Challenging Dogma - Spring 2008

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

Tuesday, April 22, 2008

Small Steps Misses the Point in a Big Way: mis-targeting risk factors, bad psychology and an incomplete approach to self-efficacy- Rebecca Atlas

Small Steps to preventing obesity: missing the mark in a big way
Obesity is one of the fastest growing and most costly public health problems of the 20th century. Over 64% of the US population is overweight or obese and the percentage of obese adults has doubled (15% to 30%) from 1980 to 2000 (1). The surgeon general estimated that the direct and indirect costs were as high as $117 billion dollar annually (2) and the cost of obesity and related diseases represent approximately 10% of all US health expenditures (3). In response to the obesity epidemic, the US Department of Health and Human Services and the Advertising Council created an ad campaign called Small Steps to "increase awareness, change behavior and promote healthier lifestyles among millions of Americans who are currently unhealthy and overweight and at risk for obesity and long-term chronic disease"(4). The ads were meant to get people’s attention with shocking and humorous images so they visit and learn over 100 small steps to a healthier lifestyle.
The campaign’s logic is based on the Health Belief Model (HBM), which postulates that people weigh perceived threats and benefits to rationally decide whether or not to engage in a particular health behavior (5). When rationalizing benefits, people compare perceived barriers of a healthy behavior (i.e. having to make time to exercise) to perceived benefits (i.e. weight loss) to determine the behaviors worth. According to HBM logic, if the behavior is deemed beneficial, the person will engage in that healthy behavior. Small Steps aims at increasing the perceived benefits and decreasing the perceived barriers to individual behaviors by showing people how easy it is to lose weight and look sexier. However, the HBM assumes that intention leads to behavior change and fails to take into account social, environmental, and psychological risk factors that contribute to people’s health behaviors. In addition, the campaign does not address self-efficacy, which is a person’s self-confidence in his or her ability to perform specific behaviors (6). Self-efficacy is needed to maintain the over 100 small steps suggested in the campaign. Small Steps is flawed because it only targets individual risk factors, assumes that intention leads to action, and fails to completely address self-efficacy.

I. Mis-targeting Risk Factors: A misconception that individual behaviors are the primary cause of obesity
The logic behind the Small Steps campaign assumes that awareness of healthy behaviors will lead to the adoption of healthy behaviors. In the section of the campaign report entitled Factors contributing to the overweight-obesity in the US, the campaign organizers cited individual behaviors as the only cause of the obesity in America: "It is believed by many health experts that variation in environment and behavior, such as sitting for hours watching television or overeating large portions of high fat, calorie-dense foods and sweetened drinks, may contribute to many people becoming overweight and obese"(4). By assuming that the main causes of obesity are individual behaviors, the campaign targets changing individual behaviors, one small step at a time. However, it fails to take the various social and environmental factors that contribute to obesity into account.

Sociological Causes of Obesity: SES and environment
Merven Susser asserts that the focus on individual risk factors is no longer sufficient in understanding what causes disease (7). Researchers are starting to shift away from looking at individual behavioral risk factors to broader sociological factors. Link and Phen explain that it is important to understand the fundamental causes of disease, such as social networks and environmental influences, rather than just proximate individual factors (8).
Researchers are beginning to understand the physical and social environmental risk factors of obesity. Physical environmental barriers to activity have been well cited in the literature (9,10). Barriers include lack of safe parks, lack of pedestrian pathways for walking and increased technology, which reduces physical labor (9,10). More recently, studies have looked at social environments as well. A Framingham study found that individuals gain weight when other people in their environment gain weight. Specifically, people’s risk for obesity increases by 57% if they have a friend who became obese in a given time period (11). This suggests that people’s family or peers significantly influence eating habits and leisure activities and that shared experience and environment are more important in weight gain than individual health behaviors.
Socio-economic factors also impact obesity. Studies have found that socio-economic status alone contributes to disease, even when controlled for individual health behaviors (12,13). Poverty is significantly associated with obesity for several reasons such as the high price of nutritional food and lack of access to nutritional food in low-income areas (14). One study found that low-income women with large families who were not receiving support from their parents are also at greater risk for obesity (15). Small Steps tries to target individual’s behavior and fails to address the broader sociological factors that contribute to the epidemic.

II. Bad Psychology: Individuals do not make rational health decisions.
Based on principles of the HBM, the campaign focuses on decreasing perceived barriers and increasing perceived benefits to lead to intentional behavior change. This model suggests that individuals make rational decisions by weighing the costs and benefits of a healthy behavior with barriers to implementing that healthy behavior (16). For example, the costs of a healthier lifestyle are decreased pleasure from eating decadent foods, hunger, and exhaustion from activity. The benefits are feeling better and looking sexier. The perceived barriers are an inability to find time to exercise or the money to prepare healthy meals. Small Steps focuses on decreasing perceived barriers to adopting healthy behaviors and increasing perceives benefits of a healthy lifestyle. In one ad, a couple sits next to an ambiguous object at a movie theater. The man says, "It is back fat, someone must have lost it eating a smaller bag of popcorn." Eating a smaller bag of popcorn has relatively few barriers and results in a significant benefit, looking thinner and more attractive.
Based on HBM logic, decreasing perceived barriers and increasing perceived benefits would lead to a rational decision to adopt healthy behaviors. The ads assume that if people see how easy it is to adopt little behaviors and lose ugly body parts, they will change their lifestyle. While this may seem sensible, the psychology behind the campaign fails to take into account that intention does not always lead to behavior change. Individuals do not make rational health decisions and while they may intend to adopt healthy behaviors they may not actual follow through. There are various psychological factors, such as stress and emotional eating, which prevent people from turning intention into action.

Psychological factors that prevent rational health decisions
Psychological factors such as stress and emotional eating are associated with weight gain and obesity. Stress alone can play a big roll in weight gain. Often people use food to deal with stressful or upsetting situations and use food as a temporary relief from negative feelings (17, 18). In a sample of African American women, perceived stress prevented women from planning out meals, promoted emotional eating, and increased the amount women snacked on sweets throughout the day (19). The relationship between mood and over eating is very complex and researchers believe that binging acts as a distraction from stress or masks the source of depression (20).
Researchers are beginning to argue that diet plans must target reducing over eating rather than only promoting a low calorie diet (21). Psychological factors like stress and emotional eating make it very difficult to maintain a low calorie lifestyle, and as a result only 20% of people who lose weight keep it off (21). The HBM and the Small Steps campaign do not take into account emotional eating, which is an important part of weight loss. While people may intend to eat less and take small steps to a healthy lifestyle, psychological factors make it difficult for individuals to turn intention into action.

III. Faulty logic: Small Steps fails to implement Social Cognitive Theory to improve self-efficacy
In the Small Steps campaign report, organizers explain the importance of self-efficacy in a weight loss programs (4). Self-efficacy is a person’s self-confidence in his or her ability to perform specific behaviors (6). The organizers explained that by providing examples of small steps, such as eating smaller portions and exercising for ten minutes a day, people would have increased confidence in their ability to perform these small simple behaviors. However, they do not address the self-efficacy needed to maintain the over 100 small steps over time. Maintaining 0ver 100 healthy behaviors is not a small step, but a huge lifestyle change that requires a great deal of self-efficacy. Small Steps is flawed because it does not appropriately address self-efficacy.
Social Cognitive Theory and Self-efficacy: essential part of any weight l0ss plan
Albert Bandura’s concept of self-efficacy explains that a person’s decision to engage in a behavior and his or her persistence in obtaining a particular goal is influenced by the perception of his or her ability to complete the given behavior and achieve the goal (6). A meta-analysis investigating weight loss programs have shown better results when self-efficacy is addressed in the weight loss plan (22). The more a person thinks he or she can lose weight, the more successful they are at weight loss.
Social Cognitive Theory, an extension of self-efficacy, explains that a person’s self-efficacy is improved by seeing other relatable people perform the action (6). A study examining how Social Cognitive Theory relates to adolescents smoking can shed light on how the theory can improve weight loss programs. In the study, the more similar the adolescents image of themselves were to the images of the typical smoker on various dimensions of physical health, toughness, and interest in the opposite sex, the more likely the adolescents were to smoke (23). In other words, the more the adolescent identified with the typical smoker, the more likely they were to model the behavior. This can be applied to weight loss: the more an individual identifies with someone adopting healthy behaviors and losing weight, the more likely they are to be confident in their ability to lose weight and stick with the program. However, Small Steps does not show images of other people losing weight so a viewer does not have an opportunity to relate to someone that maintained healthy behaviors and lost weight. All the ads show are images of lost body parts, so viewer never has the opportunity to gain the self-efficacy needed to maintain a healthy lifestyle.

In order for Small Steps to be successful, the campaign must appropriately address self-efficacy and the socio-economic, environmental, and psychological factors that contribute to obesity. By targeting individual risk factors, the campaign ignores the fact that poverty and a person’s physical and social environment contribute significantly to his or her eating habits and physical activity. Based on the HBM, the campaign does a good job decreasing perceived barriers and increasing perceived benefits to healthy behaviors to convince people that it’s easy and beneficial to lose weight. However, individuals do not make rational decisions about health behaviors. Psychological factors such as stress and emotion make it difficult for individuals to follow through with healthy decisions. The campaign also does not promote self-efficacy by showing images of people successfully losing and maintaining weight. While the campaign ads are funny and entertaining, it falls short of a successful weight loss program.

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