Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Saturday, April 19, 2008

“Milk Matters:” An Inadequate Campaign by the NIH to Promote Calcium Consumption among Tweens and Teens – Jennifer Culbert

Studies have shown that most tweens (kids ages 9-12) and teens are not getting enough calcium in their diets (1, 2, 3). The National Institute of Health (NIH) Consensus Development Conference Statement on Optimal Calcium Intake (4) recommended 1200 to 1500 mg of calcium per day for adolescents 11 to 24 years of age. In their statement, the committee acknowledged that a certain threshold level of dietary calcium is necessary to allow growing adolescents to achieve their genetically pre-determined bone mass. According to dietary data survey, dietary intake is insufficient in adolescents; females who are 10 to 17 years of age have an average intake of 780 to 820 mg/day, and boys of the same age have an average intake of 800 to 920 mg/day (2).

In an effort to promote calcium consumption among tweens and teens, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) launched the Milk Matters Calcium Education Campaign in 1997 (5). The public health campaign consisted of free publications such as posters and booklets about the importance of calcium. Some of these items are geared toward parents and health care professionals, but the majority of promotional materials target tweens and teens, and these are the publications that will be the primary focus of this paper. One poster directed at ages 11-18, features the image of milk being poured into a glass and states, “Young Teens Need Calcium. So pour it on!” (5) The text on this poster includes a straightforward message about the early teen years as a critical time for bone growth, and that including 3 cups of milk every day plus other calcium-rich foods is all it takes to build strong bones (5). Another poster, whose intended audience is children and teens, depicts images of young children participating in sports. This caption on this poster states, “Bone Up on Bone Loss! Exercise to Build Healthy Bones!” This poster stresses the importance of calcium and exercise to prevent osteoporosis later in life (5). It should be noted here that although there is evidence supporting the role of exercise in bone health, the mission of the campaign specifically lists calcium education as its goal, and not exercise.

Healthy Bones Theory
The NICHD’s public education initiative directed at children was flawed because it focused on a media campaign based on the Health Belief Model. The Health Belief Model (HBM) was developed in the 1950’s as a way to address disease prevention. According to this model, for an individual to take action to avoid a disease, he would need to believe that he was susceptible to contracting the disease and that the consequences of the disease would be severe (6). The second part of the model involves the perceived benefits and costs to the individual. For example, in order for an individual to take a particular action that would be perceived as beneficial in reducing his susceptibility to the disease or decreasing the severity of the disease, the perceived benefits would have to be greater than the perceived psychological barriers, such as cost, convenience, discomfort or embarrassment (6). A key problem with the HBM model as it relates to children is that children do not believe they are personally susceptible to future disease; they are more inclined to think about immediate consequences of an action, rather than a negative health outcome such as osteoporosis that is so far into the future.

One of the reasons children are unable to process that they may be susceptible to osteoporosis and its severity is that the brain is not fully developed until after the age of 18, and the way the brain develops creates a period of risk-taking vulnerability that is greatest around puberty (7). Jay Geidd, MD, the chief of brain imaging at the National Institute of Mental Health (NIMH) states that this period of adolescence is when the balance is tipped most in favor of high emotions and risk taking (7). Geidd goes on to say that the key parts of the brain involved in controlling impulses and risky behavior don’t really reach maturity until about age 25. Research conducted by Lawrence Steinberg, PhD, at Temple University has confirmed that the brain systems involved in decision-making mature at different times (7). His research has shown that the brain most involved in emotion and social interaction becomes very active during puberty, while the section most critical for regulating behavior is still maturing into early adulthood (7). He states that, “kids have much more difficulty controlling their impulses and regulating their behavior than adults do,” and goes on to say that we need to provide more structure in the environment to regulate it for them (7).

Environmental Influences and Milk Intake
Some environments facilitate the performance of certain behaviors, while others inhibit them. Structure should be provided in environments where this vulnerable population has the ability to make personal choices for beverage selection, such as fast food establishments and homes, since calcium intake is strongly influenced by beverage consumption (8). Beverages contribute more than 20% of energy to the diet of US children (9). The replacement of soda for milk has been shown to be one of the biggest risk factors of not meeting calcium requirements (2, 10). As soft drink consumption increases during adolescence, milk consumption decreases (9). Male adolescents average 30 ounces of soda per day and 8 ounces of milk per day. Female adolescents average 24 ounces of soda per day and less than 8 ounces of milk per day. As teenagers have begun to double and triple their soda consumption, they have begun decreasing their consumption of milk by more than 40% (2).

The abundant resources spent on marketing have contributed to the soft-drink infiltration in our environment. For example, Coca-Cola, PepsiCo, and Cadbury-Schweppes spent over $850 million marketing their sweetened beverages in the United States in 2003 and were listed as one of the top 100 corporate spenders on advertising that year (11). Between the years 1977 and 1998, the proportions of youth consuming soda increased from 34% to 58% among boys and 36% to 63% among girls (11).

Fast Food Influence on Milk Intake
Consumers are creatures of habit, and tend to do things that are familiar and comfortable, especially when food is involved (12). In order to establish fast food “habits” early on, fast food establishments purposely choose new locations based on walking proximity to schools (11). The pairing of soda with fast food, rather than milk, started for teens and tweens years ago when they were introduced to “Happy Meals,” a meal that typically consists of a hamburger or chicken nuggets, fries and a soda. In addition, consumers are encouraged to consume soda with their meals as a result of the ways meals are “bundled” into special offers, for example, free soda with the purchase of a sandwich and fries. Thus a situation is created in which the pairing fast food and soda becomes a habit or the “norm.” This establishment of soda as the “norm” relates to the Social expectations theory, which is based on the idea that (1) the media convey information regarding the rules of social conduct that the individual remembers and (2) that directly shapes overt behavior (13). Soda is habitually ordered by tweens and teens as part of fast food meals because it is appropriate for this particular situation. Because of this, ordering milk with fast food might be considered by teens and tweens to be an embarrassing beverage to order, and therefore a perceived barrier to change.

There has also been an increase in the consumption of fast food, and this has been a key contributor in the decreased calcium consumption among today’s teens and tweens. Fast food restaurants supply approximately 22% of the soda consumed by youth (11). Children who eat fast food, compared to those who do not, consume more calories, fat, added sugars, and sugar-sweetened beverages, and fewer servings of milk, fruits, and non starchy vegetables (11).
In a cross-sectional evaluation of parent interviews and adolescent surveys from Project EAT (Eating Among Teens), results showed that parents who reported purchasing fast food for family meals at least 3 times per week were significantly more likely than parents who reported purchasing fewer fast-food family meals to report the availability of soda in the home (14). Adolescents in homes with fewer than 3 fast-food family meals per week were significantly more likely than adolescents in homes with more fast-food family meals to report having milk served with meals at home (14).

Home Influence on Milk Intake
Teens and tweens also make decisions regarding beverage selections in the home, especially during family meals. Frequency of family dinners is associated with healthful nutrient patterns, notably higher intakes of calcium and lower consumption of soda (15, 16). However, if child-feeding strategies that restrict children’s access to “bad” foods, such as soda are utilized, the restricted foods become more attractive (17). This is because children form associations between foods and the social context in which eating occurs. When children are given food as rewards for positive behavior, their preference for those foods is increased (17). In contrast, when children are offered rewards that are contingent upon eating a certain food (“if you eat your vegetables and drink your milk, then you can watch television”), the foods eaten to obtain the rewards become less desirable. Research has suggested that in the long run, parental control attempts have negative effects on children’s diet quality by reducing their preferences for those foods, especially when foods are categorized as either “good” or “bad” and “bad” foods are restricted (17).

A shortcoming of the NICHD promotional materials directed at parents and health care professionals is that no education is provided for parents on the benefits of family meals or the negative consequences of dietary parental control. If parents are not provided with information that gives them the skills to address ways to increase calcium consumption in the home, they will not have the self-efficacy to be successful. However, to be fair, the brochure for parents and health care providers is a much better intervention tool than the materials produced for children. For example, parents are much more likely than children to see the perceived susceptibility and severity for osteoporosis. In addition, the brochure provides the parents with menu suggestions for increasing calcium and addresses potential barriers to success, such as children’s dislike of the taste of milk. Strategies to deal with lactose intolerance are also addressed; however, the information provided fails to consider the proportion of the population who are unable to afford the higher-priced lactose-free milk products and over-the-counter medications they recommend, as well as the higher percentage of minority populations who perceive themselves as lactose intolerant due to culturally determined dietary practices learned early in life (18).

Although the consequences of low calcium consumption may not be seen in children and adolescents, failure to consume adequate calcium during this critical time of bone mass accrual places one at risk of osteoporosis later in life. Osteoporosis is a serious and potentially debilitating disease, which can lead to a variety of health complications and a diminished quality of life. It is a significant public health concern in terms of morbidity, mortality and financial costs, and is particularly concerning at the present time due to the increasing numbers in the population at risk for osteoporosis. The number of adults over age 65 years in the United States is projected to reach almost 25% by 2020, more than double the number since 1988. According to the American Association of Clinical Endocrinologists, one out of every two women over the age of 50 will experience an osteoporosis-related fracture in her lifetime. Another 20% will die each year because of osteoporosis related complications, such as hip fracture (2). Although osteoporosis affects both sexes, women are more severely affected because they have a smaller skeletal mass than men have and because they live longer.

The NICHD failed to consider that traditional nutrition education that has focused on imparting nutrition knowledge has not been successful at promoting healthy diets. Food choice, like any complex human behavior, will be influenced by many interrelating factors. It is not determined entirely by nutritional needs or the belief that certain nutrients will reduce the risk of disease, but is also influenced by social and cultural factors. The culture in which individuals are brought up has a very strong influence on the types of choices made, and social interactions have a profound effect on our views of foods and our eating behavior. In order to design sound program interventions, it is necessary to choose the most applicable theory for the intervention target, and apply the principles of that theory to the intervention design.


1. Lytle L: Nutritional issues for adolescents, J Am Diet Assoc.102:S8, 2002.
2. Mahan, L, & Escott-Stump, S (2004). Krause's Food, Nutrition, & Diet Therapy. Philadelphia, PA: Saunders.
3. Borrud L, Enns CW, Mickle S. What we eat: USDA surveys food consumptions changes. Commun Nutr Insti. 1997;27:4-5.
4. National Institutes of Health, NIH, DHHS. (1994). Optimal Calcium Intake. NIH Consensus Statement online, 12(4):1-31. Retrieved March 4, 2008, from retrieved March 4, 2008).
5. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
6. Boyles, Salynn (April 13, 2007). Teens are Hardwired for Risky Behavior. Retrieved March 13, 2008, from Web site:
7. Ballew C, Juester S, Gillespie C. Beverage choices affect adequacy of children’s nutrient intakes. Arch of Pediatr Adolesc Med. 2000;154:1148-1152.
8. Friedman, LA, Snetselaar, L, Stumbo, P, Van Horn, L, Singh, B, & Barton, BA. Influences of Intervention on Beverage Choices: Trends in the Dietary Intervention Study in Children (DISC). J Am Diet Assoc. 2007;107:586-594.
9. Striegel-Moore RH, Thompson D, Affenito SG, Franko DL, Obarzanek E, Barton BA, Schreiber GB, Daniels SR, Schmidt M, Crawford PB. Correlates of beverage intake in adolescent girls: the 10. National Heart, Lung, and Blood Institute Growth and Health Study. J Pediatr. 2006;148:183-7.
11. Wiecha JL, Finkelston D, Troped PJ, Fragala M, Peterson KE. School Vending Machine Use and Fast-Food Restaurant Use are Associated with Sugar-Sweetened Beverage Intake in Youth. J Am Diet Assoc. 2006;106:1624-1630.
12. Bell R and Meiselman HL (1995). The role of eating environments in determining food choice (pp 292-310. In DW Marshall (ed), Food Choice and the Consumer. London: Blackie Academic Press.
13. Defleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition), Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.
14. Boutelle KN, Fulkerson JA, Neumar-Sztainer D, Story M, French SA. Fast food for family meals: relationships with parent and adolescent food intake, home food availability and weight status. Public Health Nutrition. 2007;10:16-23.
15. Gillman MW, Rifas-Shiman SL, Frazier AL, Rockett HR, Camargo CA Jr, Field AE, Berkey CS, Colditz GA. Family dinner and diet quality among older children and adolescents. Arch Fam Med. 2000;9:235-240.
16. Neumark-Sztainer D, Hannan PJ, Story M, Croll J, Perry C. Family meal patterns: Associations with sociodemographic characteristics and improved dietary intake among adolescents. J Am Diet Assoc. 2003;103:317-322.
17. Birch LL. Development of food preferences. Nutr. Rev. 1992;19:41-62.
18. Jarvis JK, Miller GD. Overcoming the barrier of lactose intolerance to reduce health disparities. J Natl Med Assoc. 2002;94:55-66.

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