradox which refers to the epidemiological finding that Latinos in the U.S. tend to paradoxically have substantially better health than the average population in spite of what their aggregate socio-economic indicators would predict (26). Instead, the high prevalence of obesity, especially among Black and Hispanic children, supports the concept that the health status of immigrants deteriorates after acculturation to U.S. norms (26). Although obesity is widespread, a behavior modifying intervention should be targeted towards those at higher risk. Hence, due to the demographic profile of those at risk in NYC, changing the current campaign material to a culturally appropriate awareness campaign is proposed.

In order to combat obesity, we need to recover the traditional values of immigrant people. Similar to the Pouring on the Pounds campaign, the proposed campaign This is my Neighborhood, This is my Food aims to create awareness through community mediums of eating habits among immigrant families. The proposed campaign aims to emphasize traditional customs for maintenance of protective behaviors. The program is based on the concept that prevention begins in the home and embedded as tradition to future generations. Three major components will be the focal point of the campaign:
(1) Create awareness of the built environment by informing the community about their vulnerability as target consumers of fast and energy-dense processed foods,
(2) Empower perceived benefits by encouraging traditional eating habits, and
(3) Focusing on a proactive view of healthy weight.

These methods will serve as motivators to empower the community to integrate traditional customs in food consumption and preparation.


The components of the campaign will be disseminated through prominent mediums of communication in the community. Similar to the Pouring on the Pounds campaign, the material will be posted in city subways, near bus stops and near supermarkets in low-income communities around the city. Language specific material will be designed and posted in corresponding neighborhoods. However, knowing and adjusting to the most effective mediums of communication for immigrant families will be a major component of the campaign.


Create Awareness of Behavior Induced by the Built Environment
Although obesity can have many causes, most studies agree that environmental
influences are the primary factor in the current epidemic(11). The proposed campaign is based on the fact that modifying urban development is much more challenging that modifying human behavior (27). Therefore, the campaign serves to inform residents of their risk factors and susceptibility to fast food consumption. This is based on the idea that disseminating awareness of the environmental context transfers empowerment to the communities’ purchasing power of healthier foods. In low-income communities, the built environment is usually comprised of fast food restaurants, small shop bodegas and energy-dense foods (11). Unapparent to many local residents, this urban planning makes them highly susceptible to purchasing high-fat foods instead of healthy option. Therefore, informing the community about their controlled behavior by the built environment will hopefully produce a rebellion against this force. Consequently, a plan of action will be implied in the campaign ads. Encouragement to revert to traditional methods of food consumption and preparation will lead to an overt action of healthier eating habits. This plan of action however, must imply that unfavorable health outcomes were not as prevalent when practicing traditional eating habits. Therefore, proposing an awareness campaign that implies power, freedom and the perceived benefit of reverting back to traditional protective customs will be hopefully overcome the risk factors induced by the built environment.


Empowering Perceived Benefits of Traditional Values
In contrast to the traditional lifestyle in households, immigrants have been increasingly adapting to U.S. eating habits and forgoing the rice, vegetables, and fresh fruit drinks their grandparents ate and drank (26). Dietary standards in a traditional immigrant household consist mostly of home-made food with locally grown and purchased produce. Most recently, however, assimilation to U.S. eating habits has led people to flock to U.S.-style fast food and calorie-laden dishes once reserved for special occasions. Adaptation of food tailored for the mainstream American market usually is also very different than food typically served in other countries as well. This leads to the production of convenient, frozen, packaged foods and soft drinks that are widely available in local markets. To combat this trend, the campaign will serve to remind the target population that the unfavorable health outcome has occurred because of the adaptation to U.S. eating habits further induced by the built environment.

Contrary to the Pouring on the Pounds, the perceived costs of the proposed campaign are undermined because it does not discourage habits embedded in lifelong traditions. Instead, it incorporates them back into diets. By discreetly informing women that traditional values in eating habits have changed and their children’s health is at risk, women will realize that they have the power to change the outcome. This concept of the campaign strengthens perceived benefits by promoting healthy habits through tradition sustainability. It aims at changing culturally adaptive social norms, thereby allowing less perceived threat of freedom. Ultimately, the content in the material will be framed in a way that gives people control of their purchasing and eating behavior.


Focusing on a Proactive View of Healthy Weight
The focus of the This is My Neighborhood, This is My Food campaign is to modify the perception of social norms in eating habits. This is done by pointing out and targeting the risk factors, such as the context of the built environment and assimilation, of unhealthy eating habits. The campaign avoids placing blame on individuals for their eating habits, but instead implies power and freedom of taking charge of their communities and eating habits. To some extent the campaign shifts the problem from individual responsibility to corporate responsibility. In a way, the campaign skips eating habits and links obesity to the risk factors. Similar to the concept of the causation of lung cancer, the blame should be placed on tobacco manufacturers instead of smoking (28).

Transferring the association of obesity to external factors eliminates the threat of stigmatization on individuals. Instead the campaign will induce a comparison between traditional and current norms and the change in the prevalence of obesity. To this end, disseminating risk factors, encouraging modified behavior that provides empowerment and promoting proactive methods of healthy weight will prove more effective in reducing and preventing obesity in New York City communities.


References
(1) Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA. 2010;303(3):235-241.
(2) Mokdad A, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors. JAMA. 2003;289:76-79.
(3) Wang Y. Beydoun MA. 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.
(4) Martínez JA, Moreno MJ, Marques-Lopes I, Martí A. Causes of obesity. An Sist Sanit Navar. 2002;25(1):17-27.
(5) New York City Department of Health and Mental Hygiene. Pouring on the Pounds. www.nyc.gov/health/obesity. Accessed 4/19/10.
(6) Chan S. New York Times. New Salvo in City’s War on Sugary Drinks. August 31, 2009. http://cityroom.blogs.nytimes.com/2009/08/31/new-salvo-in-citys-war-on-sugary-drinks/?hp. Accessed 4/19/10.
(7) Loewenstein G. Emotions in Economic Theory and Economic Behavior. Preferences, Behavior and Welfare. May 2000;90(2):426-432.
(8) Loewenstein G. Out of control: Visceral influences on behavior. Organizational Behavior and Human Decision Processes. 1996;65(3):272-296.
(9) New York City Department of Health and Mental Hygiene. Community Health Profile: East Harlem. 2006.
(10) Dwyer JC. Hunger and obesity in East Harlem: Environmental Influences on Urban Food Access. 2005.
(11) Block J, Scribner R, DeSalvo K. Fast food, race/ethnicity, and income: A geographic analysis. American Journal of Preventive Medicine. 2004;27(3): 211-217.
(12) Black JL, Macinko J. Changing distribution and determinants of obesity in the neighborhoods of New York City, 2003–2007. American Journal of Epidemiology. 2009;
(13) Phillip EM. Schneider JC, Mercer GR. Motivating elders to initiate and maintain exercise. Arch Phys Med Rehabil. 2004;85(3):S52-7.
(14) Hill J, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: Where do we go from here. Science. 2007;299(5608):853-855.
(15) Vakratsas D, Ambler T. How advertising works: What do we really know? The Journal of Marketing. 1999;63(1):26-43.
(16) Strecher V, McEvoy B, Becker MH, Rosenstock IM. The role of self-efficacy in achieving health behavior change. Health Education and Behavior. 1986;13(1):73-92.
(17) Nelson TE, Oxley ZM, Clawson RA. Towards a psychological of framing effects. Political Behavior. 2004;19(3):221-246.
(18) McLeroy KR, Bibeau D, Steckler A, Glanz K. An Ecological Perspective on Health Promotion Programs. Health Education & Behavior. 1988;15(4): 351-377.
(19) Crocker J, Park LE. The costly pursuit of self-esteem. Psychological Bulletin. 2004;( 130): 392-414.
(20) Gray WN, Kahhan NA, Janicke DM. Peer victimization and pediatric obesity: a review of the literature. Psychology in the Schools. 2009;46(8):720-727.
(21) Hayden-Wade HA, Stein RI, Ghaderi A, Saelens BE, Zabinski MF, Wilfley DE. Prevalence, characteristics, and correlates of teasing experiences among obese vs. non-obese peers. Obesity Research. 2005;13:1381–1392.
(22) Thompson JK, Shroff H, Herbozo S, Cafri G, Rodriguez J, Rodriguez M. (2007). Relations among multiple peer influences, body dissatisfaction, eating disturbance, and self-esteem: A comparison of average weight, at risk of obese,
and obese adolescent girls. Journal of Pediatric Psychology. 2007;32:24– 29.
(23) Neumark-Sztainer D, Falkner N, Story M, Perry C, Hannan PJ, Mulert S.Weight-teasing among adolescents:Correlations with weight status and disordered eating behaviors. International Journal of Obesity. 2002;26:123 – 131.
(24) U.S. Census Bureau. Access Community Survey. 2006-2008.
(25) New York City Department of City Planning. The Newest New Yorkers. 2000.
(26) Abraído-Lanza AF. Chao MT. Flórez KR. Do healthy behaviors decline with greater acculturation?: Implications for the Latino mortality paradox. Social Science and Medicine. September 2005;61(6):1243-1255.
(27) Hill JO, Wyatt R, and Peters JC. Modifying the Environment to Reverse Obesity. Essays on the Future of Environmental Health Research. 2006:108-115.
(28) Boos J. Cigarette Smoking-Who is to Blame? University of Maryland. 2009.

MyPyramid – MyFriend or MyFoe? – Alison Krajewski

Introduction
Since its inception, the Food Guide Pyramid has used the same nutritional standards for everyone, regardless of age, height, or weight. To address the inadequacies in these nutritional standards, the United States Department of Agriculture (USDA) restructured its design and introduced MyPyramid. The new MyPyramid campaign has began to implement a personalized plan of action; however, there are still many revisions that still must be completed. Some of the modifications to consider are the following: enhance education on how to use MyPyramid, understanding the dietary guidelines, and the importance of healthy eating; incorporate societal input to gain an understanding of how to effectively market their campaign, as well as the public’s knowledge of MyPyramid; and increase accessibility not only to information about MyPyramid, but also to healthy foods, such as fruits and vegetables.

The Food Guide Pyramid was created in 1992 by the USDA. The pyramid provided suggested daily nutritional guidelines for carbohydrates, vegetables, fruits, proteins, and oils through a illustrative diagram of a pyramid (Figure 1). This graphical representation was used a general guide for individuals to choose healthy foods that were right for them. The Food Guide Pyramid was created with three key concepts at its core: variety, proportionality, and moderation (1). Variety was considered to be a balanced mixture of all food groups; proportionality was based on the recommended serving sizes; and moderation referred to the means to control one’s eating from being excessive (1). The Food Guide Pyramid became the basis for nutrition and healthy eating in America, taught in schools, appeared in countless media articles and plastered on cereal boxes and food labels. Every five years, the USDA reassesses the current guidelines for necessary revisions and updating when emerging nutritional issues arise. Such was the case in 2005 when the Food Guide Pyramid was up for review. Consideration of its effectiveness, in addition to how to incorporate new trends in eating, such as vegetarianism and veganism were focal points. Hence, the USDA retired the old Food Guide Pyramid and replaced it with MyPyramid, a new symbol and “interactive food guidance system” (2). Additionally, MyPyramid was supposed to help stop the increase of obesity rates; however, obesity rates in adults and children continue to rise and obesity-related diseases, such as cardiovascular diseases, are also increasing. Thus, MyPyramid has come under scrutiny over its effectiveness. Currently, the United States is once again working to re-evaluate its dietary recommendations for the general population.

MyPyramid was designed to be a simplistic representation for dietary standards. The new design is color coded and depicts a stick figure ascending stairs on the pyramid to represent the importance of physical activity, which the previous pyramid neglected to represent (Figure 2). The core concepts that were previously used for the Food Guide Pyramid were expanded upon to incorporate the necessary changes in nutrition and maintenance of healthy lifestyles. Now, the anatomy of the pyramid consists of proportionality, variety, moderation, activity, personalization, and gradual improvement. Proportionality is represented by the widths of the food bands; variety is symbolized by the six colored bands; moderation is represented by the narrowing of each food group from the bottom to top; activity is represented by the steps and the person climbing them as a reminder of the importance of daily physical activity; personalization is represented by the person on the steps and the word “My” in MyPyramid; and gradual improvement is encouraged by the slogan “Steps to a healthier you” (3). Although this new pyramid is an improvement from the previous design, it still lacks information for people to make informed choices about their diet. With rates of obesity and obesity-related diseases, such as type 2 diabetes and cardiovascular disease, soaring, the pyramid has once again come under intense scrutiny (4). Currently, the USDA is assessing the dietary guidelines, and it is predicted that revisions will be made to MyPyramid in 2010 (3). The question remains whether there needs to be change in how nutritional information is conveyed to the public or if the problem lies elsewhere.


Critique 1: Usability
The new design of MyPyramid was meant to be substantially simpler than the original version. However, there are issues with the new design. The design is ultimately too simple, MyPyramid is impossible to interpret without the accompanying online tool (5). The colored bands are ambiguous as they do not indicate what food groups are associated with which color (5). For example, orange represents grains, green for vegetables, red for fruits, a teeny band of yellow for oils, blue for milk, and purple for meat and beans (3). There is no logic behind the color coding, making it difficult to interpret. Without visiting the website, one would never know what the colors represent. Furthermore, making MyPyramid solely internet based limits the availability to only those with internet access. Millions of Americans who do not have access to the internet, most often those of low socioeconomic status, are considered to have the least knowledge about nutritional information since most people now get this type of material from the web (5). Consequently, the people in most need of MyPyramid are the ones who cannot obtain the information readily. Although the government has made a valiant effort to keep up with the use of modern technology as a way to convey public health messages, the restricted access to MyPyramid as an interactive online tool puts limitations on its usability.

MyPyramid does not follow the traditional representation of a pyramid. The original Food Guide Pyramid outlined portions American should eat, from the most at the base (grains) to the least at the apex (fats, oils, sugars) (6). With MyPyramid, however, the shape of the pyramid has nothing to do with serving size like the original. Furthermore, without text on the design, it is necessary to visit the website in order to learn what the nutritional recommendations are for each food group. These nutritional recommendations were designed to be personalized, based on age, sex and activity level; however, the online tool makes it optional for the user to include body size (height and weight) – the most important determinant of caloric needs (5). The generated recommended intake can thus be inappropriate for one’s body size or weight, easily recommending hundreds of calories per day too high or too low (5). Additionally, MyPyramid fails to incorporate any other specific dietary needs. Although USDA boasts that the new pyramid is personalizable, the online questionnaire does not take into account adjustments for special dietary needs such as individuals with diabetes, heart disease, high blood pressure, high cholesterol or food allergies.

MyPyramid was designed to be simple. Yet the simplicity of this new design limits its usability. With information about the dietary recommendations only available through interactive online tools, it restricts the accessibility. Furthermore, the dietary recommendations provided by MyPyramid do not take into account the needs of individuals with dietary restrictions due to health-related illnesses, such as diabetes or heart disease.


Critique 2: Dietary Recommendations and Serving Sizes
The Food Guide Pyramid and MyPyramid were created as a way to inform the public about nutritional information through easy-to-read diagrams (3). Dietary guidelines provided individuals with recommended dietary allowance and serving sizes for each food group. USDA defines recommended dietary allowance as the dietary intake level that is sufficient to meet the nutrient requirement of nearly all healthy individuals in a particular life stage and gender group (7). This term is most commonly known as recommended serving, not to be confused with serving size. Serving size, as defined by USDA, is a standardized amount of a food, such as a cup or an ounce, used in providing dietary guidance or in making comparisons among similar foods (7). Adding to the complexity, serving size is sometimes confused with portion size, which is defined as the amount of a food consumed in one eating occasion (7). The terms as defined above are often undifferentiated amongst the general public, and this confusion can result in over or under eating of the dietary guidelines.

The previous Food Guide Pyramid recommended a range of serving sizes without elaborating on why there was a difference in serving sizes. For instance, the pyramid recommended 6-12 servings of grains every day, but did not specify who was supposed to eat 6 servings and who was supposed to eat 12 servings (6). Instead, MyPyramid uses recommended servings in conjunction with the theory of planned behavior, which states that individuals take personal responsibility and utilize moderation to make healthier choices (6). This technique of personal responsibility and moderation to make the “right” food choices is a major downfall for many people because of lack of self-control, lack of knowledge, or even lack of awareness of the issue. Furthermore, the MyPyramid campaign fails to incorporate the importance of self-efficacy, meaning that an individual believes s/he will be able to perform the behavior of healthy eating. It also neglects to incorporate personal empowerment which allows an individual to overcome the obstacles and perform the behavior of healthy eating. Individuals will not be able to successfully navigate their way through MyPyramid if they do not understand the information provided to them or believe that s/he will be able to follow the guidelines.

After using the online form to enter in one’s age and physical activity level – weight and height are optional – the personalized MyPyramid Plan appears. It is when one enters in this information that s/he is able to see the appropriate serving sizes. Nevertheless, as a population, we still have issues understanding what constitutes as a serving and portion control. Portion size per serving has increased in the last thirty years, which continues to affect the rising obesity rates (8). Larger portions encourage people to eat more (8). With the on-the-go lifestyles that many people live, fast food options are ideal. Fast food corporations pride themselves on their larger sizes, like Supersizing at McDonald’s. The Big Mac Meal at McDonald’s has 1350 calories, nearly 68 percent of the total calories an average adult should consume in an entire day (9). Many would take this meal as one portion, which it is clearly is not. Furthermore, chain restaurants promote large portions on their menus and in marketing campaigns, such as the grand slam breakfast at Denny’s. At minimum, this breakfast meal contains 820 calories and 1270 mg of sodium (10). It is difficult for people to control their portions and follow the dietary recommendations of MyPyramid when they are constantly bombarded with media campaigns suggesting that they abandon those principles.

The dietary recommendations for MyPyramid are supposed to be the most up-to-date and based on scientific evidence (3). There has been speculation that the USDA is influenced by the agricultural and food industry groups such as the National Dairy Council, the National Cattlemen’s Beef Association, and the U.S. Potato Board, to incorporate their products in MyPyramid rather than solely depending upon scientific research to make dietary recommendations (11). The tiniest change to the guidelines or pyramid can swing food companies’ sales by millions of dollars, either way (11). Thus, it is suggested that the guidelines are promoting the sales of certain types of foods rather than promoting healthy eating. For example, the guidelines suggest that it is fine to consume half of our grains as refined starch. However, since refined grains behave like sugar, they act simply as empty calories when incorporated into the diet (2). The U.S. Potato board and baked goods lobby groups are depending on this recommendation to keep sales steady by continuing to have recommendations for refined starches (11). The guidelines continue to lump together red meat, poultry, fish, and beans and ask consumers to judge these proteins by the total fat content to make choices that are lean, low-fat, or fat free (3). This guideline ignores scientific evidence that all these proteins have different types of fat, like the heart healthy omega-3 fats found in fish. Furthermore, this recommendation completely ignores the scientific evidence and research studies which have found that replacing red meats with a combination of fish, poultry and beans provides numerous health benefits, such as a reduction of the risk for coronary heart disease (12). This recommendation could be the result of pressure from the National Cattlemen’s Beef Association on the USDA to keep consumption of red meats in the guidelines to keep their products in demand (11). Although recommending fish as a replacement for red meat has been shown to have a multitude of health benefits, this recommendation does not address the issues of methylmercury found in fish. Methylmercury can have profound adverse side effects of the nervous system, especially in pregnant women (13). The recommendation should include which types of fish contain the least amounts of methylmercury or a caution that fish should be consumed sparingly. Lastly, MyPyramid recommends consuming either three glasses of low-fat milk or other dairy products per day even though such a recommendation adds more than 300 calories to one’s daily intake (3, 2). It is unclear whether the recommendation is based on scientific research that says consuming dairy products has health benefits or if it is based on pressure from the National Dairy Council to keep dairy sales steady. These recommendations need to be reassessed to incorporate the most accurate scientific research studies, instead of integrating the interests from agriculture and food industry lobbyists.

In a recent interview with restaurant chefs, it was found that 60 percent of chefs serve steaks that are 12 ounces or larger, which is four times larger than the recommended three ounce serving according to the MyPyramid dietary guidelines (3, 14). In addition, the survey found that most restaurant chefs dish up one to two cups of pasta with a meal; a serving is half cup (14). When eating at restaurants or fast food establishments, people automatically assume that what they are ordering and eating is one serving. It is difficult to see how people are supposed to make healthy food choices when they are confused about what is a recommended serving versus serving size or how a portion size relates to MyPyramid dietary recommendations. If the USDA hopes to be successful in promoting their campaign of MyPyramid, then they need to simplify what a serving size is versus a portion size and how the recommended dietary allowance fits into everyday life.


Critique 3: The Use of Theory of Planned Behavior
MyPyramid is based on the theory of planned behavior (TPB). TPB focuses on rational, cognitive decision-making processes, meaning that people think about what they are going to do before they actually do it (15). TPB derives from the theory of reasoned action (TRA). TRA is defined as behavioral intention that is influenced by an individual’s attitude toward performing a behavior and by beliefs about whether individuals who are important to the person approve or disapprove of the behavior, the subjective norms (16). TPB includes one additional construct - self-efficacy. Self-efficacy, or perceived behavioral control as applied in context with this intervention, means that a person believes that they can control a particular behavior, in this case, food consumption (16). This decision-making process does not apply here because eating, the defined behavior, is not always planned and rational; sometimes it is based on spontaneous, irrational decisions. A person may believe that they can control their food intake but in reality may not be able to do so.

MyPyramid was designed to be an interactive online tool. As stated above, the details of how to use the pyramid, dietary recommendations, and physical activity advice is only available on the website. Only the most motivated people will take the time to fully explore the website (5). The majority of people will not utilize the tools on the website to find out their specific caloric needs and plan their meals accordingly. One study found that 47 percent of the household food budget is consumed out of the home, which translates to the increased consumption of fast food or take out (5). With the on-the-go lifestyle that many people have, their dietary recommendations as provided by MyPyramid are the least of their worries. Thus, people are more likely to neglect their dietary recommendations and disregard planning their meals based on MyPyramid guidelines for whatever is most convenient.

Although TPB considers the influence of peers, it underestimates how influential peers can be on an individual, ultimately deterring that person away from the desired healthy behavior. Individuals who work in corporate settings are often persuaded into making unhealthy decisions during the work week. Many corporations order fast food on a daily basis and provide light snacks like starchy cookies and sugar-laden sodas. Even if an individual packs a brown bag lunch, these day-to-day temptations lure otherwise healthy people into the fattening and detrimental world of fast food. It is easy for many employees to disregard their healthier meals from home for those with little nutritional value and thus abandon the principles of MyPyramid in order to join their co-workers in an unhealthy lunch time meal. Though they may have been good intention to eat food that is healthy, the need to go along with the majority is stronger than individual choice in this case. Therefore, the TPB did not work for this group of individuals. They planned a behavior and performed a behavior that was based on the subjective norms of their peers. The intended behavior was to eat a nutrient-rich lunch, which was replaced by eating the catered fast food. The planned behavior was neglected, which demonstrates the failure of TPB.

The guidelines of MyPyramid assume that people are eating for the sole purpose of nourishment and does not take into consideration the phenomenon of emotional eating. People use eating as a sort of emotional crutch and will eat out of depression, happiness, or even boredom. When an increase in food intake is in response to negative emotions it is called emotional eating (17). Emotional eating can be considered to be an ‘inapt’ response (17). Emotional eating is a consequence of the inability to distinguish hunger from other aversive internal states, or of using food to reduce emotional distress, probably because of early learning experiences (18). Research studies have found that emotional eating increases the consumption of sweet and high-fat foods in particular (19). Emotional eaters overeat in response to negative affects because they have learned that it alleviates them from aversive mood states (17). When people eat for emotional reasons, it is spontaneous and irrational; they are not going to stop their behavior because it does not fit into their dietary recommendations, thus, abandoning the principle theory for which the intervention was created.

As humans, our actions are not always rational or planned. Using a social behavioral theory like the theory of planned behavior for the MyPyramid campaign, will often result in failure. Norms created by larger society will often influence the behavior of an individual. The previous examples demonstrated that people do not always use logic to make nutritional choices. Sometimes when individuals do plan to make rational decisions, those plans are thwarted by peer pressure. Human behavior is a dynamic process that does not always rely on sensible decision making and thus, using a model that is too rigid to predict health outcomes will be unsuccessful.


Proposed Intervention
While MyPyramid has its faults, there are a few things that are beneficial about it. First, regardless of whether people understand MyPyramid or even the older Food Guide Pyramid, it is widely recognizable. The pyramid shape divided into the six food categories is an iconic symbol in the world of nutrition. Secondly, the new design incorporates the importance of physical activity, which was neglectfully left unincorporated in the last design. Lastly, MyPyramid employs the use of current technologies to try and circulate information about dietary recommendations. Any successful intervention will continue to use these principles and then expand on them to further utilize the MyPyramid campaign to its fullest potential. It is also commendable that USDA did not use statistics and information that is unfamiliar or incomprehensible to the general public in this campaign.


Defense of Intervention: Education
Possibly the simplest but most necessary addition to the MyPyramid campaign is education. Not only because of the simplicity of the design, but in general, people still do not fully understand that the symbol represents dietary recommendations. It is important for people to understand that the balance of nutrition, exercise, and eating healthy does not need to be a difficult process. Education that clarifies definitions like the recommended dietary allowance and serving size will simplify the MyPyramid campaign. The addition of clear and straightforward explanations to the MyPyramid campaign will encourage members of the general public to look into MyPyramid.

Using the online tools for MyPyramid is beneficial, but first, people have to know the website exists, have access to the internet, and then understand how to navigate the website. To fix this issue, there first needs to be awareness of the MyPyramid campaign and that there is an accompanying website. Although one may use the website, it does not mean that the individual will understand the information provided. Information on the website, including the recommended dietary allowance and serving size, needs to be stated in way that is understandable to the general public. Information about how healthy eating and physical activity relates to obesity and obesity-related diseases should be made available for all. Furthermore, in addition to the online tools, local community centers need to have copies of MyPyramid and supporting documents so that those without internet access can have the information. In addition, the local community centers should hold classes on nutrition, guiding people on how to properly utilize the resources of MyPyramid.

Education about the MyPyramid campaign in schools would also be beneficial. Children are greatly influenced by what they see their parents or other adults around them doing. If a parent is constantly eating fast food, foods high in fats and sugars, children will also develop those habits. Teaching children the importance of healthy eating at an early age will help them develop and stick with healthy eating habits throughout their lives. In addition to educating children, parents need to be educated as well. They are the ones buying the groceries, packing lunches, and preparing meals. They are the food role models for their children, and they need to understand how important it is for children to develop a healthy relationship with food.


Defense of Intervention: Societal Input
To find the best way to reach the target audience for MyPyramid, there needs to be societal input. While education is an important first step in any successful campaign, societal norms and roles need to be accounted for as well. One of the best ways to do this is to go directly to the source. For example, in 1998, Florida launched its own version of the “truth” campaign. This campaign was a youth anti-tobacco education and marketing program that was extremely successful. From the beginning, this campaign involved youth. The marketing team convened a 500 person youth summit to gain insight into where youth felt the effort should head (19). They provided the team with what they did and did not like and provided positive feedback to help guide the creative process (19). One of the successful strategy techniques that the team used was interviewing youth about the reasons behind their decision to smoke. They then used all this information to brand their “product” (the “truth” campaign). The key strategy to this campaign was the direct involvement of the target audience. By utilizing the resources available to them, the team was able to build a campaign that proved to be a success – teen smoking decreased by 7.4 percent in middle school and 4.8 percent in high school (19).

The strategy that was employed by the Florida “truth” campaign could also be fruitful in branding MyPyramid. The USDA should employ a marketing team to research the reach and awareness of the MyPyramid campaign. This outreach program could be done through surveys. In addition, the team should interview individuals from all different age groups to fully understand what compels them to eat, their awareness of MyPyramid, their knowledge portion sizes and serving sizes, and the feelings towards following the USDA’s dietary recommendations. Conducting interviews, surveying the target audience, and having the direct involvement of that audience will strengthen the power of the campaign.


Defense of Intervention: Accessibility
The main goal of the dietary recommendations set forth by USDA is to promote eating a healthy balanced diet among the six food groups; however, solely promoting this is not enough, there needs to be accessibility too. National data indicates that less than three percent of men and less than six percent of women aged 19 to 50 years consume the daily servings of fruits and vegetables recommended by MyPyramid (20). National surveillance data and numerous other research studies consistently indicate that low-income populations are less likely to meet recommended fruit and vegetable intake levels, compared to high-income populations (20). Whole grains, fruits, and vegetables tend to be higher in price than other groceries; consequently, millions of Americans either cannot afford these items or would prefer to purchase more affordable items. One research study found that low-income neighborhoods had more convenience stores and fast food establishments and fewer supermarkets, fruit and vegetable markets, specialty stores and natural food stores (21). If the MyPyramid campaign is to be used by all people, regardless of socioeconomic status, then all people need to have equal access to healthy foods like fruits and vegetables.

A solution to the disparities in the accessibility to food is community gardening programs. Community gardens are defined by the American Community Gardening Association as any piece of land gardened by a group of people (20). Researchers have found that community gardening readily provides opportunities for community involvement and experiential education about growing, as well as opportunities to strengthen community ties and build social capital (20). Researchers have concluded that community gardening programs increase the intake of fruits and vegetables in low-income communities (19). By involving the community directly in gardening programs, it gives people the opportunity to access fruits and vegetables. Research has illustrated that when people are directly involved in the process of planting and harvesting, they tend to be more willing to increase their intake of fruits and vegetables, which ultimately reinforces the goal and outcome expectancies of the MyPyramid campaign (19, 20).


Conclusion
The Food Guide Pyramid and now MyPyramid were created to promote nutritious, well balanced eating among Americans; however, these tools have been unsuccessful for the most part. In order to increase the successfulness of MyPyramid, there needs to be substantial modifications to the current campaign. Public health officials, nutritionists, and physicians need to better educate people of the importance of maintaining a healthy lifestyle through eating sensibly as well as engaging in daily physical activity. In addition to education, there needs to be access to healthy foods such as fruits and vegetables. Creating community gardening programs gets people directly involved in the process, while providing them with produce they may not have access to otherwise. Lastly, societal input is key in developing a successful campaign. Knowing how to reach the target audience and what is important to them will create a more successful campaign for nutrition and healthy eating.


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