Challenging Dogma - Spring 2008

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

Wednesday, April 23, 2008

Walking In The Wrong Direction: A Critique Of The Smallstep Anti-Obesity Campaign – Brad Karalius

The obesity epidemic is bad and getting worse. The prevalence of overweight and obese Americans, ages 20-74, increased from 47% (1976-1980 survey results) to a recent level of 65% (1999-2002 survey results) according to the CDC’s National Health and Nutrition Examination Survey (NHANES). Obesity has risen from 15% to 31% for that same time period. In adults, the CDC defines overweight as a Body Mass Index (BMI), calculated as weight in kg divided by height in meters squared, of 25.0 – 29.9 and obese as BMI ≥ 30.0. Interestingly, the CDC recently adopted a different set of classifiers for children and established that those with BMI between the 85th and 95th percentile of the CDC Growth Chart are deemed “at risk of becoming overweight” with overweight children listed as ≥ 95th percentile of the growth chart. The statistics for children and adolescents are at least if not more alarming than for adults. Currently, there are over 9 million overweight children and teens ages 6-19 or a 16% proportion of the population and triple what it was in 1980 (1). Even preschoolers are getting fatter with overweight prevalence among children ages 2 through 5 increasing from 7.2% to 13.9% since 1990 (2). The CDC NHANES data has also shown that minorities are disproportionally affected with 21% of non-Hispanic black adolescents listed as overweight and 23% of Mexican-American adolescents while their white counterparts are 14% overweight. Similar data exists for children ages 6-11(1).

There is an increased risk for a myriad of deleterious conditions that comes with being overweight or obese including hypertension, osteoarthritis (degeneration of cartilage), high cholesterol and triglyercides, Type 2 diabetes, coronary heart disease, stroke, gallbladder disease, sleep apnea, respiratory problems, and even some cancers such as breast and colon cancer (3). In 2001, the Surgeon General’s Call to Action noted that not only do unhealthy diet and sedentary lifestyle together account for approximately 300,000 deaths each year but that the epidemic is also a burden to health care costs (4). In fact, in 2003, the total price tag of obesity that Americans pay was estimated at $75 billion (6). With the Medicaid population’s prevalence of obesity 50% higher than the privately insured population and obese adults incurring medical expenditures 40% higher than a normal BMI adult on average, the problem affects all tax-paying Americans (2,4,5).

In November of 2005, the US Department of Health and Human Services mounted an anti-obesity media campaign called Smallstep. The campaign has both adult/teen and kids components, each with their own website and set of media advertisements. The campaign’s goal is reducing overweight and obesity prevalence by offering information and tools in the form of small steps that the busy American can take to improve their health (7,8). While nobly preaching the integration of healthier eating and a more active lifestyle into the typical American’s life, the campaign doesn’t always do this in a compelling or effective manner.

The deteriorating obesity situation America is facing requires a multi-factorial, multi-contextual approach due to how deeply the underlying causes of obesity are embedded within society. The obesity quagmire is not unlike a rotten onion. Moving from the center out are the causes of obesity: the individual’s behavior, the individual’s family environment, local geographic and social environment, SES, free market conditions, agricultural infrastructure, and US policy. Americans value portion size and cheap prices. Readily available fast food providers and chain restaurants satiate such desires and conventional farming, in turn, provides the food service industry with cheap, energy-dense, low-in-nutrition food products. Government subsidies further encourage the production of high energy foods while failing to equally support produce growers. The US Department of Health and Human Services’ Smallstep campaign falls far short of what is needed to fix the obesity/health situation in America. The effort fails by only considering individual behavioral factors, and doing so insufficiently, while totally neglecting community, environmental, and political causes.

The Smallstep Media Campaign Doesn’t Send a Powerful and Effective Message
Smallstep Adult/Teen
The Smallstep media based campaign, like so many other public health initiatives, is based on the Health Belief Model; a model that states that the individual will weight perceived susceptibility, severity, and barriers to taking action against perceived benefits of taking that action to decide on an intention that directly leads to behavior (9). The adult/teen component of the campaign features a variety of television, print and radio ads produced by the Ad Council. The television ads typically feature people stumbling upon a mass of flesh identified as lost love handles, double chin, thunder thighs, etc. and conjecturing that it was lost while performing one of the diet or physical activity small steps the campaign advocates. The print ads take a similar approach showing concentric, dashed lines carving out excess body mass on susceptible body parts with a different small step connected to each dashed line. The final dashed line expresses a goal such as wearing a bikini or changing one’s name to “buff-daddy” (7). These ads aren’t designed to resonate deeply with the overweight and obese population. Just showing mounds of flesh scattered about the earth and relating it to a small step results in a very distal relationship between being a healthier, happier person and taking these small steps. In fact, the people who were changed by these small steps aren’t even featured in the TV ads. With the print ads, not only is the font often vertical but it is also very small. If these were billboards on a highway, no one would possibly be able to observe anything other than a picture of an overweight person. Advertising Theory argues that you design your ads around deep core values and use effective images to sell the promise and the product (10). One would be hard-pressed to admit that losing love handles is a deep core value and randomly dispersed mounds of flesh are effective images. As for the print ads, although wearing a bikini might represent a stronger core value, most of the other goals are humorous instead of deep: for example, “fights urge to run on the soccer field and play forward,” in the Soccer Mom print ad. Both the TV and print ads are humorous but they fall short of hitting home with their message. An effective ad using advertising theory might look more like a once overweight woman finally being able to complete that 5k charity race to benefit her mother who suffers from a disease for which finding a cure is the aim of that race.

Smallstep Kids
The Smallstep campaign for kids features television ads and a web page fully loaded with cool games and pointers on becoming healthier through improved diet and increased activity. The campaign includes six television spots, some of which are actually quite well written along with others that aren’t (8). The campaign is correct in its concern about children’s sedentary lifestyles. One study found that children ages 2-7 watched an average of 2.5 hours of TV per day and children 8-13 watched an average of 4.5 hours of TV per day. It should be noted that this study did not consider time spent playing video games or using the computer (11). Also, according to the US Surgeon General reports, 25% of young people ages 12 to 21 reported no vigorous physical activity and 14% reported no recent light or moderate physical activity (2). The Smallstep website is informative but is somewhat counterintuitive by featuring online games children can spend time playing (8). A few of the Smallstep Kids television ads aren’t particularly attention grabbers either. “Birds,” “Bull’s eye,” and “Grandpa” discuss nutrition using a monotone narrator, but do incorporate some humor. More effective are the “Shrek” and “NFL Play 60” ads that include characters from Shrek and professional football players, respectively. The kids in these ads are playing in parks or basketball courts with the Shrek characters or football players and they all appear to be having great fun doing so. The “Shrek” ad even features a catchy song. However, the park featured in the “Shrek” TV spot that the kids are playing in is conveniently very nicely equipped. The fields of the park are well maintained and expansive and the playground is enormous. Such an outlet is not realistically available to all demographics of children, particularly those in urban areas or of lower socioeconomic status (11,12). The NFL Play 60 ad is based in a basketball/tennis court though, which is more readily available to most children, regardless of their socioeconomic or geographic situation.

The nutritional information provided to children by the Smallstep campaign is ineffective because children are largely at the mercy of their environments. It is their parents or guardians who do the grocery shopping, pack their lunches and prepare or purchase their dinners and it is the school environment that provides children with lunches and vending machine snacks. To ask children to have a significant impact on their diet is misguided. Social Learning Theory explains that people perform actions because they see others doing it and Social Expectations Theory infers that people’s behavior is dictated by established social norms (9,10). Children learn diet and how to behave largely through observing their parents in daily life (13,14). Parental lifestyle has been found to be significantly associated with their children’s BMI. Specifically, obese parents were more likely to have obese sons and daughters (15). A related study found that parents have significant influence over child-feeding behaviors. Left to make their own food choices, children tended to opt for foods high in added sugar. But, when the parents imposed restrictions, the effect was exacerbated and the risk of weight gain increased. The study concluded that parental dictation of food availability was more likely the appropriate solution (16). Furthermore, it is not just parents that have direct influence over a child’s risk but also their friends. In one study on the spread of obesity, both parents and friends, particularly mutual friendships, were found to have significant impact on one’s risk of obesity. In fact, even friends of friends were found to have significant impact on risk (17). Ultimately, a Social Network Theory, Social Expectations Theory or Social Learning Theory approach would have proven more efficacious for the Smallstep campaign in addressing the proximal causes on children’s diets.

Smallstep Does Not Take Socioeconomic and Race Factors into Consideration
A significant flaw of the Smallstep campaign was that it did not target especially susceptible populations such as minorities and people of lower SES. As stated previously, the social environment, including parents and friends, has been shown to have an effect on one’s risk for obesity (14-17). SES has influence over one’s social environment and race is interlinked with SES (18). From 1971 through 2004, the level of poverty has consistently been associated with a higher prevalence of obesity. The difference has been diminishing, however. Between 1971 and 1974 the prevalence of obesity in the population below 100% of the poverty level was 21% compared to 12.5% for the population ≥ 200% poverty level. The 2001-2004 results revealed that while the prevalence of obesity in the population below 100% poverty level had increased to 35%, the prevalence among the population ≥ 200% poverty level was now at 31%. The difference in obesity prevalence among men of different ethnicity wasn’t nearly as significant as the difference seen in women: 31% for white women, 40% for Mexican women, and 52% for African American women. The race and weight gain disparity was also seen in children (2,11). Logically following from these data, regional differences in obesity prevalence were also observed within the US. In 1998, CDC data showed 17.1% prevalence in the southern states compared to 10.8% prevalence in the western states. Some southern states like Mississippi and Alabama had prevalences over 25% in 2002 (11). These findings are not surprising when considering that the southern US geographic area touts both a higher minority population and lower average per capita income than the western states (19,20). In Starr Country, Texas, where 59% of the children live below poverty level, 24% are overweight or obese by the age of four, 28% by kindergarten, and 50% of boys and 35% of girls by elementary school. Also, almost half of the adults in this community have Type-2 diabetes (6). Rationally, an increased risk of disease would follow from an increased risk of obesity and indeed, a lower SES was significantly linked to an increased risk for Type-2 diabetes in the Alameda County Study (21). Additionally, one study found an association between education level and income with risk of cardiovascular disease events (22).

The obesity imbalance between subpopulations results from the economic and food/build environment resource disparity between different SES tiers. Fast food, soft drinks, and other foods high in sugar, fat, and calories are cheap, largely as a result of the high fructose corn syrup and hydrogenated fats used to prepare such foods. High fructose corn syrup, America’s favorite sweetener, is also the cheapest and it keeps excellently (2,23,24). Hydrogenated fats, made from soybeans, are also cheap and very prevalent in inexpensive and fast foods (2,24). To really put this into context, from 1983 through 2005, the price of fresh fruits and vegetables increased almost 200% while the cost of fats and oils increased 65% and the cost of carbonated drinks increased only 30% (2). The bottom line is that it is expensive to eat healthy. A more effective approach by Smallstep would have included subsidizing fruits and vegetables rather than just telling people to eat more of them.

There also exist barriers to accessing health food for those of lower SES. Supermarket availability is less in low-income neighborhoods. With larger food stores and chain supermarkets being more likely to stock healthful foods than smaller stores and nonchain supermarkets, and there existing a correlation between supermarket availability and BMI, especially in African-Americans, the role of resource availability becomes clear in this battle against obesity (25). A study was conducted in East Harlem, New York to look at racial disparity with food store availability. The researchers found zero supermarkets or grocery stores in predominantly African-American neighborhoods compared to reference mixed race neighborhoods that contained many (26). Additionally, a study based in Queensland, Australia found that the cost of healthy foods increased with remoteness of location. Availability of food items was also inversely associated with rural areas. The researchers felt that these results had interesting implications for disadvantaged socioeconomic groups, particularly indigenous peoples, who were more likely to reside in remote locations (27). Dr. Risa Lavizzo-Mourey, president and CEO of The Robert Wood Johnson Foundation, an institution dedicated to fighting obesity, offered the following summary of the situation: “Obesity rates are the highest in communities afflicted by poverty. Families in these communities simply don’t have the same opportunities to make healthy choices as families in other neighborhoods. They don’t have grocery stores that stock affordable fresh fruits and vegetables” (6).

Lower SES groups are also at a disadvantage when it comes to the availability of physical activity facilities. Both the World Health Organization and The National Academy of Sciences has recognized this particular aspect of the build environment as key in the fight against obesity, but the Smallstep campaign never sought to address it (11,28). A recent study from the Journal of Pediatrics found that low-SES and minority geographically occupied areas were significantly associated with having less facilities than higher-SES occupied areas. The researchers also found that a greater number of facilities per area was associated with a decrease in overweight prevalence (12). With lower SES groups and minorities having lower availability of both healthy food and physical fitness resources, the Smallstep campaign could have benefited from targeting these highly susceptible subgroups.

Smallstep Does Not Address American Food Culture, Food Industry Infrastructure, and Politics
The true root of obesity lies in Americans’ values, culture, food industry, and the government’s influence over agriculture. These are the final, overarching causes of obesity and were never addressed by the government’s Smallstep campaign. It is not uncommon in American culture today for both parents to work full-time. Adolescents of full-time working mothers have been shown to be more affected by food store availability than their counterparts (25). The results are sensible because less time to prepare meals translates to making due with your immediate resources which entails eating whatever is ready to eat in your surrounding environment’s food stores and restaurants. Less eating in and more eating out impedes ones ability to dictate nutritional value and portion size of the meals they are consuming (2). Americans also desire value; they want large portions for affordable prices. Restaurants accommodate our desires to maximize business. Ruby Tuesday’s has the 1,677 calorie Ultimate Colossal Burger (2.5 lbs. beef on a triple-decker bun with cheese), Denny’s has the 1,128 calorie Grand Slam Slugger Average, Hardee’s has the 1,410 calorie Monster Thickburger, and Burger King now has the BK Stacker with 4 beef patties. Consistent with those offerings is the reality that portion sizes have dramatically increased in the past 20 years simply because larger portions sell better. The average serving size for a bagel went from a 3-in. diameter to 6-in., French fries from 2.4 oz. to 6.9 oz., soda from 6.5 oz. to 20 oz., and popcorn from 5 cups to 11 (2,29). When Ruby Tuesday’s tried to reduce its portion sizes, they actually lost customers. They then quickly made adjustments and added back to their portion sizes, even increasing them beyond what they were originally (2). Understandably, pricing has an effect on food choice. One study looked at how reducing the cost of healthy foods such as carrots by 10%, 20%, and 50% would affect sales. It did indeed with sales increasing 9%, 39%, and 93%, respectively (29). Price was shown to be particularly important when purchasing food among the Hispanic culture (30). This evidence further emphasizes how the Smallstep campaign was incomplete for ignoring the psychology of pricing and value with food choice.

Our schools aren’t helping much either. In fact, they may be downright hurting the anti-obesity efforts. School lunches average 40-120 kCal more than home prepped lunches. In 2000, 43% of elementary schools, 89% of middle schools, and 98% of high schools had vending machines where junk food could be purchased (2). These junk foods are known as competitive foods. They are not part of the federal school meal programs and thus are very minimally regulated on a federal level and inconsistently regulated by states (11). Amazingly, Taco Bell products are now being sold in over 4500 school cafeterias and Pizza Hut, Dominos, and McDonalds are even sold in some school cafes. Pizza Hut also sponsors the Book-It program where kids are rewarded with a free personal pan pizza for reading enough books (23). The physical education side of the situation is equally as bleak. Daily high school enrollment in PE dropped from 42% in 1991 to 28% in 2003 (2). The percentage of high schools requiring PE according to a 2000 survey for grades 9 through 12 were about 20%, 10%, 5%, and 5%, respectively (11). Increasing pressure for schools to perform academically lest they face fines is the cause for some of the cuts in school PE programs because the cuts allow for more time to be allotted to academic studies (2). Yet, the Smallstep campaign still asks kids to make healthy choices even though kids have little to no control over school food options and programs.

Child culture has changed at home too; particularly in regards to free-time activity choices. With the availability of video games, hundreds of television channels, DVD players, and computers in today’s culture, kids are faced with a number of seductive opportunities to be sedentary. Sedentary activities have been linked to obesity in a number of studies (31-33). 17% of children watch more than five hours of TV per day, 16% watch three to five hours, 31% watch one to three hours, and only 36% watch less than an hour of TV per day. These numbers also differ by race in the 8th, 10th, and 12th grade brackets with 42-58% of African-Americans watching four hours or more of TV per day compared to 16-23% of whites (2). During Saturday morning television, 56.5% of commercials were for food and the primary foods advertised were cereals, snacks, candy, and soft drinks (11). Subsequently, snacking, primarily on unhealthy foods, has been linked with the act of watching TV (2,11). One study randomized children to an intervention or control group with the intervention group having children reduce their television viewing time and computer usage by 50%. This intervention significantly lowered energy intake (34). Although the Smallstep campaign is airing ads that are competing against high energy, nutritionally bereft foods, the task is certainly formidable. Their relatively small budget must compete against the $1 billion allotted by the food industry for television commercials targeting kids (5).

Unhealthy, readily available foods such as fast food are cheap and abundant in America. As mentioned previously, much of it contains high fructose corn syrup and hydrogenated fats from soybeans. The United States is the number one producer corn and soybeans in the world. Such large production levels are encouraged by government subsidies for the two crops. The government also offers subsidies to wheat and rice farmers, crops often used to create less healthful, refined grains. Together with soybeans and corn, these crops account for 90% of all government subsidies. The subsidies were originally created to spur the agricultural industry to meet the nutritional demands of a growing nation back in the depression era but these subsidies are no longer as relevant as they once were (2,5). Corn is in fact so cheap and plentiful that it is even used to feed animals not normally meant to diet on the crop, like cows and chickens (5,24). Corn-fed cows are less healthy than their grass-eating counterparts because their meat is fattier and less dense in omega-3 fatty acids. Concentrated Animal Feeding Operations (CAFOs) are notorious for doing this (24). With conventional farming, operations are segregated. For example, corn or soybeans would be the only crops grown on a particular plot of land and the nutrient depleted soil, due to lack of proper crop rotation, would be supplemented with industrial fertilizer. Organic farming, typically a small farmer operation, offers an alternative to this. Cows are fed a mixed diet of legume crops & grass grown on the plot and then produce nitrogen-rich manure that is in turn used to fertilize subsequent heavy nitrogen-consuming crops like corn (35). The shift away from the conventional large agrochemical farming industries and their disproportionate growing of corn has been hampered by the lobbying power of these companies along with the effects of the government’s subsidy legislation (5). ConAgra, one such company, was even able to orchestrate state tax breaks due to its pull through the amount of jobs it created in that state. Since Richard Nixon took office, the fast food industry has had its allies in Congress and this has helped their efforts to oppose food safety laws. Fast food has also been effective at getting their slice of the subsidy pie as they benefit, as well, from a wide variety of government subsidies (23). The US government first set the pieces in motion that led us to this obesity epidemic, and kept with the legislation regardless of how times changed. It is ironic that the same government is now attempting to solve the problem by ignoring its own real role and instead placing the onus on its people with the Smallstep campaign.

The Smallstep campaign against obesity meant well but put forth an almost entirely futile effort towards ameliorating the obesity epidemic in the United States. The focus on individual behavior and action through the Health Belief Model is inappropriate for such a complex problem that’s causes are associated with family, social networks, socioeconomic status, race, culture, American values, industry, and policy. More complex theories such as Social Network Theory, Social Expectations Theory, and Advertising Theory would have been better suited for implementation but even that would provide just part of the solution. The World Health Organization and The National Academy of Sciences has advocated for a multi-factorial approach that includes providing more healthful foods and portion sizes through restaurant and fast food channels, increasing supermarket and healthy food store availability, improving the build environment to accommodate for more physical activity and less use of motorized transportation, community support programs, school support programs including PE and improved nutritious food options, recognition of especially afflicted subpopulations, increased preventative action by health care providers, and supporting legislation (11,28). Innovation has been lacking in solving this problem. Shining examples of these needed innovations are the Nintendo Wii and arcade games like Dance Revolution. Although not originally intended as public health initiatives, they are effectively serving as such. These video games and video game system involve moderate to high levels of physical activity, thus dispelling the norm that video games are sedentary activities. Involving schools in local farm programs for food access and education is another example of a thoughtful and effective measure to promote healthful eating and information on the concept. Organic products are also increasingly finding the favor of consumers and this demand must be met by higher levels of supplies. There are highly effective solutions to this obesity epidemic, just not the solutions that the Smallstep campaign had to offer.

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