USDA Fails to Proactively Remove Dangerous “Downer Cows” from Human Food Source – Punit Patel

The Committee chairwomen and Democratic Representative from Connecticut aggressively claimed that the United States Department of Agriculture (USDA) needs to take the issue of Mad Cow Disease seriously and take more stringent measures to ensure the safety of the American people. She pointed out that 5,000 Americans die each year due to insufficient inspection of food based on current regulations and compared their deaths to the 3,000 American lives lost in the World Trade Center attacks and vehemently stated, “This Nation went to war because of those deaths. We have 5,000 people every single year in this nation who die from food-borne illness. Do we not believe we should go to war against the system that allows that to happen?”(1) Of the 5,000 people accounted for about 250 die each year from Mad Cow Disease that was ingested from the processed meat of a “downer cow” on American soil(2). Downer Cows are sick and weak cows that are not able to stand on their own feet any longer and have a very high chance of having Mad Cow Disease.

Although the actual percentage of deaths from downer ingested meat is relatively low, it is important to note that symptoms from Mad Cow Disease appear years after meat ingestion has occurred. (3)The nature of such a prion disease is that it constantly is changing so it is difficult to contain and has the potential to incorporate itself into a part of the DNA passed down to the next generation.(4) Hence, we can only know of the past prevalence of the disease from how many people have currently died. However, epidemiologists predict a steady increase in deaths from downer ingested meat once the current infected population begins to show symptoms (5).

Since the USDA is the federal agency in charge of providing “leadership in food, agriculture, natural resources, and related issues based on a sound public policy, the best available science, and efficient management,”(6) the responsibility to make “sound public policy” lies in their hands and that is what is currently lacking. In March 2004 US legislation passed a law banning all downer cows from entering into slaughterhouses for the use of meat for human consumption. (7)In July 2007 the USDA removed this ban, and once again allowed USDA policy to include downer cows.(7) There was a stipulation to this ban lift stating that downer cows would be considered and included in the human food supply, only after the downer cow in question was re-inspected by a USDA certified veterinarian. (8) The USDA felt that a certified veterinarian would be qualified enough to understand the health implications of allowing a downer cow to pass USDA inspection. (8) The USDA’s policy allowing downer cows to be used as processed meat and re-enter the American food supply is irresponsible and unsafe taking into account the flawed foundation behind the policy, the lack of responsible and consistent implementation of it, and the dire consequences to the overall American Public Health.

Political Foundation
The political drive behind this policy is evident in that there are a series of obvious assumptions regarding the meat packers and convenient loopholes within the policy that allow the USDA to “look the other way” when certain regulations aren’t followed all the time. The USDA has two major responsibilities as an organization, one is to promote the agricultural industry via its Agricultural Marketing Service (AMS) and the other is to maintain the safety of food quality for the American public via its Food Safety and Inspection Service (FSIS).(6)

Though the intention of this paper is to critique the intervention or lack thereof via the policy and not the USDA or the federal organizational issues regarding overall food safety, it goes without saying that they go hand in hand as their is an inherent conflict of interest that cannot be overlooked. The USDA is expected to crack down on safety measures while maintaining the growth of the agricultural industry placing them in a political catch 22 situation.(2) Unfortunately, they choose not to enact seriously needed strict policies because they are influenced by the lobbyists from the meat industry and thus safety loses at the hands of marketing because of the meat industry’s strong political power over the USDA.(2)

Secondly, this policy is based on unreliable data and flawed laws from previous years which fall short of full proofing the food supply. For example, the 2006 USDA Inspector General Report stated that all annual inspections of Mad Cow Disease after the initial outbreak were voluntary and not random which misrepresented the actual sample size of potential cows with Mad Cow Disease. (11)This annual inspection is what the USDA uses when formulating the relative risk of the disease in the cow population of the United States which meets the 40,000 cows to be tested goal but ends up testing mainly healthy cows and not ambulatory downer cows.(9) This system works for the USDA as well as the meat industry since meatpackers who utilize a higher number of downer cows into their food source would not want to reveal themselves to the USDA and the USDA can fulfill their quota of testing without doing any serious damage to meat packers. Countries like England and Japan test all of its cows for Mad Cow Disease while the United States only tests .1% of its cows breeding a false sense of security from inadequate testing. (9)Though it might seem that there is no need for this, the Japanese originally had no cases of the disease but once they started testing they found 31 cases so the trend seems to be the more you test the more you find. (2) In the United States, testing isn’t even proportional to the number of cows slaughtered per state and in no way reflects the current risk in cattle.

The USDA relies heavily on the 1997 law stating the cattle feed cannot be fed to other cattle and spinal cord and brains of cows 30 months or older cannot be utilized as food but blood from cows can be incorporated in cattle feed.(7) The problem here is that prions can still travel via blood and what about the risk of a downer cow with Mad Cow Disease of 29 months?(8) Such laws with numerous loopholes cannot be considered the fundamental basis of safety from Mad Cow Disease in general or specifically from downer cows.

Finally, this new policy is a continuation of past mismanagement of food quality and safety as a result of basing the approach to safety solely on the Health Belief Model causing the responsibility and decision making to fall in the hands of the distributor of the processed meat and not the regulator, the USDA. (10)It is based on the idea that if the meat packers feel that a downer cow is susceptible to Mad Cow Disease and if they are informed of the seriousness of the disease, the industry will automatically choose the perceived benefit of public safety and accept the cost of the downer cow as lost revenue for the sake of the public’s health. It is also assumed that their intention of protecting the meat supply from disease will lead to responsible and safe behavior on the part of the meat packers. The assumptions this model makes are not only unrealistic but they are dangerous because they give so much power to an industry whose key incentive is profit and this one major fact automatically alters the outcome from this model. This is something the USDA has failed to realize allowing them to claim that according to their new policy, derived from this model, food safety is accounted for but the real question here is if the individual factories and their employees that makeup the industry are following through on that model?

Unsatisfactory Implementation of the Policy

The only way this policy would be able to successfully promote the interests of the meatpackers while still maintaining the safety of food quality from diseased downer cows is, if the state level implementation was carried out impeccably and if every single division and subdivision of this hierarchical ladder would honestly and carefully carry out his or her duties. Unfortunately, there are organizational deficiencies in staffing and training within the FSIS (the body that handles state-wide inspections and enforces regulations) as well the individual meat packing factories that have lead to a high level of inconsistencies confirming the risk of increased Mad Cow Disease prevalence in future years.

Training Issues

There is a serious lack of quality training being offered to both USDA officials and none is offered to the managers or their employees who are the ones assessing the on-site status of downer cows. A USDA Training and Development Consortium has been established “to provide coordination and consistency to the training function within USDA. The Consortium is authorized and empowered to direct mission areas and agencies to comply with its programs, procedures, and guidance” but one of the major goals as stated within their priorities is to “eliminate duplication of effort” so this is clearly training that is geared towards efficiency and conservative budgeting schemes than to genuinely train the employees for safe and tedious inspection of unsafe cattle. (6)

The FSIS deals mainly with managers of meat factories and rarely interacts with employees so no specific training is given to any employee by the government regarding state and federal regulations and that responsibility lies with the individual managers. (6) Though, it may seem fair and cost effective to not train private employees, there is no standard test or license or even certificate of completion or any document that states that the particular necessary training has been provided for the proper treatment and exclusion of downer cows. Every manager will train his or her employees and this is where the inconsistency occurs in quality of meat because though the policy requires a USDA certified veterinarian to inspect the downer cows for safety, before used as meat, the person making that decision is the ill trained employee whose expected to observe the downer cows on a federal standard of safety but works for a biased employer who would benefit from incorporating as much meat as possible. (2) Therefore, the employees may be “encouraged” to overlook certain regulations in an attempt to increase output causing the employees to not inform the USDA veterinarian and the potentially diseased downer cow ends up in the American food supply being distributed to various companies to be incorporated in hundreds of products.

The issue of inconsistency does not stop with the ill trained employees of the factories, but spills over into the main body enforcing the regulations, the FSIS. Staffing is limited requiring a higher level of “efficiency” which results in inconsistent implementations of policy. This allows for an ambiguous gray area where managers tend to use their own “discretion” and that is where the enactment of the policy fails.

Staffing Issues

There are 7,800 inspectors working for the USDA for 6,200 facilities, though this may seem adequate, each facility on average slaughters 500 cows which leaves approximately 1 inspector to every 400 cows for inspection per day. (6) Of that, there is an average vacancy of 500 inspectors which creates a 7%-21% lack of much needed inspectors within the districts. (6) The actual ratio should be of inspectors to number of cows within a facility since it clarifies the immense amount of responsibility for every inspector. Not only do they have to check the downer cows for injuries and disease, they also have to sample butchered meat for E. coli and various other bureaucratic tasks as well which leaves little time for actual thorough inspection.

Even if the inspectors manage to find regulations not being followed within factories, there seems to be an inherent inconsistency in the inspection process showing a dangerous level of leniency in some states. For example, the state of Pennsylvania has 139 meat plants but only 4 citations were written least year whereas in a more stringent and safer state like California there were 15 citations written where there are only 32 plants. (5) Though, it is a fair argument that the number of citations do not have to be proportional to the number of plants, there is a serious number of discrepancies in the above two states and the disheartening thing is that inspectors of both states receive the same federal and state level training. (6)

Finally, if inspectors do stay on there toes and actively issue citations when needed, there may be piles of citations before anything is done about the plant in terms of closing it down for violations or increasing on site inspections. There is no written rule of “x number of strikes and your out” so each violation amounts to a fine and tends to stop there. (7) For example, the Westland Meat Company in Chino, California was recently closed down and the largest meat recall in the history of the USDA was done amounting to 147 million pounds of meat after having received numerous violations from the USDA for the last 10 years. (2) This shows how long the meat company has been able to freely pass on dangerous meat into the food supply enhancing the argument of the increase in future deaths and current prevalence of Mad Cow Disease.

Consequences
Along with the medical dangers of this policy, there are a series of social consequences that prove to be detrimental to society psychologically, through the inhuman treatment of downer cows, and financially through the numerous recalls that occur in increasing numbers annually. The way in which the USDA has formulated this policy it seems that the only loophole to utilizing the maximum amount of downer cows is either to get the cows to stand by forceful means or injure the downer cows so that they may pass the inspection as “injured” rather than automatically excluded as “diseased.” (12) Though, downer cows are segregated for inspection separately, the sheer number of downers to inspect per day causes the quality of inspection to suffer. Here is where meat packers take advantage of the situation and through inhumane treatment inflict injury on the cows while trying to force them to stand.(12) And if an injury is found on a downer cow, the chances of it passing inspection as “injured” is much higher, taking advantage of the USDA’s Chairman, Ed Schafer’s argument that “injured downer cows are not a threat to the food supply and should be allowed.”(2) A key thing to remember here is that a downer cow with Mad Cow Disease can also get an injury and end up passing the test because of the nature of the disease. Veterinarians have trouble deciphering between the actual disease and an injury because the disease causes similar external symptoms of weakness as does an injury. (8)

Inhumane Treatment

Unfortunately, this policy harbors and instigates meat packers to employ inhuman methods of electrical prodding of downer cows, power hosing them, or simply pushing them with a fork lift until they stand up and walk into the slaughter house assembly line or get injured in the process and end up inspected and labeled as “injured” and then forced into the assembly line. (12) In fact, the Westland and Company factory was even cited for “too much electrical prodding” but was allowed to continue there slaughtering after a fine. (12) The Humane Society of the United States has clearly agreed that this policy is “dangerous and deplorable taking into account the large economic incentive the meat packers have to force downer cows into slaughter lines and the risk that even those cows with broken limbs and weak muscles are 49 to 58 times more likely to have Mad Cow Disease as the disease weakens muscles.”(12)

A major danger of this mistreatment is the greater impact on the industry as a whole as this creates a type of Meat Plant Culture of abuse and mistreatment of downer cows that is passed on as some sort of tradition to each new generation of employees. The entrance of a new employee into the meat factory and the training one receives as a result is based on the Social Learning Theory (10) where an employee will do what he sees his fellow workers doing and in this case it will be the illegal and inhumane attempts at trying the get downer cows to stand or pulling them with chains to the slaughter line. There is no question of any Reasoned Action () as the concept of self efficacy does not exist for most of these workers who are poor immigrants who are living pay check to pay check and are afraid of losing their job if they voice any sort of opposition to existing methods. As time goes on, the employee that initially entered the work force and learned this behavior of mistreatment through modeling has become a member of that very Social Network as in the Theory of Social Networking (10) and his or her behavior is a result of belonging to that Social Network which forms the “Plant Culture” of inhumane treatment and maintains this tradition through the Theory of Social Learning and a cyclical series of events occur over generations and the tradition of force and abuse continues as the next wave of employees arrive.

Recalls

In an effort to correct their wrongs of this policy, the USDA issues recalls whenever proof is presented of mistreatment of animals or risky entrance of un-inspected downer cows into the human food source as an attempt to protect the public from products containing the risky meat via the loopholes of this policy. (12) Unfortunately, recalls are a voluntary procedure and the USDA does not have the power to force any plant to comply and as the Consumer Federation of America’s Food Policy Institute points out “critical time can be lost in negotiating between the USDA and the company over the terms of the recall” prolonging the risk of Mad Cow Disease from the downer ingested meat. (13) Recalls cause the public to go under a scare and paranoia infiltrates members of society causing mistrust of food products and as a result the economy is effecting when United States quality of meat is questioned when other countries like France refuse American beef and revenue is lost. (1) Also, as was the case for 220 employees of the Westland and Company, hundreds of employees lose their jobs when a recall occurs as the loss of credibility leads distributors to pull out of their contracts with the plants. (2)

Finally, the meat from these factories which have recalls does not remain in a concentrated geographic area, but travels across the nation to millions of people as the meat is first sent to distributors and companies which process the meat for different products, 466 in the case of Westland and Company, so containing the potentially diseased meat is close to impossible. (2) In fact, the meat from the Westland and Company was distributed to the National School Lunch Program as well as to needy families with low income and that is a serious risk. (2) Most children who are approved to be a part of a school lunch program are required to be from medium to low income households and those very children’s parents might be ones receiving a part of the quota of meat distributed to needy families so that child is at risk two times more than the average person. (2) Children in general have lower immunity but coming from a low income household, whether child or adult, it is clear in the literature that healthcare options are limited if at all available. (12)

Conclusion
This policy is a threat in itself to the safety and well being of millions of Americans and needs to be changed immediately. The USDA is inherently not able to and lacks incentive to prevent downer cows from entering the human food supply and that needs to change. If nothing is done, we will have to watch an entire generation of beef consumers becoming infected with Mad Cow Disease and there will be nothing that can be done for them. One of public health’s main goals is prevention and we might have missed the current population but we can surely save the next one if action is taken now.

The ethical implications of allowing such a small group of people, in the industry, to control the health status and health outcome for millions of people is disturbing and unsafe. The fact that our world today is becoming smaller and smaller is a haunting fact when thinking of meat from downer cows and the increasing geographic area in which such meat is consumed. The factory owners in the industry weigh the chances of higher profits against the future sickness of the public and choose the immediate profit. One of the main reasons for this is that this is a decision for which the consequences will occur in the long run and by that time it will be nearly impossible to trace the meat to the original factory. Hence, the industry sees utilizing downer cows as a crime without a consequence and it is the current policy which gives them this security and causes such discomfort within the field of public health as well as the masses that may be at risk as of now.

REFERENCES
1. Lee, Christopher. Washington Post. USDA Rejects “Downer Cow Ban”. February 29, 2008.
2. http://www.pe.com/reports/2008/cattle/vitindex.html
3.http://www.usda.gov/wps/portal/usdahome
4. Zimmerman, Janet. United States Department of Agriculture Handbook of Laws. Washington, DC: Penguin Press, 2007 Edition
5.CJD deaths 'may have peaked'. BBC News (2001-11-23). Retrieved on 2008-04-08.
6."BSE: Disease control & eradication - Causes of BSE", Department for Environment, Food, and Rural Affairs, March 2007.
7."The BSE Inquiry", led by Lord Phillips of Worth Matravers, report published October 2000.
8. Harden, Blaine (2003-12-28). Supplements used in factory farming can spread disease. The Washington Post. Retrieved on 2008-04-08.
9.Bovine Spongiform Encephalopaphy: An Overview (PDF). Animal and Plant Health Inspection Service, United States Department of Agriculture (December 2006).
10. Association of Health Practitioners. List of Health Behavior Models. Washington, DC. Association of Health Practitioners. http://www.aph.org/health.
11. United States Department of Agriculture. 2006 USDA Inspector General Report. Washington, DC.
12. Humane Society of the United States. Westland and Co. Surveillance Report. New York, NY.

An Evaluation of the Implementation of the Department of Health & Human Services’ Breast Feeding Campaign’s Lack of Effectiveness—Victoria María Klyce

Introduction
It is well documented that babies who are breastfed have lower morbidity and mortality rates than babies who are bottle-fed (1). The protective properties of breastfeeding are well understood. Breast milk contains a wide range of many biologically active compounds including cytokines, hormones, and enzymes that function in the maturation of a child’s immune system (1, 2, 3). Breast milk also transfers immediate protection against microbes from mother to child through the specific immune response via activation of antibodies and the non-specific immune response via activation of proteins, glycoproteins, and lipids. In an effort to increase breast feeding rates among women, in June 2004 the United States Department of Health and Human Services (DHHS) launched a nationwide campaign to increase exclusive breastfeeding for at least 6 months to 50% (4). The need for a breastfeeding promotion campaign is clear. In 1995, 59.7% of mothers initialized breastfeeding, and only 21.6% of mothers were breastfeeding at 6 months (5). In a randomized experimental study published in the Journal of Nutrition, babies in the exclusive breastfeeding group crawled sooner and were more likely to be walking at 12 months than infants in the group where formula supplemented breastfeeding (6). The DHHS website lists many benefits to breastfeeding, including easier digestion for the baby, and the baby being at lower risk of SIDS (in the first year of life), and Diabetes type I and type II, lymphoma, leukemia, Hodgkin’s disease, overweight and obesity, high cholesterol and asthma (4). Studies have also shown that breastfeeding helps the mother lose the weight gained during pregnancy (4, 6), as well as lowering the mother’s risk for ovarian and breast cancer, and lessening postpartum uterine bleeding (4). The DHHS Breastfeeding campaign used radio, video, and print to with the goal of increasing the percent of mothers exclusively breastfeeding for six months. However, due to incorrect source, audience, message, and destination of the intervention this campaign was not successful.

DHHS National Breastfeeding Campaign
The DHHS Breastfeeding campaign includes two video commercials, two radio spots, and four print ads. The video ads show women doing reckless behavior while pregnant, both finishing with the statement: “You wouldn’t take risks before your baby is born, why start after?” Both radio commercials are narrated by men telling women to breastfeed exclusively for six months. The print ads show images of dandelions, ice cream scoops, and otoscopes simulating breasts, and the bold words “Babies were born to be breastfed”. The three print ads with images state in small letters: “Breastfeed for six months. Help reduce your child’s risk for _______”, with varying ailments which correspond to the picture (i.e. obesity with ice cream) (4).

The DHHS campaign to promote exclusive breastfeeding has not been successful. Firstly, the campaign’s focus is inappropriate, having “Babies were born to be breasted” as the take-away tag line is not constructive to promote exclusive breastfeeding for six months. Secondly, it applies only the Health Belief model and Social Cognitive Theory, assuming that the only barriers to mothers breastfeeding are that they are ignorant of the severity and susceptibility their child will have for disease if they do not breastfeed, and that they lack self-efficacy, which is promoted through guilt. Both these assumptions are incorrect. Lastly, the campaign lacks an effective frame. The campaign needs to employ social science and alternative modeling methods in order to be effective, including Social Market Theory, Framing Theory, Social Expectations Theory, Advertising Theory, and Stigma Theory.

Initialization of Breastfeeding is Not the Right Message
The DHHS Breastfeeding intervention’s message of demanding women to initialize breastfeeding is misguided. Seventy-four percent of mothers breastfeed their babies immediately after birth, while only 30% are breastfeeding at three months and 22.3% are breastfeeding at six months (7). The fact that 26% of mothers do not initiate breastfeeding could be for a variety of reasons, such as maternal infection with HIV/AIDS, adoption, inability to produce milk, or baby allergy. Therefore, an intervention aimed at achieving that these 74% of mothers who initiate breastfeeding continue to do so exclusively for six months will have the more significant benefit to society. Furthermore, the DHHS study’s self-identified goal is not to increase initiation of breastfeeding to 100%, but to increase exclusive breastfeeding for six months to 50% (4). An effective campaign requires a proper message, and the DHHS campaign to promote exclusive breastfeeding for six months does not provide one. The take away catch phrase—babies were born to be breastfed—promotes breastfeeding initiation, not exclusive breastfeeding for six months. The facts are clear on that there is not a great need for a campaign to increase the initiation of breastfeeding.

The campaign needs to focus instead on who is not continuing to breastfeed and why. There is great variation in breastfeeding rates amongst sociodemographic characteristics. Only 19.8% of African American infants were breastfed for three months, compared to the national average of 30%. Young mothers breastfed for three months at a rate of 16.8%, and mothers with a high school education (22.9%) or less (23.9%) were also far less likely to breastfeed for three months. Only 18.8% of unmarried mothers who initiated breastfeeding continued to do so at three months, and rural mothers and mothers who were poor each had breastfeeding rates of 23.9% (7). These mothers chose to initiate breastfeeding, so one can infer that they see the value in breastfeeding but met an obstacle that disallowed them from continuing.

The DHHS campaign, which aims to persuade these women to continue to breastfeed through its media campaign, will not only fail to achieve this goal, but could have additional harmful effects. Stigma Theory tells us that an individual will live up to a label placed on him or her, or the primary group he or she identifies with (8). In this case, a woman who chose to initiate breastfeeding but was unable to continue will see the DHHS ads equating not exclusively breastfeeding for six months with risky, reckless behavior and be labeled as a “bad mom”. This will have two major consequences. The first is that she will think of herself as a bad mom, and Stigma Theory tells us she will be more likely to live up to that label. Secondly, she will feel judged by the public health campaign, and this will foster distrust and animosity toward health campaigns in general. This mother will now be harder to reach regarding childhood immunizations, cigarette smoking, fruit and vegetable consumption, et cetera.

Instead of stigmatizing mothers who do not continue to breastfeed with the current implementation, DHHS should instead widen their view of why half of mothers begin to breastfeed and stop before six months. The current campaign applies only the Health Belief Model and Social Cognitive Theory, assuming that the only barriers that impede a mother breastfeeding for six months are that she is unaware of the risks of not doing so and that she lacks the necessary self-efficacy to achieve it. These models are not appropriate to be the primary tools implemented in this intervention because there exist other more fundamental causes for the low rates of breastfeeding, which should be addressed with Social Expectation Theory.

Social Norms and Legislation are Barriers to Breastfeeding
Currently 21 states have laws decriminalizing breastfeeding—which leaves 29 states where breastfeeding is considered a lewd act (9). The barrier is thus not lack of assertiveness or ignorance on the mother’s part, but the social norms, values, and expectations of society, which are reflected and reinforced by the legislature, or lack or legislature. Most states do not require employers to allow mothers to breastfeed or pump while at work. Even those that do have exceptions, such as “if it is busy in the office” (10). These issues are of special importance to mothers who are poor and cannot take time off, single working mothers, and mothers with less education who work in hourly paid jobs.

States that do not count breastfeeding as a lewd act still do not create a culture accepting of breastfeeding. Missouri, for example, states that mothers must breastfeed "with as much discretion as possible". Thus, the language frames breastfeed as a necessary evil, a shameful procedure that should be minimized. Furthermore, the ambiguity of the language gives individuals the power to approach a breastfeeding mother and accuse her of not being discrete enough, and thus committing a lewd act (9).

In states where laws exist protecting breastfeeding they are not always honored. There have been high profile cases in many states where mothers were told to leave public and private establishments where they legally had the right to breastfeed (10). In the last month alone there have been many instances in the news of discrimination against breastfeeding mothers. In Vermont a woman, her husband, and their baby were removed from a plane when the mother declined the flight attendants demand that she cover her baby’s head with a blanket while breastfeeding. After waiting on the plane for nearly three hours due to delay, she had begun to breastfeed her daughter, sitting at her window seat, with her husband sitting beside her. She told the flight attendant that she was exercising her right to breastfeed her child, but was still forced off the plane in tears (11, 12). A woman in Maryland was sentenced to a night in jail and a $150 fine when she asked to postpone jury duty in order to breastfeed her 12 week old baby (13). In Texas a mother was kicked out of a hair salon in the middle of her haircut because she attempted to breastfeed her infant (14). Clearly, without changing the public’s attitude toward breastfeeding the rates of breastfeeding cannot increase.

The DHHS campaign does attempt to use Agenda Setting Theory to create awareness of the necessity of breastfeeding, however, store owners who ask a mother to breastfeed in the bathroom, or legislators who demand breastfeeding be “discreet” do not need more information on the list of diseases that breastfeeding can avert. What they need is a change in the culture of the United States. They need to be more comfortable with the image and presence of a breastfeeding mother. Posters with dandelions about asthma will not make a restaurant owner allow a woman to breastfeed in his store. He needs to fell assured that a woman breastfeeding will not disturb or offend the other patrons. He needs to consider it “socially acceptable”. The DHHS breastfeeding campaign does nothing to achieve this.

Lack of Imagery of Mothers, Babies, and Breastfeeding
The frame that the DHHS attempts to employ is not continuous across media types, with the exception that each includes the catch-phrase: Babies were born to be breastfed. The video frame is that not breastfeeding is reckless and irresponsible; and not doing so means a mother is knowingly and willingly disregarding her baby’s well being, The radio commercials both attempt to be creative through comic music spoofs, but both consist of the leading man telling the female back-up singers that if they don’t breastfeed they are bad mothers. The print ads list diseases that a baby who is not breastfed for six months is at higher risk for. Not one of these ads in any of the three medias portrays a mother breastfeeding. The radio commercial is not a woman talking about the joy of breastfeeding and how happy she is to do it. Not one of the two forms of visual media shows an image of a mother breastfeeding: in fact, none of them show babies at all. An effective frame should go for the heart, not discuss rational decision-making.

An appropriate frame should portray a mother breastfeeding as a beautiful, harmonious image. These images should be both displayed on billboards around town in print ads and shown in the video commercials. This would create a unifying feeling throughout the campaign and improve the public’s image and comfort with breastfeeding. When people see a mother breastfeeding in a café they will not associate the exposed breast with a lewd act, but with the warm feeling they experienced when they saw the breastfeeding campaign ad. Likewise, a woman who is breastfeeding will not feel awkward and apologetic, she will feel beautiful and the center of the world, like the women in the breastfeeding ads. Especially in a nationwide intervention targeting a diverse population on many levels, the DHHS should think carefully about what the takeaway message of the campaign will be. According to ABC news, America’s very low breastfeeding rate (the lowest of any industrialized country) could be due to Americans’ discomfort with the image of a breastfeeding woman (15)

Conclusions
The DHHS breastfeeding intervention is thus inappropriate because it fails at a number of points. McGuire’s Communication Persuasion Matrix lists the five pieces necessary in changing behavior: source, audience, channel, message, and destination (16). When we apply this matrix to the DHHS Breastfeeding campaign we can quickly see that the campaign’s failures are comprehensive. The source of the message is an omnipresent voiceover in the videos, a critical man in the radio commercials, and an unclear government entity in the print ads. As for the audience, the ads are directed at mothers and future mothers: “You wouldn’t take risks before your baby is born, why start after?” This targeting of mothers places all the burden of breastfeeding on the mother. The intervention attempts to use guilt to persuade mothers to breastfeed in the current climate and social norms (which are not accepting of breastfeeding) instead of targeting society as a whole. In order to increase rates of breastfeeding the DHHS would need to properly determine what the barriers are to breastfeeding and address those barriers. The channel—video commercials, radio commercials, and print ads—is appropriate because they reach mass audiences. The message is flawed in more than one way. The tag line, “Babies were born to be breastfed” is offensive in its judgment—it implies that if a woman is unable to breastfeed her child she is failing to provide her baby with a basic and essential human right. The tag line is also inefficient due to incorrect focus on initialization of breastfeeding. The second part of the DHHS message, that your baby will be at high risk for obesity, asthma, diarrhea, SIDS, and infectious disease if not breastfed, simply ads more guilt and stress to mothers who are already anxious due to lack of protective legislature and social norms supporting a breastfeeding mother. Lastly, the problem with the destination—the intervention’s intended and desired result—is tied closely to the problem with the target audience. The intervention’s destination is for mothers to choose to breastfeed. However, in a country with social and legislative barriers, like those present in the United States, this destination is not appropriate.

The need for an intervention to promote breastfeeding for six months nationwide is apparent due to the low rates of breastfeeding and the benefits of breastfeeding to baby, mother, and society. However, the Department of Health and Human Services’ breastfeeding campaign is not the needed intervention. The study achieved an increase in the public’s perception of the susceptibility of babies who are not breastfed to disease and the severity of that disease. However, after one year of the intervention, fewer women felt “very comfortable” breastfeeding their own baby in public, and fewer women felt “very comfortable” seeing another woman breastfeed her baby in public (17). Thus, more people see not breastfeeding as dangerous, and fewer people feel comfortable breastfeeding or seeing others breastfeed. This targeting and blaming of mothers for low nationwide breastfeeding rates has the potential to cause distrust by mothers—not only for the breastfeeding intervention, but also for public health interventions at large. These mothers who feel attacked by public health, the source of the campaigns, will be less likely to embrace future public health interventions. The intervention could be implemented in a manner that is effective by utilizing social science principles and perspectives, such as Social Expectations Theory, Framing Theory, and Stigma Theory. Had focus groups been held with mothers the DHHS could have learned about the social and legislative barriers to breastfeeding for a mother in the United States and appropriately set the audience, message, and destination to battle the barriers to breastfeeding instead of battling the mothers.


REFERENCE
1. Parker, L. 2001. Breast-feeding and cancer prevention. European Journal of Cancer. 37:155-158.
2. Lightfoot, T.J. 2005. Aetiology of Childhood Leukemia. Bioelectromagnetics Supplement. 7:5-11.
3. Lightfoot, T.J. and Roman, E. 2004. Causes of childhood leukemia and lymphoma. Toxicology and Applied Pharmacology. 199:104-117.
4. U.S. Department of Health & Human Services. (2005). National Breastfeeding Awareness Campaign—Babies were Born to be Breastfed: http://www.4women.gov/Breastfeeding/index.cfm?page=Campaign
5. Ryan, A.S. 1997. The Resurgence of Breastfeeding in the United States. Pediatrics. 99:12-19
6. Dewey, K. G., Cohen, R.J., Brown, K. H., Rivera, L.L. Journal of Nutrition 131: 262–267, 2001. http://jn.nutrition.org/
7. Flore, Marrecca. (2007). CDC: Almost 75 Percent of New Mothers Breastfeeding. Retrieved from Fox News: http://www.foxnews.com/printer_friendly_story/0,3566,291878,00.html
8. Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S., Phelan, J.C.. Stigma as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People With Mental Illnesses. Psychiatr Serv 52:1621-1626, December 2001
9. National Conference of State Legislators (updated 2008). 50 States Breast Feeding Laws: http://www.ncsl.org/programs/health/breast50.htm
10. La Leche League International. (2003). LLLI Center for Breastfeeding Information: US Breastfeeding Legislation, Sept. 15, 2003.
http://www.llli.org/llleaderweb/LV/LVJunJul05p51.html
11. Fox 28 (2008). Woman Discriminated for Breastfeeding. Retrieved from Fox News: http://www.fox28.com/News/index.php?ID=35278
12. Barsch, Sky. (2008) Panel finds breast-feeding discrimination. Retrieved from Burlington Free Press: http://www.burlingtonfreepress.com/apps/pbcs.dll/article?AID=/20080328/NEWS02/803280308/1007
13. ABC 7 News. (2008). Breastfeeding Mother Sentenced to Jail for Postponing Jury Duty. Retrieved from ABC News: http://www.wjla.com/news/stories/0308/506006.html
14. NBC5i. (2008). Breastfeeding Mom Claims Salon Kicked her out. Retrieved from NBC5i: http://www.nbc5i.com/news/15555280/detail.html
15. Vargas, E., Hoffman, L., and Varney, A. (2006). Is the Breast Better?: Ad Campaign Rattles Mothers on Breast-Feeding Controversy. Retrieved from ABC News: http://abcnews.go.com/2020/story?id=2188066
16. McGuire, W.J., Input and Output Variables Currently Promising for Constructing Persuasive Communications. In Rice, R. & Atkin, C. (Ed.)
17. Haynes, Suzanne. “National Breastfeeding Awareness Campaign Results-Babies were Born to be Breastfed: http://www.4women.gov/Breastfeeding/campaign_results.pdf

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

Introduction
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.

Conclusion
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.

REFERENCES
1. CDC National Center for Health Statistics. Health E-Stat. NHANES data on the Prevalence of Overweight Among Children and Adolescents: United States, 2003–2004. 28 Mar. 2008. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm.
2.Finkelstein EA, Zuckerman L. The Fattening of America. New Jersey: John Wiley & Sons, Inc., 2008.
3. CDC. Overweight and Obesity. 28 Mar. 2008. http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm.
4. US Department of Health and Human Services, The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity (Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001).
5. Ammerman AS, Cavallo D, Leung MM, Gustafson A. Farm, Food, Health: How Public Policy Affects Childhood Nutrition. Harvard Health Policy Review 2006; 7(2):152-165.
6. Winterfeld A. Overfed But Undernourished: Not will power, but purchasing power, may determine who eats healthy foods. State Legislatures 2005; April:34-36.
7. Smallstep Adult and Teen. 28 Mar. 2008. http://www.smallstep.gov.
8. Smallstep Kids. 28 Mar. 2008. http://smallstep.gov/kids/flash/index.html.
9. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
10. SB721 class notes, 14February2008
11. Institute of Medicine of the National Academies. Preventing Childhood Obesity. Washington, DC: National Academies of Science, 2005.
12. Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the Built Environment Underlies Key Health Disparities in Physical Activity and Obesity. Pediatrics 2006; 117:417-24.
13. Stanrock JW. Children, 5th edition, Boston, MA: McGraw Hill, 1997.
14. Birch LL, Fisher JO. Development of Eating Behaviors Among Children and Adolescents. Pediatrics 1998; 101:539-49.
15. Burke V, Beilin LJ, Dunbar D. Family lifestyle and parental body mass index as predictors of body mass index in Australian children: a longitudinal study. International Journal of Obesity 2001; 25:147-157.
16. Clark HR, Goyder E, Bissell P, Blank L, Peters J. How do parents’ child-feeding behaviours influence child weight? Implications for childhood obesity policy. Journal of Public Health 2007; 29(2):132-141.
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18. U.S. Census Bureau. Current Population Survey (CPS). Annual Social and Economic (ASEC) Supplement. Income Distribution Measures, by Definitions of Income: 2006. (INC RD-AEI 1).
19. U.S. Census Bureau. Race and Ethnicity: 2006. 3 April 2008. http://factfinder.census.gov/servlet/ACSSAFFPeople?_submenuId=people_10&_sse=on
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21. Maty SC, Everson-Rose SA, Haan MN, Raghunathan TE, Kaplan GA. Education, income, occupation, and the 34-year incidence (1965-99) of Type 2 diabetes in the Alameda Country Study. International Journal of Epidemiology 2005; 34:1274-1281.
22. Albert MA, Glynn RJ, Buring J, Ridker PM. Impact of Traditional and Novel Risk Factors on the Relationship Between Socioeconomic Status and Incident Cardiovascular Events. Journal of the American Heart Association 2006; 114:2619-2626.
23. Schlosser E. Fast Food Nation. New York: Houghton Mifflin Company, 2001.
24. Pollan M. The Omnivore’s Dilemma. New York: Penguin Group, 2006.
25. Powell LM, Auld MC, Chaloupka FJ, et al. Associations between access to food stores and adolescent body mass index. Am J Prev Med 2007; 33:S301-7.
26. Galvez MP, Morland K, Raines C, et al. Race and food store availability in an inner-city neighbourhood. Public Health Nutr 2007; 1-8.
27. Harrison MS, Coyne T, Lee AJ. Leonard D, Lowson S, Groos A, Ashton BA. The increasing cost of the basic foods required to promote health in Queensland. MJA; 186(1):9-14.
38. World Health Organization. Global Strategy On Diet, Physical Activity And Health. 28 Mar. 2008. http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf
29. French SA. Pricing Effects on Food Choices. The Journal of Nutrition 2003; 133:841S-843S.
30. Kaiser Family Foundation: The Role of Media in Childhood Obesity. February 2004.
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35. ATTRA National Sustainable Agriculture Information Service. An Overview of Organic Crop Production. 28 Mar.

A New Discrimination For A New Millenium? – Elizabeth Gifford

Adult obesity is a major public health concern in the United States today. Since 1980, the obesity prevalence has more than doubled. In 2005-2006, more than 34% of people over the age of 20 were obese (1). There have been many interventions to try to address the behavior that leads to this condition, from individual to societal efforts, but they have not yielded much success. One such effort at changing behavior was a proposed law in Mississippi that would ban obese people from eating in restaurants. The proposed state law, presented by Representative W.T. Mayhall, would give the Mississippi Department of Public Health the authority to prescribe the criteria for determining whether or not a person is obese and provide this information to food establishments (2).

The law may have been proposed with the best of intentions, especially when, in 2005 Mississippi had the highest prevalence of obesity in the United States: 30.3% of Mississippians were obese (3), unfortunately, it does little in the way of helping the problem.

It is understandable that someone would have an impulse to enact a law like this. There are numerous research studies linking obesity to many different health risks such as cardiovascular disease and diabetes. Another problem linked to obesity is the associated costs; obesity related sicknesses cost the country an estimated $117 billion in 2000 (1) To address this epidemic at the societal level such a policy level change can be effective when it takes into account the target populations needs and services available to them. However, it is clear that this law is limited in the scope and the level of resources to actually work in making change. This intervention by power of coercion simply focuses on shaming the individual into a diet, by force, and therefore ignores the real reasons obesity is such a problem in Mississippi. This intervention does not take into account the social culture of Mississippi, nor does it give those that are banned the skills and tools to replace the eating habits that contribute to their obesity. Perhaps using the theory of reasoned action as a basis for the intervention, rather than power of coercion, would create a more comprehensive approach to intervening in the State’s obesity epidemic.

Law Ignores Southern Culture
After World War II, the amount of black middle-class people rose dramatically in the south and with that came a time of cultural development (4). Most importantly, cultural development was based around food and the traditions people grew up with from their ancestors. Those ancestors included Africans who came over during the slave trade, those emancipated and also those that lived through the civil rights movements. Soul food is a term that came out of the civil rights movement and the desire to create an independent identity for black American’s (4). Black Americans would frequently gather and cook the traditional foods such as fried chicken and cornbread while catching up on the day to day family matters. This is an important aspect to southern culture and a tradition that has been handed down from generation to generation. A law that bans people from eating in restaurants completely misses the target population in this instance. In Mississippi, 72% of African Americans are overweight compared with 62% of white Americans.(5) One answer to this trend in obesity is the deep rooted culture in food and social gatherings among this group. They aren’t necessarily going out to restaurants to eat, but gathering together, cooking large meals with relatively unhealthy food while eating throughout the day.

The law does nothing to educate people about how to practice healthful dietary and lifestyle choices that they could fit into their culture. Teaching people about portion control or how to replace the unhealthy traditional food with healthier options would be more beneficial to this group. Also, teaching people about exercise and its effects on weight loss would help. Because group dynamic is so important to the Mississippi culture, an intervention that stresses exercise at the group level might have an impact on obesity. Those implementing an intervention could recruit families to go on walks together, which may be beneficial on a societal level when other families begin to see the healthy changes in their lifestyles. This part of the intervention would show families that a walk together can achieve the same level of cohesiveness as chatting over platefuls of food. Simply banning people from eating in a restaurant does not mean they will go on a diet. Giving people the skills and knowledge on how to lose weight will have more of an impact on their weight loss. The U.S. Preventive Services Task Force found that counseling and person-to-person meetings that were aimed at educating people on weight loss were highly effective (6).

Food is the root of Southern culture. Food is a means to get together with family, have guests over, or show concern for those that may be going through difficulties. While social gatherings often involve food in most cultures, the importance of food in Southern culture seems more prominent (7). A proposed law to intervene on the obesity epidemic in this state would benefit from taking this into account.

Law Ignores Individual Barriers
The underlying objective of this proposed law is to reduce obesity by losing weight with increased exercise and healthier eating. Unfortunately, there are many barriers to exercising and eating more nutritional foods. Such barriers may be on a societal or an individual level. While many people may want to lose weight by exercising or eating better, they often face barriers that are difficult to overcome. The proposed law does not take into account the barriers people face on a daily basis when it comes to losing weight.

Income
Limited income may contribute to increased weight gain. While Mississippi was the leading state for obesity, it had the lowest median income in 2006, with the average household making $34,343; $14,000 less than the average household in the United States (8). The Commissioner of Massachusetts recently stated that currently, low SES families are at greater risk for increased weight gain, which is a new phenomenon within the last decade. From the statistics on obesity and income in Mississippi, it is clear the trend is not limited to Massachusetts.

Families in lower social economic status may have limited or no health insurance. Unfortunately, having limited health insurance means less access to the tools to help lose weight, such as subsidized weight loss programs, that many often find through their health insurance or jobs. 18% of Mississippians were not covered by health insurance during 2004-2006, which is higher than the average uninsured rate of the United States (9). An overweight parent who is not insured and living at the poverty level must sacrifice healthful options for the food they can afford. Those types of foods are usually canned goods, high in preservatives or other less healthy options.

Being in a lower social economic status does not translate into eating out in restaurants often. People with limited income may be more concerned with putting food on the table at home than eating out in a restaurant. The proposed bill does not take into account those with limited income. Nor does it take into account recent research correlating obesity with lower income. An intervention focusing on those living in lower social economic communities would be more beneficial.

Comorbidities
Other barriers an individual might face are medical conditions. One such medical condition is arthritis; in fact, being overweight is a risk factor for arthritis (10). Obese people are more likely to have joint pain. Once these types of problems occur, people may not want to embark on an exercise program because it physically hurts them. Asthma is also a condition known to be worse in obese individuals. Obese people were more likely to be at higher risk for daily symptoms of asthma compared to less overweight people (11). Medical conditions like these are difficult to live with, let alone start a weight loss program. While many physicians hope that it is conditions like these that will push people to lose weight for the sheer fact that doing so can lower the risk of them (12), for the obese individual, it’s easier said than done.

Self Efficacy
One more barrier to losing weight for an individual is the idea of self efficacy. Self efficacy is defined as a” person’s belief in his or her ability to take the action (13).” In other words, this is the idea that someone thinks they can move forward with action because they have the skills and the knowledge to carry out the action. Simply eating less and some minimal exercising does not necessarily mean losing weight. It’s likely that people embarking on a weight loss program may try this route at first and find that it is difficult to stick with, most likely due to the barriers described above or for other environmental barriers that will be discussed later. They may not know that eating correctly, instead of eating less, is more important to losing weight. In order for people to lose weight, they need to feel like they can by being equipped with the appropriate tools and knowledge.

One study found that individuals with increased self efficacy were more apt to lose weight (14). This study found that using the correct intervention, and targeting self efficacy and barriers, women were more likely to meet physical activity recommendations and lose weight. The proposed law does not take into account the barriers, nor does it replace the barriers with skills that the individual needs in order to overcome them.

Law Ignores Environmental Barriers
It is doubtful that Boston Sports Clubs and Whole Foods Markets will be found in rural Mississippi. Research studies tell us that environmental resources are important factors to take into account when trying to change behavior. Without resources that are both available and affordable, overweight people will find it difficult to begin a weight loss program while living in lower income areas.

While Mississippi is the 5th most rural state in the United States (8) the metro areas grew at twice the pace of rural areas in Mississippi in 2000 (15). That growth includes people leaving the rural areas for the metro cities, as well as people moving in from out of state. Growth like this also means job growth in cities, but job loss in rural areas due to a diminishing population. Because there are less job available, there will be a higher poverty level, which the statistics show. 19% of Mississippians were living below the poverty level, while the average percentage for the United States was 12% (16). Rural Mississippi is also known for jobs in farming and textiles, not nutritionists and Personal Trainers that are mostly found in higher populated areas such as the big cities. This means that finding such gyms and programs to help with weight loss will not be in abundance in rural towns, but in the bigger cities of Mississippi. Because of these limited resources and lack of access to services, such as gyms, it is vital that when planning an intervention for obesity, it uses state and national programs to target the rural areas. Simply using organizations at a local level, that in some cases, may not exist due to the rural conditions, will not be enough to make a dent in the obesity problem. If such organizations do exist on a local level, state funded programs should equip them with tools, education and services that will target the populations most in need of help.

What Would Help?
The proposed law would have benefited from taking into account the social norms and barriers, and come up with an appropriate intervention that would have targeted population most in need, while giving them the skills to aid in weight loss. Studies exist proving that people want to lose weight and will work at it under the right conditions. Researchers have concluded interventions should focus on addressing behavioral strategies, barriers and self efficacy to increase physical activity and improve weight loss (14).

The Theory of Reasoned Action takes into account all that the proposed law misses. The theory is based on the idea that behavioral intention comes from a person’s attitude towards the behavior and their perception of social norms associated with that behavior. The most important aspect in this theory is the social norms. Southern culture revolves around food and if the norm is to eat and drink in social situations and that an individual may feel shunned by the group if they do not participate, that individual will likely not follow through on the intended behavior.

Targeting overweight people is not without risk. According to the U.S. Preventive Services Task Force, one risk is the societal stigma attached to being labeled as obese (6). Some people may have feelings of self doubt and depression with this label. Embarrassing those that are turned away from restaurants can be harmful to one’s mental health. When using an appropriate intervention, the task force says that the benefits of targeting that group far outweigh the risks of being overweight (6). By including education, counseling and meetings, this could help overcome the stigma and help those who would benefit from weight loss the most.

Conclusion
Representative Mayhall may have had good intentions in mind when proposing this law by trying to bring the problem of obesity to light, but it is not the most effective intervention. It does not take into account the southern culture and most importantly, it does not give people the tools and skills to help them lose weight.

While using the Theory of Reasoned Action would have been more beneficial, it is not to say that a power of coercion approach could not have worked under different circumstances. A state law could have taken into account the state funds that are designated for weight loss programs. Policy makers who distribute funds at a local and state level could have been educated about the rural Mississippians who have a higher rate of obesity and lack the resources to aid in weight loss. Armed with this knowledge, they could build up the food and nutrition assistance programs that are so vital to this population and often their only source of education about nutrition. Under a proposed law, state funds could be allocated for case workers or advocates to hit local areas and provide support and education which, in turn, could lead to support groups and an overall sense of healthy living among the local population. State funds through a proposed law could also be allocated to build parks or paths for walking or running. Using a law to build an obesity intervention can work when taking into account the social norms and barriers of the target population but proposing a law that bans people from eating in restaurants misses a host of factors and does not contribute to weight loss at all. It is unlikely that obese people are in such a condition because of the food they eat in restaurants alone.

Tailoring an intervention to account for all of the factors discussed would be most beneficial. Of course, there may still be barriers, but continuing to tailor an intervention based on those findings will prove to be the most helpful in the long run. Discriminating against obese people by banning them from restaurants is not helpful; it’s shameful, especially given the history of the South.

REFERENCES
1. Centers for Disease Control: Chronic Disease Prevention. Physical Activity and Good Nutrition: Essential Elements to Prevent Chronic Diseases and Obesity. 2006.

2. House Bill 282. Representatives Mayhall, Read, Shows. Regular Sesion; January 25, 2008.
3. Center for Disease Control and Prevention. Morbidity and Mortality weekly Report. September 15, 2006; Vol 55: pp.985-988.
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