Limitations of Restaurant Nutrition Labeling in Promoting Healthier Choices and a Proposal for Increasing Its Effectiveness – Stacey Kokaram

An increasing number of cities and towns across the US are requiring restaurants to provide nutrition information for their menu items (1, 2). Currently, the Nutrition Labeling and Education Act (NLEA) gives the Food and Drug Administration (FDA) the authority to require and regulate nutrition labeling for most food products regulated by the Agency (3). Over the past years, several pieces of legislation have been introduced in Congress to expand the FDA’s authority to also require nutrition labeling in restaurants (4). A recent observational study published in the American Journal of Public Health, showed that only 0.1% of patrons entering four popular fast-food restaurants referenced in-store available nutritional information (5). The study did not analyze whether the information had an effect on the food choices of these consumers. Nutrition labeling in restaurants would provide information for consumers to make healthier food choices but is only a small component of what is necessary to promote and support healthier eating among consumers.
This paper explores three key limitations that prohibit restaurant nutrition labeling from leading to healthy eating behavior. These limitations include: 1) the amount and accuracy of information posted; 2) the belief that intent to eat healthier will lead to healthy eating behavior; and 3) the lack of access to healthier food alternatives.

Nutrition Labeling Requirements & Accuracy
Many of the current restaurant nutrition labeling regulations require restaurants to post minimal nutritional information. The labeling requirements in King County, Washington require chain restaurants with 15 or more establishments to include total number of calories, grams of saturated fat, grams of carbohydrate, and milligrams of sodium for all standard menu items (2). This amount of information is not adequate in order to promote healthy dietary habits. Additionally, variability in nutritional content of foods requires that additional steps occur in order to make the available information useful to consumers.
The American Dietetic Association (ADA) convened the Task Force on Restaurant and Nutrition Labeling Research to analyze the effects of restaurant nutrition labeling using scientific principles tested through research and to identify gaps in the available research (6). The task force, comprised primarily of public health officials and registered dieticians, raised a key concern about the unintended consequences potentially caused by nutrition labeling. The concern is that by posting minimum caloric information, consumers will make choices based solely on calories and not on other nutritional values. Overall nutrition is particularly important for children and adolescents whose bodies need nutrients and who tend to eat at fast-food restaurants most frequently.
Another concern raised by the ADA’s task force is the accuracy of nutritional analysis programs. The task force reports that nutritional information can vary significantly in packaged foods, which are produced in tightly controlled environments, therefore the probability is high that even greater amounts of variability will occur in restaurant nutrition labeling. Steps should be taken to reduce this variability and this variability information should accompany any labeling initiatives to ensure that the information provided to consumers is accurate. Providing inaccurate information to consumers would counter the intentions of the restaurant nutrition labeling initiative.

Healthy Eating Intent vs. Behavior
Restaurant nutrition labeling initiatives follow the principles of the health belief model (7,8). The principle most affected by these initiatives is the consumer’s perception of the severity of eating unhealthy foods. These initiatives assume that most people know that high calorie foods are bad for them and will avoid eating foods they know are high in calories. Like the health belief model, restaurant nutrition labeling erroneously assumes that because a person intends to eat healthy foods, they will actually eat healthy foods.
The United States Department of Agriculture’s (USDA) Economic Research Service (ERS) conducted a study in which the researchers analyzed consumer food choices based on the consumer’s long-term health objectives and immediate visceral influences, such as hunger and stress (9). The analysis used behavioral economics to develop models to predict the effects of time pressures and hunger and compared these models to results from the 1994-96 Continuing Survey of Food Intake by Individuals and the Diet Health and Knowledge Survey. The results found that those under stress and those who had gone longer without eating were more likely to eat more calories per meal than those who were not under these influences when faced with immediate food choices. These results remained true even for those who had long-term health goals.
Another key limitation of using the health belief model for this initiative is the assumption that people will make rational food choices. Even if a person is presented with accurate nutritional information, knows the severity of eating unhealthy foods and is not under stress, there are still other factors that could lead the person to choose unhealthy foods over healthier options. A study challenging the notion that intention leads to behavior was published in the Journal of Marketing in 2003 (10). This study found that health claims and nutrition information generally had an effect on consumer’s attitudes towards food items but for many, this evaluation did not actually influence the consumer’s actual consumption behavior.
Consumer’s attitudes towards taste of healthy foods can play a significant factor in their decision to choose either the healthy item or the unhealthy item. A study conducted by Horgen and Brownell (11), suggests that consumers may associate the term healthier foods with bad taste. The study looked at the effects of price decreases, health messages and the combination of the two methods on consumer choice of targeted food items. Although the combination of price decreases and health messages produced an increase in sales of the healthy items, the results suggested that the perception of the taste of healthier foods attenuates the effect of price decreases alone in these healthier food choices.

Access to Healthier Alternatives
In a 2006 study of fast-food restaurant patrons, 87.2% indicated that price was an important factor in their food choice while only 57.9% indicated that nutrition was an important factor (12). While cost is a factor in food choices for most people, for some cost is THE deciding factor. Restaurant nutrition labeling may provide consumers with the information to make healthier food choices but the labeling initiative does not go far enough to ensure that those who want to make healthier choices have the resources to follow through with their intention. Even if these individuals know the nutritional information related to the food they’re purchasing, there may not be a cost-effective alternative available for them to purchase. Several studies have been conducted which show that diet-related health outcomes are worse in areas with less access to supermarkets and more access to convenience stores and fast-food restaurants than in areas with large supermarkets (13,14) The populations that live in the areas with less access to large supermarkets in general have a lower socioeconomic status than those who live in areas with accessible grocery stores (15).
An earlier study mentioned in this paper, showed that price decreases on food items had a more significant impact on the purchase of these items than did the inclusion of health messages promoting the items (11). If prices for healthier food options were decreased, this suggests that the likelihood of consumers purchasing these items would increase.
Finally, healthy food options available at restaurants need to increase in order to assure that people have choices in what they can eat. Glanz, et al (16) evaluated the major factors that influence restaurant chains to plan their menus. They found that growing sales and increasing profits were not surprisingly the most important consideration, with health and nutrition much less influential. Several respondents to the survey noted that healthier food options have been offered in order to prevent loss of business from certain health advocacy groups. The study suggested that consumer demand is likely the major factor that will influence major chains to include and keep healthier food options on their menus. Additionally, the researchers suggest that public health and government agencies should work towards increasing chain restaurant perceptions of consumer interest and also incentives for restaurants to offer healthier food options. The availability of healthier food options will help reduce a potential barrier consumer’s face while trying to adopt healthier eating habits.

Conclusion
Restaurant nutrition labeling initiatives have the potential to provide valuable information to some consumers who wish to improve their dietary health. These initiatives facilitate healthy eating among those who already perform healthy eating behaviors but do little to promote healthy eating behaviors among those who do not regularly make healthy food choices. Strategies to expand the benefits of restaurant nutrition labeling to wider audiences must include other components that affect food choice behavior and reduce barriers to healthier food choices.

Counter-Proposal for Intervention
The three limitations of the restaurant nutrition labeling program presented above can be remedied. The remainder of this paper will present a modification to the program which will address these three main limitations. The redesigned restaurant nutrition labeling program should be comprehensive and include multiple public health campaign components rather than simply providing information to the public. A committee at the Institute of Medicine “strongly suggests that interventions need to use multiple approaches (e.g. education, social support, laws, incentives, behavior change programs) and address multiple levels of influence simultaneously (i.e., individuals, families, communities, nations)”(17). The proposed campaign has three key components that improve upon the previous intervention. The first component is for restaurants to provide more complete and accurate nutrition information to the public using a system that allows consumers to easily identify healthier menu items. Secondly, the campaign would use social sciences theories to promote the use of the system to consumers so hey could make healthier food choices. Finally, the campaign would focus on making restaurants that used these labeling systems easier to access for those who would like to make healthy food choices.

Complete and Accurate Information System
The information that restaurants are required to post should take into account nutrients rather than just calorie count and fat content as some restaurants have done (1,2). By providing only calorie count and fat content, people may not be making the healthiest food choices. According to the ADA, posting of calorie and fat information without additional nutrient information could take the focus away from healthy eating and put the focus on calorie counting alone (6).
Comprehensive posting of nutritional information, however, may become burdensome for both the restaurant and the consumer if there are lots of items on a restaurant’s menu. An alternative strategy for condensing prominent displays of nutritional information while still providing complete nutritional information for patrons could be done using two components. The first should be a pamphlet with complete information on all products the restaurant serves. This gives the customer the option of seeking out specific amounts of various nutrients in foods if, for example, they are diabetic and need to watch their sugar intake or if they have high blood pressure and need to limit their sodium intake. The majority of consumers would use the second component which would be a nutritional posting similar to the “DDSMARTTM” menu used by Dunkin’ Donuts (18). This type of menu creates a visual way for consumers to more easily identify foods that are the healthiest on the restaurant’s menu. This menu would allow consumers to see which items are healthiest in the restaurant and would allow them to make smarter food choices without having to analyze the nutrition content of every item served by the restaurant. According to a study by Malhotra (19), consumers have finite ability to absorb and process information given a short amount of time. If given too much information in a short time, consumers can actually make poorer decisions than they would if they didn’t have as much information. This theory supports concise but accurate restaurant labeling which could serve as a compromise to promote healthier food choice and prevent restaurants from being overburdened by extensive menu labeling. Nutritional standards would have to be developed by agency enforcing the restaurant labeling regulation in order for foods to make it on to the “healthy options menu.”

Promoting the Labeling System
Once an acceptable system is established to identify the healthiest items on restaurant menus, the system needs to be marketed to consumers. If a consumer can easily identify a brand to mean healthier food, without having to process lots of information at the point of purchase, then they would be more likely to make a healthier food choice than if they had to process lists of nutritional information (19). Branding theory is based on analyzing a target audience to create a brand that has attributes with which the audience can identify (20). Once this identity and sense of shared attitude is established, consumers will recognize the brand and may become loyal to it (21). The association by consumers of healthier foods with bad taste suggested by the Horgen and Brownell (11) study could be combated by this branding campaign. This type of branding and brand loyalty would make it easier for consumers to choose items from the menu with which they were familiar. The branding would have to include a visually appealing and easily recognizable menu design that consumers could identify once in the restaurant. The simple act of being able to identify healthy choices without sorting through nutritional information will increase the likelihood that people who intend to eat healthy will eat healthy. The simplification of the choice reduces an irrational barrier that prevents people from following up their intent to eat healthy with the actual behavior (19).

Increase Availability of Restaurants With Labeling System
Finally, once the labeling system is in place in the restaurants and is made easily recognizable for consumers through the promotion process, policy makers should ensure that consumers have access to get to these restaurants. The labeling policies in both New York City (1) and King County (2) both had limitations on which type of restaurants had to comply with the labeling law. If an area does not have a high quantity of restaurants that must comply with the regulation, then the labeling system would be virtually useless to the consumers who lived in that area. Policy makers should ensure that the majority of restaurants must comply with the regulation or that the restaurants that do have healthier menus are more accessible within neighborhoods.

Conclusion
Although current restaurant nutrition labeling programs in various cities have good intentions, the programs do not go far enough to ensure that the labeling program itself is effective. By assuming that providing more information will lead consumers to make healthy behavior changes, policy-makers are erroneously designing interventions based on the Health Belief Model (7,8). While having more information may change consumer intentions, their behavior at the point of purchase in these restaurants is what should be addressed in order to truly promote healthier food choices.


References
1. Board of Health Vote to Require Chain Restaurants to Display Calorie Information in New York City. New York City Department of Health and Mental Hygiene Web site. Available at http://www.nyc.gov/html/doh/html/pr2008/pr008-08.shtml. Accessed on April 5, 2009.
2. Trans fat and nutrition labeling in King County. King County Public Health Web site.
Available at http://www.metrokc.gov/health/healthyeating/. Accessed on April 5, 2009.
3. Nutrition Labeling and Education Act. http://www.fda.gov/ora/inspect_ref/igs/nleatxt.html#GUIDE%20FOR%20REVIEW %20OF%20NUTRITION
4. HR. 1334
5. Roberto C, Agnew H, Brownell KD. An Observational Study of Consumer’s Accessing of Nutrition Information in Chain Restaurants. Am J Public Health, 2009;99:xxx-xxx.
6. American Dietetic Association. Task Force Report on Restaurant Nutrition Labeling Research. http://www.eatright.org/ada/files/RLR_Task_Force_Report_FINAL.pdf.
7. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones & Bartlett Publishers, 2007.
8. Salazar MK. Comparison of Four Behavioral Theories: A Literature Review. AAOHN 39(3) 128-135: 1991.
9. United States Department of Agriculture. Is Dietary Knowledge Enough? Hunger, Stress and Other Roadblocks to Healthy Eating. ERR, 2008; 62.
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11. Horgen KB, Brownell KD. Comparison of Price Change and Health Message Interventions in Promoting Health Food Choices. Health Psych, 2002;21(5):505-512.
12. O'Dougherty M, Harnack L, French S, Story M, Oakes J, Jeffery R. Nutrition labeling and value size pricing at fast-food restaurants: A consumer perspective. A J Health Promot. 2006;20:247-250.
13. Morland KB, Evenson KR. Obesity Prevalence and the local food environment. Health & Place. 2008;15:491-495.
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15. Morland K, Wing S, Roux AD, Poole C. Neighborhood Characteristics Associated with the Location of Food Stores and Food Service Places. Am J Prev Med, 2002; 22(1):23-29.
16. Glanz K, Resnicow K, Seymour J, et al. How Major Restaurant Chains Plan Their Menus: The Role of Profit, Demand and Health. Am J Prev Med, 2007; 32 (5): 383-388.
17. Institute of Medicine. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington, D.C.: National Academies Press, 2000.
18. DDSMART Nutrition Advisory Board. https://www.dunkindonuts.com/aboutus/BreakfastChoices/Nutrition_board.aspx .
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20. Huhman M, Heitzler C, Wong F. The VERBTM Campaign Logic Model: A Tool for Planning and Evaluation. Preventing Chronic Disease: Public Health Research, Practice and Policy. 2004; 1(3): 1-6.
21. Evans WD, Wasserman J, Bertolotti E, Martino S. Branding behavior: the strategy behind the truth® campaign. Soc Marketing Q. 2002;8(3):17–29.

Why 5 A Day Fell Short And Alternative Solutions in the form of Community Supported Agriculture– Jacquelyn Murphy

Fruits and vegetables are an important part of everyone’s diet. They provide vitamins, fiber, and few calories, which are all things anyone, especially most Americans, could benefit from. With these things in mind, the National Cancer Institute and the Produce for Better Health Foundation teamed up to found a nutrition program, entitled 5 A Day for Better Health, in 1991 (4). The 5 A Day program very simply encourages people to eat five servings of fruits and vegetables every day as part of a low-fat, high-fiber diet, marking packages of acceptable fruits and vegetables with the small trademark symbol (2). On the Center for Disease Control and Prevention Website, there are recipe ideas to incorporate servings of fruits and vegetables into meals as well as tips on how to reach the five servings, such as having fruit or vegetables for in-between meal snacks. In 1991, when the program first began, and in 1997 after six years of spreading the “5 A Day” message and pouring millions of tax dollars into raising awareness on this critical nutrition issue, there was no significant difference in fruit and vegetable consumption after researchers adjusted for demographic shifts (4). The 5 A Day program is flawed in that it is based on the Health Belief Model and thus the assumption that people act rationally, it lacks consideration for environmental factors, and it advertised poorly. These flaws could account for part, or all, of the lack of response after millions of dollars were spent on increasing awareness of the 5 A Day for Better Health program.
Based on assumptions of Health Belief Model.
The 5 A Day program is based entirely on the idea that if people are educated about what actions they should take to optimize their health, in this case eat at least five servings of fruits and vegetables daily, then they will do it. Like many public health interventions based on the Health Belief Model, it is limited in various ways and assumes a few different things. Many individual level models assume that people act rationally and plan their behavior. The Health Belief Model is no different. In general, the Health Belief Model is based on increasing perceived susceptibility or perceived severity, or both, of the consequences of performing or not performing a certain action (3). From here, people determine the perceived benefits of adhering to guidelines set by the intervention, as well as barriers preventing them from following the guidelines of the intervention outlined by the Health Belief Model. Finally, they come to a conclusion and determine their intention, which they then carry out through their behavior, which is both planned and rational (3).
Specifically, the limitations and assumptions of the Health Belief Model come into play in a few different ways in the 5 A Day nutrition campaign. First, this campaign gives people information about what they should be doing, eating five servings of fruits and vegetables per day. From there, it assumes they will change their behavior to eating five or more servings of fruits and vegetables just because they know it is beneficial to their overall health. The campaign does not take into consideration that people oftentimes do not care about their health, or care about it enough to give up their unhealthy, but perhaps tastier, habits, such as eating a cookie instead of an apple. People value their health as much as they do not want to be sick or feel poorly, but many people do not think about their actions’ impact on their long term health. They usually invest their thought in other things, such as appearing attractive or being well-liked, rather than spending their time thinking about their slightly increased chances of certain types of cancer years down the road due to poor nutritional choices.
Secondly, and somewhat deviating from the limitations of the Health Belief Model, this campaign does little to raise people’s perceived susceptibility or severity of the consequences of not eating five servings of fruits and vegetables, which is a trademark of interventions based on the Health Belief Model. If the campaign was more strictly based on the Health Belief Model, it would incorporate more information about the negative repercussions of their lack of eating at least five servings of fruits and vegetables in order to scare people into action. However, this campaign tries to get people to eat five servings of produce without the aspect of increasing people’s perceived susceptibility or severity of potential negative consequences.
Thirdly, since it assumes that people’s behavior is rational, it obviously does not capitalize on the ways in which the behavior of most people is irrational. There are three main facets to irrational behavior, as discussed in this lecture January 29, 2009. The first is that people have expectations of how things should be, and their experiences impact their expectations. The second is that people enjoy owning things and have an aversion to losing the things they own. The third aspect of irrational behavior is that people generally do not have as much self-control as they think they do. Rather, they are mostly lazy procrastinators. The 5 A Day campaign mostly disregards the second of the three features of irrationality in that it did not take into account the strength of people’s habits. They own their unhealthy eating habits, and they will only relinquish these unhealthy habits and practice self control, another feature of irrational behavior not taken into account by the 5 A Day campaign, if they think they will be rewarded with a result that they deem to be worthy of their sacrifice and effort to change their behavior.
Lacks consideration for environmental factors.
Another reason that there was such an insignificant change in the amount of fruits and vegetables people ate before and after the implementation of the 5 A Day nutrition campaign is the lack of consideration for environmental factors. Barriers to consuming the recommended five servings of fruits and vegetables, according to a survey of single mothers included cost, lack of availability, time and effort required to prepare produce, a preference for other foods instead and habit (6). Some of these environmental factors were discussed in the experiments performed during the first seminar meetings on January 22, 2009. Groups went to grocery stores in Roxbury and the South End, two different neighborhoods near the Boston University Medical Campus. The groups that went to the South End, the wealthier of the two neighborhoods, found plenty of full-sized grocery stores, such as Trader Joe’s and Whole Foods, which contained many varieties of fruits and vegetables, usually including a lot of organic produce as well. On the contrary, groups that went in search of produce in Roxbury could only find small and overpriced convenience stores in their designated neighborhood, which usually contained a very small selection of fruits and vegetables which did not look appetizing, especially relative to the produce from the South End grocery stores. Therefore, the residents of Roxbury and other similar neighborhoods had to put in a larger time and effort to get the same quality of food which residents of the South End and other comparable neighborhoods can get quickly and easily.
Aside from availability of produce in their neighborhoods, students in the seminar groups also pointed out the safety of the two different neighborhoods. Roxbury has a much higher crime rate than the South End, adding an element of danger to getting groceries at night after people get out of work, which is when most people have time to do so. Since produce spoils faster than less nutritious, packaged snacks, such as cookies or crackers, it requires more frequent trips to the store. The lack of safety of a neighborhood makes keeping fresh produce available in the house even more difficult than it would be if the grocery store were closer or the trip there less risky.
Finally, amongst a variety of other environmental factors that should have been taken into account by the 5 A Day campaign, financial cost was not considered. As is easily observed in any grocery store, the fresh produce that the 5 A Day campaign strongly encourages is much more expensive than other foods that are perhaps less nutritious but would fill stomachs when parents’ main concern is making sure their children are all able to have dinner. The campaign did not enlist the government to subsidize the cost of produce in any way or perhaps try to organize farmers to sell their produce directly to the customer at farmer’s markets, which would be beneficial to both the farmer and the customer in terms of cost.
In short, the 5 A Day campaign was set up as if people made their decisions in a vacuum, but they do not. They have to think about availability of produce, their own safety when they are en route to buy food for the family and how they will bear the financial costs, among many other environmental factors which are likely too numerous to list here.
Poor advertising methods and media.
Lastly, the methods of advertising employed by the 5 A Day campaign were another shortcoming of the national nutrition intervention. They did not utilize basic principles of communications theory or the idea of agenda setting within the theory. Agenda setting within Communications Theory notes that the target audience, in this case people who are buying food for their families or deciding what to eat when faced with different options, must view the information as important enough to really hear the message and act on it (1). Being bombarded on a daily basis with countless messages about what is best for a healthy lifestyle, it is difficult to distinguish the useful information from the useless. If people do not care, they will not spend the extra money on fresh produce or decide to eat that instead of tastier, less nutritious foods. Creating a message the person in the situation can relate to is the primary focus of agenda setting because the goal is to dramatize the issue and get the audience to care about the issue enough to act, since they view it as important (1). Advertising created with this in mind, and using basic principles of agenda-setting theory, such as dramatizing an issue to make it important to people, would be most effective.
However, the main method of advertising used by the 5 A Day campaign was to put a logo on the sides of packaging which contained acceptable servings of fruits and vegetables and to distribute informative pamphlets in the offices of primary care physicians. Not only is this foolish since most people already know what counts as a fruit or vegetable, but this medium, which the 5 A Day campaign chose to use, does not reach the target audience. People who are purchasing products with this logo on them are already attempting to reach their five servings, or at least already have enough information to know that fruits and vegetables are worth their money. The target audience for this message should include the large portion of the population who drastically fall short of the five servings per day mark, which tends to be adults with less education, lower income and uncertainty about whether or not they will consistently have food in the near future (6). This part of the population is either not at the grocery store for reasons mentioned before, or they are not in that aisle, examining the produce closely enough to see the small 5 A Day logo encouraging them to buy that product. They are likely deciding which foods to buy based on the amount of money they have and possibly also what will keep their family feeling satisfied longest. A second reason that this medium is ineffective is that it in no way dramatizes the issue, which would increase the likelihood that people would care enough to pay attention and change their behavior, which showed by a self-reported survey that most people do not get five servings of fruits and vegetables daily (5). It simply provides guidance to the products condoned by 5 A Day, should the person already have established that habit. There was a small improvement with the information in the doctor’s offices, since they actually provided reasons why the reader should try to incorporate more produce instead of simply putting a logo on a package and expecting a drastic improvement. The pamphlets and the information about this program on the Center for Disease Control and Prevention website provide information from studies that found five servings to be where they saw lowered rates of many chronic illnesses such as cancer and obesity, which is where this campaign incorporates tenants of the Health Belief Model, as outlined above.
In conclusion, the 5 A Day campaign tried to change the nutrition of a nation by raising awareness, but awareness does not change behavior. The first flaw of the 5 A Day campaign is assuming that people plan their behavior, which is always rational, and do what they intend to do. As extensively studied, behavior is oftentimes irrational, a fact disregarded by the 5 A Day for Better Health Program. Secondly, the 5 A Day campaign assumes that behavior takes place in a vacuum, and it does not consider various environmental factors that impact people’s food choices, such as the high relative cost of fresh fruits and vegetables, the lack of access people in neighborhoods with a low average socioeconomic status have to grocery stores, and the safety of these neighborhoods for them to get to the grocery store in the first place. Lastly, a lack of consideration for how to deliver the message, by picking ineffective media to deliver the message through, and a lack of dramatizing the issue of incorporating enough produce into a healthy diet have both lead the general public to be largely uninformed or unengaged – as uninformed or unengaged in 1997 after the intervention as they were in 1991.

Since the vast majority of the population falls short of the goal of five servings of fruits and vegetables every day, other groups had to develop ways, separate from the government’s 5 A Day for Better Health program, that those most in need could have access to produce. Four factors have been found to increase fruit and vegetable consumption, including point-of-purchase (POP) information; reduced prices and coupons; increased availability, variety, and convenience; and promotion and advertising (11). Instead of asking the government to subsidize the cost of fresh produce they were encouraging the citizens to eat, in turn further increasing many of the deficits at the state and federal level, Community Supported Agriculture was developed. Little known to many people, Community Supported Agriculture is a grassroots movement that puts produce within reach of people of all socioeconomic backgrounds. Community Supported Agriculture is an intervention that addresses the 5 A Day campaign’s poor advertising, lack of consideration for environmental factors and assumption that people hold their health as one of their core values. In addition, Community Supported Agriculture offers both a wide variety of produce and lower costs, two factors shown to directly increase fruit and vegetable consumption.
First, an explanation of Community Supported Agriculture is necessary, because despite them being quite widespread, not everyone has heard of, or is knowledgeable about, such programs. These farms can come about in a number of ways. Farmers sign up their farms with organizations, or they simply designate their farm as Community Supported Agriculture land without the organization (8). Another way is for a city or town to own land and a group of committed individuals take responsibility for the land each season. Either way, they sell shares, also known as subscriptions or memberships, to people who do not own a farm, known as the consumers. In exchange for a flat rate that consumers pay to cover the costs of growing materials and supplies on a per season basis, they receive a box of fresh, locally grown produce, usually vegetables. They can pay more or less depending on the size box and variety of produce within the box. Additionally, most Community Supported Agriculture farmers will accept food stamps if that is how the family would normally pay for produce, were they to purchase the food in a grocery store. Families may also choose to trade labor for food if they do not have food stamps or the money to pay up front, which is a problem for many families (9). Especially if they have been unemployed or are consistently living beyond their means even as they subsist in unpleasant living conditions, the “labor for food” option offers membership to those who are struggling most. Finally, these memberships are not for sale to those strictly adjacent to the farm. On the contrary, the farmers usually have several drop off locations to reach a wider customer base (8).
More effective advertising.
Community Supported Agriculture does not advertise or communicate with the public as a typical public health campaign is expected to. They do not have commercials on television or the radio, but they use what has been the most effective method of advertising for years: word of mouth. Before the growing season begins, farmers typically try to sign people up for memberships in order to get their cash flow jumpstarted, as they usually have been without a reliable income during the winter. Satisfied consumers will likely spread the word about where they got their produce, and encouragement from a trusted friend or family member is usually most successful in convincing someone that buying something, in this case a membership, or spending their time doing something, such as helping on the farm in exchange for produce, is worthwhile. Additionally, people in the Community Supported Agriculture would be looking for people to share the costs, monetary or labor, which would lead to them recruiting people they trust to follow through on either or both accounts.
The whole premise of Community Supported Agriculture is to keep costs down to everyone, so a mainstream, widespread advertising campaign would, in itself, be contradictory to the message of the Community Supported Agriculture. Instead of spending their time trying to convince people that they should be eating more fresh vegetables, they provide it for those that want it and are willing to buy or work for it. Also, due to hearing about the Community Supported Agriculture through friends, it makes sense that skepticism would be reduced, which is oftentimes high when people are asked to change something about their lifestyle by the government.
Availability of nutritious foods has been shown to have a positive association with their consumption, therefore Community Supported Agriculture makes this food truly available to consumers, unlike the small corner stores typical in supermarket desserts which contain a very small, very expensive produce selection (7).
If Community Supported Agriculture were to improve or expand upon this method of advertising, they should put their information where the largest amount of their target audience will be reached. Needless to say, this is not on the label of a package of produce, as the 5 A Day campaign is currently advertising. The point of such a campaign is to get the potential consumer to walk over to that section of the store and pick up the produce in the first place. Perhaps in community health clinics, which are the main, or only, source of medical care for those without health insurance, informational brochures could explain what Community Supported Agriculture is and the benefits it offers as well as and provide a phone number to call or person to contact if they were interested in getting a membership to that particular farm. Also, in community centers, such as the Boys and Girls Club, a large percentage of the attendees there would benefit from knowing of a Community Supported Agriculture farm, so more information could be distributed at similar places.
Consideration for peoples’ varying environments.
Community Supported Agriculture not only takes environmental factors into consideration, on the contrary it was seemingly founded on the principle of providing produce for those who have difficulty accessing it. Given the way environments are currently, with supermarket desserts, as witnessed in Roxbury, Massachusetts in the seminar exercise, not only is fresh produce expensive once people get to the grocery store, but for residents of neighborhoods similar to Roxbury, it is a huge time investment to take a trip to the grocery store. The drop off locations that many Community Supported Agriculture farms have organized still require the consumers to pick up the produce as they would in a grocery store, but the drastically reduced cost alleviates one of the major stressors people encounter when buying fresh produce. Of course, there are limitations to this idea, especially if the potential consumer is not located near the farm itself or near to a drop off location and does not have a car to get there. However, on the whole, the two major environmental factors which the 5 A Day campaign ignored were the monetary access and geographic proximity to a store with a decent selection of fresh produce. Additionally, the logistical limitations will always be difficult to get around, and the farmers and consumers must work together to set up the most convenient place for as many people as they are able.
As previously mentioned, for people who cannot pay for the vegetables up front, they can work in exchange for a membership to the Community Supported Agriculture. This is another level of alleviating the financial burden and offering inclusiveness, since it provides a way for people who are unemployed and underemployed to also have a membership and access to healthy food. For many, being unemployed usually means an absence of all nutritious or extra food except the bare minimum, in quantity and quality, families can afford.
Not based on Health Belief Model assumptions.
Unlike the 5 A Day for Better Health campaign, community supported agriculture is not based on the major assumption that people behave rationally. This idea does not try to convince people, as 5 A Day does, to eat five servings of fruits and vegetables because it is good for them and then they will be healthier and possibly have reduced cancer risk years from now. It simply offers the option of eating healthier at a lower cost.
Additionally, much like the sticktoit.com website discussed in lecture, it does involve an initial monetary payment to the farm, which people do not get back if they do not pick up their food every week. When people put their money on the line, they are more likely to follow through on their actions, and certainly they would be more motivated to go get food they have already paid for.
However, there would most likely be some people who are not paying for the produce, but rather working in exchange for the box of fruits and vegetables. These individuals are driven to stick with eating the produce because they have invested time into the health and growth of the vegetables. Often, they have worked very hard every week and feel bonded to their produce or they know how much work went into producing the vegetables so they are less likely to waste them by letting them go bad or not retrieving them from the drop off stations.
Additionally, children and young people can, and should, perhaps, get involved in the Community Supported Agriculture. Studies have shown that in regards to young people, they are most likely to consume healthier foods when they choose the foods instead of being told what to eat by their parents or guardians (10). If the children had been in charge of watering the same tomato plant or corn stalk each time the family went to the farm, they would obviously have a sense of pride when the vegetable was ripe and ready to eat. This finding is not surprising, given that one of the main core values children and adolescents hold in high regard, indeed much higher regard than their own health, is their independence, separation and growth from their parents, as seen in the Truth anti-smoking campaign.
In conclusion, Community Supported Agriculture did not begin initially as a cheaper option, but it has grown into a major alternative for those of lower socioeconomic status as it provides produce at lower costs and often closer to their homes. Geography and monetary cost often prohibit their access to the government-recommended five servings of fruits and vegetables every day, but when the 5 A Day for Better Health campaign made that recommendation, they should have researched what actually gets people to eat more fruits and vegetables. Unlike that campaign, Community Supported Agriculture is based on assumptions shown to hold true about people’s behavior, that they do not care about their health but other things such as money and independence, addresses environmental factors such as making produce geographically and cost available, and advertising itself through word of mouth of previous satisfied consumers. In all these ways, Community Supported Agriculture is a better intervention than the 5 A Day for Better Health campaign.

REFERENCES
1. Edberg, M. (pp. 35-47) In: Edberg, M., ed. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
2. Heimendinger J, VanDuyn MA, Chapelsky D, Foerster S, Stables G. The National 5 A Day for Better Health Program: A Large-Scale Nutrition Intervention. Journal of Public Health Management and Practice 1996; 2 (2).
3. Rosenstock IM. Historical origins of the health belief model. Health Education Monographs 1974; 2:328-335.
4. Stables G, Subar A, Patterson B, Dodd K, Heimendinger J, VanDuyn MA, Nebeling L. Changes in vegetable and fruit consumption and awareness among US adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys. Journal of the American Dietetic Association 2002; 102 (6): 809-816.
5. Thompson B, Demark-Wahnefried W, Taylor G, McClelland J, Stables G, Havas S, Feng, Z, Topor M, Heimendinger J, Reynolds K, Cohen N. Baseline fruit and vegetable intake among adults in seven 5 A Day study centers located in diverse geographic areas. Journal of the American Dietetic Association 1999; 99 (10): 1241-1248.
6. Quan T, Salomon J, Nitzke S, Reicks M. Behaviors of low-income mothers related to fruit and vegetable consumption. Journal of the American Dietetic Association 2000; 100 (5): 567-569.
7. Williams DR. Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports 2001; 116:404-416.
8. United States Department of Agriculture. Defining Community Supported Agriculture. http://www.nal.usda.gov/afsic/pubs/Community Supported Agriculture/Community Supported Agriculturedef.shtml
9. National Sustainable Agriculture Information Service. Community Supported Agriculture. http://attra.ncat.org/attra-pub/csa.html
10. Consumer Health Interactive : The Edible Schoolyard. http://www.yourhealthconnection.com/Imagebank/audio_flash/edibleschoolyard.html
11. Glanz K. Yaroch A. Strategies for increasing fruit and vegetable intake in grocery stores and communities: policy, pricing, and environmental change. Preventive Medicine 2004; 39 (2): 75-80.

Exercise is Medicine: A Poor Prescription for Physical Activity Promotion – Maureen Harris

Regular physical activity is a critical component of a healthy lifestyle and has a strong role in health maintenance and promotion. Exercise has been shown to reduce the risk of chronic diseases such as cardiovascular disease, diabetes, and cancer; promote quality of life; aid in maintenance of a healthy weight; reduce symptoms of depression; and enhance functional health (1-2).
Despite the manifold benefits of being physically active and risks of being inactive, adherence to the recommended guidelines for activity is remarkably low. The American College of Sports Medicine (ACSM) and the American Heart Association (AHA) recommend 30 minutes of moderate-intensity daily physical activity five days per week (3), and the 2008 Physical Activity Guidelines for Americans released by the Department of Health and Human Services (DHHS) calls for a minimum total accumulation of 150 minutes of moderate physical activity per week (4). Nearly two-thirds of adults in the United States do not meet these recommendations, and a quarter do not exercise at all (5). This has clear and severe public health implications.
The “Exercise is Medicine” Initiative
To address this burning issue, hundreds of small- and large-scale interventions have been developed, yet the problem persists. Many of these programs are based on faulty or tenuous theories or, worse yet, are not based on any framework at all. The Exercise is Medicine (EiM) initiative (6), sponsored by the American College of Sports Medicine (ACSM) and the American Medical Association (AMA) seeks to improve rates of physical activity through encouraging a dialogue about exercise between patients and health care providers. Despite the best intentions, this program, like the others, is fatally weakened by multiple flaws.
The program’s goal is to make physical activity a standard “vital sign.” EiM calls upon health care providers to assess patients’ activity levels at every office visit and to counsel patients on how to become more active. Providers are encouraged to “prescribe” exercise for disease treatment and prevention just as they would prescribe a pharmaceutical as well as to refer patients to fitness professionals just as they would refer to a medical specialist. Additionally, EiM instructs patients to ask their doctors about exercise. The program’s website provides reference materials for providers to facilitate dialogue with patients, and it offers “tool kits” and educational videos for patients to help them initiate an exercise routine. The initiative aims to link exercise with medical treatment and equate exercise with more traditional and familiar modes of treatment, such as pills. It promotes the long term physical health benefits of exercise while presenting limited information on other, more immediate benefits of exercise.
EiM appears to be based on the Health Belief Model (HBM; 7-8), which presents four factors central to an individual’s health behavior motivation: perceived susceptibility (assessment of the likelihood of acquiring disease/condition), perceived severity (assessment of the physical and emotional hardship that may be experienced if the disease/condition is acquired), perceived barriers (assessment of obstacles to perform health behavior, such as cost, access, embarrassment), and perceived benefits (belief that a given action will be efficacious in preventing a negative outcome or minimizing its severity). Each of these factors is considered during decision making and, if the pros of the behavior exceed the cons, the individual will form an intention to engage in the behavior. Intention is assumed to result in behavior. EiM, following the logic of the HBM, emphasizes the risks (i.e., severity) of not exercising, assuming that if people know that they should exercise then they will exercise. Despite its good intentions, EiM’s design is fraught with lack of foresight and faulty logic that severely hinders its potential to improve adherence with national physical activity guidelines. Three fundamental issues with EiM will be discussed: the definition of exercise as a medical treatment, the choice of doctor-patient interactions as the mode of message delivery, and the failure to anticipate barriers.
Definition of Exercise as a Medical Treatment
Defining exercise as medicine is potentially damaging and counterproductive. While the definition is intended to convey the importance of exercise and stress its role in health maintenance, it is more likely to reduce intrinsic motivation to engage in physical activities. Intrinsic motivation is considered to be a desire to participate in an activity for the inherent satisfaction of the activity whereas extrinsic motivation is desire to participate in an activity for a reward distinct from the activity (9). Cognitive evaluation theory (CET; 10-11) proposes that intrinsic motivation relies on social-contextual factors such as perceived choice, autonomy, and enjoyment. Supporting this concept, self-efficacy and perceived satisfaction were shown to predict maintenance of physical activity (13). Presenting exercise as a treatment and as a "doctor's order" implies a lack of choice on the part of the patient. Moreover, by suggesting that exercise is something the patient must do, rather than something the patient wants to do, it undermines inherent enjoyment of, and desire to participate in, the activity (12). Deci and Ryan propose a hierarchy of motivation, including amotivation (no motivation), extrinsic motivation, and intrinsic motivation (11, 14). Extrinsic motivation is broken into four categories which are differentiated by the ratio of external to internal locus of causality. The most external category, external regulation, is associated with compliance and external rewards, whereas the most internal, integrated regulation, is associated with overlap between personal values and the activity. An individual has greater enjoyment of, and greater likelihood of maintaining, an activity when the locus of causality is most internal (9). Thus, intrinsic motivation, or deeply internalized extrinsic motivation, is critical for maintaining a physically active lifestyle. Through its disregard for the components necessary for intrinsic motivation, EiM substantially weakens its ability to promote physical activity. Worse yet, it may even have the unintended effect of decreasing physical activity by reducing inherent enjoyment of active hobbies (e.g., dancing, playing soccer) by suggesting that the reason for engaging in the activity is because it is necessary or "the right thing to do," rather than simply an enjoyable activity.
An additional issue with defining exercise as medicine is that adherence to medically prescribed regimes is often low (15-21), especially for difficult, complicated, or long term treatments. Poor adherence to medical regimes is even present when the consequences of non-adherence are severe, such as in the case of medication for coronary heart disease (21). Committing to an exercise routine requires significant effort and dedication, putting exercise adherence at great risk for low adherence. Although adherence is a difficult construct to assess, a review of the literature (22) found estimates of adherence between 4% and 93%, with most rates falling between 29% and 59%. A second review (23) found estimates of poor compliance in 30-50% of all patients, regardless of diagnosis or setting. These discouraging rates of adherence, especially considering the time consuming and long term nature of exercise that increase likelihood of low adherence, suggests that EiM's strategy of defining exercise as a medical treatment is misplaced. Lack of trust in physicians (24) or perceived discrimination (25) can cause patients to disregard their provider’s exercise “prescription,” further damaging the chance that patients will adhere to providers’ EiM recommendations.
Choice of Doctor-Patient Interactions as the Mode of Message Delivery
EiM aims to relay messages about the importance of exercise through doctor-patient interactions, but this limited strategy is a poor choice. First, many people do not have access to, or choose not to seek, healthcare services. People do not access health services for a wide range of reasons, including lack of insurance (26), lack of time (27), lack of nearby health facilities (28), and lack of trust in healthcare professionals or medicine (24). Rates of healthcare utilization are also low among minority groups (5, 29) and non-English speakers (30). Low income families may not have access to healthcare even if they have insurance due to barriers such as distance from healthcare providers and high financial costs beyond what is covered by insurance (31). The low rates of healthcare access and utilization among the uninsured and the consequent low rates of doctor-patient interaction in this population represents a significant weakness of EiM, particularly because members of low SES groups (1, 5, 32-33) and low education (1) have higher rates of inactivity and, therefore, are at greater need for exercise interventions than member of high SES groups. Among the general population, a 2007 study (34) reported that 21 percent of Americans has an annual preventive physical exam. This indicates that a large percentage of the population will not see a doctor unless they perceive a health problem requiring treatment, suggesting that many sedentary, but otherwise healthy people will not receive EiM's message. A recent review of health insurance and access (26) reported that 67% of adults, including both insured and uninsured individuals, had no contact with a health professional in the past year, similarly indicating EiM’s lack of reach.
Assuming patients have access to and seek healthcare services regularly, a provider’s advice may not result in increased exercise behavior. As previously mentioned, distrust (24) and perceived discrimination (25) in healthcare settings can cause patients to disregard doctors’ recommendations. Additionally, even if patients have a good trust relationship with their doctor and accept the message that exercise is medicine, intentions to exercise may improve without a corresponding increase in rates of exercise. The doctor-issued recommendation puts the responsibility to be physically active in the hands of the patient without addressing larger scale and upstream factors. Moreover, EiM’s success lies on the Health Belief Model-based premise that increasing salience of health risks associated with inactivity will increase intention to exercise. However, this logic is flawed and, even if intentions to exercise improve, behavior will not necessarily follow. The Health Belief Model assumes rational behavior, but it is clear that people often act irrationally. Moreover, the relationship between intention and behavior cannot be assumed. Research has shown that many who intend to engage in a behavior fail to do so (35) and that habits may inhibit the influence of intention on behavior (36). In order to improve behavior, EiM must do more than improve intentions to exercise through doctor-issued guidance.
Failure to Anticipate Barriers
A major flaw of EiM is its failure to anticipate barriers to exercise and its subsequent failure to address these barriers. The physical, “built” environment plays a substantial role in one’s choice to be physically active or inactive. Subjective assessment of physical activity in adolescents (37) and adults (38) as well as objective (39) measurement of physical activity in adults using accelerometers has shown that proximity to physical activity-related facilities (e.g., schools, parks, dance studios, YMCAs, swimming pools, bicycle rentals) increase engagement in physical activity. Similarly, the more convenient it is to exercise and the less convenient it is to be sedentary, the more likely an individual is to choose active over sedentary activities (40). Thus, the lack of areas and facilities suitable for exercise make it inconvenient and less likely that individuals will exercise, even if they know they should. Physical activity-related facilities tend to be less common in low SES and minority areas (37, 41). This barrier for low SES areas is particularly concerning because, as mentioned previously, rates of physical activity are lower in these population (1, 5, 32-33). An environment characterized by barriers to exercise will likely counteract the effect of increases in exercise intention motivated by EiM.
An additional, but related, barrier is the easy availability and convenience of alternative sedentary behaviors. According to behavioral economics, individuals weigh alternative choices based on costs and benefits as well as the proximity and tangibility of the costs and benefits (42). Behaviors with high immediate benefits and low immediate costs are preferred, even if high costs will be experienced later (43). The immediate costs of exercise (e.g., inconvenience, hard work, time, physical discomfort) are high and salient whereas the benefits promoted by EiM are distal and uncertain. Though exercise may reduce the risk of chronic disease, it is not a guarantee. Subsequently, from a behavioral economics perspective, a sedentary lifestyle may be perceived as more rewarding and higher value than an active lifestyle. While EiM aims to inform patients of exercise’s future health benefits, it focuses little attention on exercise’s more immediate benefits and does little to anticipate and downplay immediate costs of exercising. Evidence has shown that, given the choice between sedentary activity and exercise, most will choose sedentary activities (44). If access to sedentary behavior is restricted such that exercise is more convenient, however, exercise behavior increases (40, 45) demonstrating the utility of behavioral economics in exercise promotion programs. EiM’s failure to incorporate the ideas of behavioral economics inhibits its efficacy. Its chance of success would be far greater if it anticipated the barrier of readily available and tempting sedentary activities and encouraged perceptions of exercise as being more accessible and rewarding than sedentary behavior.
Conclusion
While the Exercise is Medicine program is intended to increase exercise behavior, its design has fundamental flaws that reduce its efficacy and may even be counterproductive. It oversimplifies the problem and the solution, creates potentially damaging associations between exercise and medical treatment, makes faulty assumptions, is too limited in scope, puts too much responsibility on the shoulders of individuals, and ignores substantial barriers. A novel intervention that capitalizes on social and behavior sciences theory and research would have higher chance of success in increasing exercise behavior and helping Americans reach national physical activity guidelines.

Active Communities Today: A Social Science-based Physical Activity Intervention – Maureen Harris
The Exercise is Medicine (EiM) initiative aims to battle the alarming prevalence of sedentary lifestyle and encourage adults to meet the national recommended guidelines for physical activity. Despite its good intentions, the program’s ignorance of social and behavioral principles greatly inhibits its efficacy. A previous critique of this program highlighted several crippling flaws. Here, an alternative program is proposed.
The Active Communities Today (ACT) initiative is based heavily on social science research. As its names suggests, it has three primary objectives. First, to get people active and moving, without necessarily framing exercise in a health context. Second, to engage communities, foster social support, avoid blaming individuals, promote policy changes to encourage activity, and to campaign for improvements in the built environment that facilitate physical activity. Third, to emphasize that the time for change is now; exercise behavior, not exercise intentions, will lead to public health improvements. These objectives are targeted by three key strategies that specifically address EiM’s fundamental weaknesses.
Strategy 1: Foster Intrinsic Motivation and Adherence
The EiM program defines exercise as “medicine” and employs medical terminology (e.g., “prescription”) throughout its materials. This definition is not only ineffective, but potentially counterproductive. By limiting the factors known to support intrinsic and internalized motivation, EiM reduces the likelihood that people will voluntarily choose to be active. The importance of protecting intrinsic motivation is more than theoretical. Applied research has shown that promotion of the factors that enhance internalization of motivation is positively related to exercise behavior (13, 46-49). ACT, guided by cognitive evaluation theory (CET; 10-11) and motivation research (e.g., 9-11, 14), promotes perceived choice, autonomy, self-efficacy, and the inherent enjoyment of physical activity to foster intrinsic/internalized motivation.
The program empowers people to make their own decisions and avoids directives and orders, with its primary goal being to allow exercise to become a naturally reinforcing activity. Through program materials and outreach events, ACT proposes a wide variety of activities, including competitive (e.g., road races and sports leagues), cooperative (e.g., recreational sports leagues and walking groups), and individual (e.g., health club workouts and swimming sessions) options from which people can choose, allowing people with all personality types to select an activity that is most appealing to them. The program recommends experimenting with nontraditional exercises (e.g., boxing or dance classes) to maximize interest and maintain satisfaction. Importantly, though abundant choices are offered, guidelines are provided. To make a noticeable public health impact, people must achieve a certain volume and intensity of physical activity. ACT advises participation in at least one activity for at least 30 minutes most days of the week in order to see short term benefits, such as increased energy and improved mood. As Whitehead notes (12), freedom of choice can be maintained within guidelines.
To enhance exercise self-efficacy, ACT encourages simple activities (e.g., brisk walking) as well as offering community classes and online tools to provide tips and skills on more complicated activities. At outreach events, fitness experts offer free consultations to help people design appropriate workout routines. While educational, the primary emphasis will be to encourage confidence. This aspect of the program is critical as self-efficacy has been shown to predict exercise behavior (46, 48-49) and adherence (13, 47).
ACT markets exercise as fun, with the goal of helping adults reconnect with the enjoyment of playful activity of childhood and to incorporate daily activity into their lifestyle. Defining exercise as a positive and pleasurable activity portrays physical activity as a satisfying choice. Furthermore, the expectation that exercise will be enjoyable increases the likelihood that an individual will perceive exercise as enjoyable. Cognitive biases often cause us to see what we want to see or experience what we predict we will experience (50). Positive exercise expectancies have been associated with exercise behavior (51).
By facilitating the factors necessary for intrinsic/internalized motivation, ACT simultaneously addresses EiM’s likely problem with poor adherence. A smoking cessation intervention that supported autonomy and perceived competence increased long term adherence to tobacco abstinence (52). Similarly, it has been demonstrated that those who adopt exercise as a personal value are more likely to adhere to regular physical activity (9).
Strategy 2: Employ Widespread, Effective Communication
As noted, many people do not see their doctor for various reasons. Even among those that do see a healthcare provider, many lack trust in him or her, meaning that directives from a provider may be disregarded. In order to communicate the core program messages effectively, ACT employs a multifaceted communication strategy.
To maximize distribution, print, radio, and television ads are used to broadcast ACT’s key messages widely. Posters are placed in public buses and trains as well as high traffic centers such as libraries, schools, and outside of grocery stores and banks. Radio and television ads are aired several times a week. Local outreach events featuring ACT representatives bring key concepts directly to community members. A website offers confidential guidance, encouragement, and tools to get started. Visitors to the site will be encouraged to offer suggestions for site improvements to maximize its utility (53). A network of message boards hosted on the site will offer a forum for social support and exchange of questions and answers. Importantly, medical experts will moderate the boards to ensure the accuracy of answers provided by community members. The site will also feature a space for individuals to get involved in policy change by reporting concerns (e.g., crime levels render neighborhood unsafe for outdoor exercise) and requesting changes (e.g., construction of bike lanes on city streets). This space is intended to open a dialogue between community members and policy makers.
In addition to being well-distributed, it is equally important that ACT’s communications are interpreted positively. This involves appealing to values of the intended audience (54), as assessed by pilot focus groups and survey samples, rather than the values of ACT staff. As an example, the program promotes commuting by bike rather than car to be “green” and doing house/yard work on your own rather than hiring landscapers to be thrifty. ACT’s materials and events feature a wide range of regular people with whom the target population can relate, including members of various racial and cultural groups, young and old, male and female. Beyond facilitating social learning (55), this shows that exercise is truly for everyone and helps develop imagery of people having fun being active. The aim is for members of the target population to begin to imagine themselves in an active lifestyle and consider adoption of an active lifestyle as an achievable goal.
Strategy 3: Reduce Barriers and Market Immediate Benefits
ACT is firmly based on behavioral economic principles and recognizes that there are infinite sedentary activities competing with exercise to fill the limited number of hours in a day. To portray exercise as a valuable choice, the short term benefits must be emphasized while short term costs are minimized (42). The program’s goal is to sell the idea that exercise is a small investment with a large immediate reward.
ACT works to reduce immediate costs by making physical activity accessible and convenient. A major obstacle in the widespread adoption of active lifestyles is the lack of exercise-friendly environments. With unsafe streets, car-dependent communities, and neighborhoods lacking recreational centers, finding opportunities to be active can be difficult, even if an individual has an intention to be active. In order to make improvements in physical environments, ACT works closely with government officials, community developers, and business leaders. The program sponsors grassroots organizations to campaign for change at the town and city level while opening a parallel dialogue with state and federal leaders. As mentioned in the second section, ACT involves the community members in this dialogue. Short term projects include establishment of bike share programs in urban centers. The long term vision is for development of high-density, “walkable” communities with low crime rates, low pollution, and abundant physical activity-associated facilities (e.g., recreational centers, swimming pools, tennis courts). These attributes are associated with higher rates of physical activity (e.g., 56-58), and a recent case study reported that increased access to recreational resources raised physical activity levels (59).
In addition to reducing structural barriers, ACT reduces perceived immediate costs by showing that exercise can be just as easy and uncomplicated as sedentary behaviors. The program website and print materials offer suggestions on how to incorporate simple exercise and non-exercise physical activity (e.g., walking for transportation, vigorous housework) into a daily routine. Moreover, it suggests inexpensive activities that can be done without leaving the house (e.g., exercise videos, jumping rope, dancing), and reminds people that if they cannot tolerate high intensity exercise, they can still reap benefits from higher frequency, lower intensity workouts.
Keeping in line with behavioral economic principles, the immediate benefits of physical activity are advertised much more heavily than long term health benefits. Program materials highlight increased energy and vitality, improved mood, higher quality sleep, improved mental functioning, reduction in mild depression, increased self-esteem, and even higher sex satisfaction. Fun activities that are considered pleasurable rather than painful (playing tag with the kids, playing tennis with a friend or spouse) are highlighted. To help physical activity gain an extra edge over sedentary activities, behaviors such as television viewing and video game playing are marketed as having few benefits. Time spent TV viewing has been shown to be inversely related to leisure time physical activity in women (60), girls (61), and adolescent boys and girls (62), suggesting that reducing TV viewing may encourage activity.
Conclusion
ACT is a broad, multifaceted program. It works primarily above the individual level to create large scale changes in the culture, physical environment, and social environment. In parallel, it targets individual level behavior by reframing exercise with positive terms and promoting exercise’s inherently reinforcing properties.



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BMI Reports Card and the Negative Impacts Caused by Traditional Approaches, Labeling and Social Frames - Maura Hackett

The increasing epidemic of childhood obesity has necessitated the creation of solutions to combat this issue. One proposed solution is the Body Mass Index (BMI) Report Card, first passed by the Arkansas State Legislature in 2003 (1). This report calculates a student’s BMI, which is the ratio of weight to height squared, and reports it to the child’s parents. It is considered a simple and effective tool in the correlation of body fat and health. Parents receive report cards based on this information informing them if their child is at risk for obesity. According to the CDC, while the concept of a BMI monitoring program appears to be beneficial there are other issues which must be considered. Currently obesity treatments do not exist, research has not proven the efficacy of this type of initiative, and many communities do not have the available resources to combine the report card with suggestions and health promotion programs for at-risk children (2).
The proposed implementation of these programs is considered controversial by many critics; because of the stigma it attaches to the child and his/her weight. From a social and behavior perspective, the program’s approach and supporting theories are flawed and ineffective. First, it relies on the traditional models of behavior to inform and inspire change in the child. Second, report cards utilize labeling theory apart of the inspiration for change. Society’s labels associated with health and obesity have far reaching consequences with regard to self-esteem and the child’s feelings of self-worth. Third, the ranking and valuation of a child’s weight in the form of a report card employs Framing theory to influence the child’s behavior based on the frame of the social norms and biases concerning health and obesity.
The report cards are intended to inform the parents of the child’s health status and whether s/he is “at risk of becoming overweight or underweight” or is “overweight” (1). It does not provided suggestions and recommendations for a healthy lifestyle or changes to the current diet. The reports cards utilize the ideas of self-efficacy, the weighing of the risks and benefits of obesity, and intention to change for motivation to change the child’s risk of obesity, key components of traditional approaches to health.
Traditional Theories
Traditional behavior theories focus on individual level behavior and the individual’s decision to change a behavior after consideration of social norms, motivation, and consequences. The models are centered on the internal rationalization that an individual has for the costs and benefits of an action and the influences of society have on whether person feels s/he is capable of accomplishing an action. In this case, the parents and child would rationalize the costs and benefits of being obese in America with the social norms of popularity, bullying, the pressure to be thin, and the alienation of morbidly obese individuals, especially in school social cliques.
The Health Belief Model presents decisions as a combination of the rational decision process that involves the consideration of the perceived barriers and the severity of the action, and creates an individual’s intention, which is a direct antecedent of behavior. Susceptibility is the person’s belief that they are vulnerable to the action, and severity refers to the intensity of the possible consequences associated with the action (3).
In comparison, the Theory of Reasoned Action is also based on a personal weighing of the behavior prior to action. However the pre-contemplation is based on the perceived social norms and the intention to carry out the behavior. The decision can be quantified as a cost-benefit analysis of the positive and negative outcomes of the behavior. This theory, unlike the Health Belief Model, draws upon the outside influence of social norms on decisions (4). The social norms in this case are the image of the perfect body and biases against individuals who do not fit this mold.
The Theory of Planned behavior is based on the foundation of the Theory of Reason Action, but also includes the person belief of whether the individual feels that s/he can accomplish the action (5). The feeling of self-efficacy takes the social norms into consideration and translates them into a personal feeling of whether the action can be accomplished. The personal beliefs of efficacy consist of the moral norms and consequences of the premeditated action (3).
The Theory of Reasoned Action focuses on the social stereotypes associated with obese and thin individuals and reinforces this idea by creating a report card system of those who pass i.e. are thin and those who fail are obese. Creating feelings of insecurity and alienation within the child or the parents decreases feeling of self-efficacy, which are components of the larger social norms and attitudes regarding weight loss and the child’s decision to become healthy.
The traditional theories have a similar disadvantage, which is problematic with regard to the BMI Report Card initiative. The theories are based on the individual’s decision to changed and do not consider the larger society or the environment as key components of the decision/ behavior process. As previously stated, communities often do not have the financial resources to implement suggestions and health promotion programs for at-risk children congruent with the report cards. Although, the Theory of Reasoned Action does account for some irrationality, the theories do not recognize the prevalence and frequency of irrationality in everyday behavior, such as the consumption of fast food, even though it is known to be unhealthy. Additionally, they assume that each action is pre-meditated with the costs, benefits and consequences measured prior to action, and spontaneity is not considered. Spontaneity in this case may include drastic measures a child may employ to combat his/her weight such as eating disorders, diet pills and vomiting.
While the theories promote the benefits of a behavior, they do not provide for the possible longevity of a behavior and the difficulty a child or adolescent may encounter in stopping or changing the behavior. The theories discuss the direct link between an individual’s intention and its product or behavior based on a variety of internal and external influences, but they do not the way an individual acts as part of a larger collective.
Labeling Theory
The valuation of weight as part of a report card implies a hierarchy within the children who are analyzed, and defines obesity as deviant from the social norm. The children, who are considered healthy, pass the test while the children who are obese or have the potential for becoming obese fail. The application of labeling theory would explain that the stigmatization of the child’s weight will not inspire the child to lose weight, but perpetuates the trend of obesity within the child. The theory identifies the way society defines and creates deviant behavior. The social groups generate rules for the members to follow and label outsiders who do not conform to the rules and sanctions (6). A report by the US Department of Agriculture stated that 17% of children identified as overweight were in fact healthy and incorrectly labeled. Critics have argued that schools lacking full comprehension of the limitations of the BMI may erroneously identify children as at risk for obesity, causing extra stress and feelings of inadequacy in the children (1).
Whatever initially caused the deviant behavior is not as important as the societal reaction to the behavior and creates a cycle of processes and reactions to the behavior (7). In other words, labeling a child as obese and outside the norm will invariably create a cycle of unhealthy behavior and stigma against the lifestyle, which can perpetuate the obesity throughout childhood and into adulthood. The marginalization of an overweight child triggers a negative self-image, limits feelings of self-efficacy with regard to change, and creates further deviant behavior.
In general, children are not afraid of becoming overweight or obese because of the health implications, rather the negative stigma associated with obesity in society. Studies have shown that children as young as five years old internalize the social stigmas and biases against overweight individuals. Consequently, overweight children have a higher risk of developing depression, low self-esteem, and social isolation. The report cards do not reduce these feelings, but highlight and intensify these thoughts (1). Decreased self-esteem places children at higher risk for alcohol consumption, smoking and feelings of nervousness and loneliness (8).
The risks of decreased self-esteem, depression, and social isolation have direct impacts on the child’s performance in school, motivation, and social relationships. The middle school years are the formative years of self-esteem development and predict the child’s potential interactions in the future (8). Report cards may prove detrimental to the development of a child’s self-esteem at a time when it is critically important. Ignoring a child’s difficulty with weight is not a solution to creating a healthier lifestyle. However, labeling a child at the onset of adolescence without positive, constructive solutions will increase the likelihood of decreased self-esteem and increase the potential of hurtful experiences (1).
The report cards serve only to identify problem of an unhealthy lifestyle and the potential risk of obesity. It is not combined with a solution initiative or prevention program which is applicable to all children as a healthy lifestyle imitative. The reports place the burden for change on the individual child and his/her parents. Although the Arkansas initiative includes provisions for restricted access to vending machines, the development of physical activity standards, and community partnerships, the main onus for change falls to the child and parents (1). This may lead to pressure to succumb to the societal definition of the perfect body and foster disordered eating. Research has shown that adolescents in particular place more importance on body appearance than actual weight. A report card stating that a child is overweight serves as further proof to the child that s/he is imperfect. These feelings increase the body dissatisfaction, the possibility of eating disorders, such as bulimia, anorexia, or compulsive eating, and may increase feelings of suicide. The child may take extreme measures to decrease their body weight rapidly such a purging, diet pills or laxatives (1).
Framing Theory
Utilizing the aforementioned stigmas and pressure to succeed, the BMI report card frame health positively and negatively frame obesity and the health consequences associated with an unhealthy lifestyle. Associating obesity with a failing grade on a report card fames the weight of the child so as to influence the child and his/her parents to choose a healthier lifestyle and decrease the child’s BMI. Framing theory is based on the perceptions of an individual regarding the outcomes of a choice and whether the choice will be profitable (9). The report card frames obesity as a negative option with health and social acceptance as the reward outcomes. Social acceptance and inclusion, especially during adolescent and pre-adolescence is critical in the development of the self-image of a child. Healthy reports on the BMI report card, encourage children who are considered healthy and in the normal range with positive reinforcement and marginalizes children who “fail” attaching a negative stigma to their health and weight.
Although the imitative to decrease childhood obesity rates is important in public health, the BMI report card is understandably controversial. Rather than promoting healthy lifestyles integrated with school curriculums, community outreach and education, the report card places the burden of change on the child and parents. The individual children and his/her parents are expected to change the components of their lifestyle that led to the risk of obesity based on the report card BMI “grade.” The report card marginalizes the child, which can negatively impact self-esteem, social relationships, personal feeling of self-worth and motivation. Without supporting health initiatives, the child is forced to either loser weight or risk becoming labeled as obese and a social deviant. Labels can positively reinforce good behavior, but they can also create a cycle of negative behavior and deviance from the social norms. Children who are not inspired to lose weight or do not have enough knowledge about how to lose weight effectively, will become trapped in the negative spiral of obesity and social stigma.





Alternative Approaches
BMI report cards are intended to inform the parents of their child’s health status and whether s/he is “at risk of becoming overweight or underweight” or is “overweight” (1). The program does not provide suggestions and recommendations for a healthy lifestyle or changes to the current diet, nor does it connect the child’s health to outside factors such as physical activity, school lunch programs, or nutritional education. The reports cards utilize the ideas of self-efficacy, the weighing of the risks and benefits of obesity, and intention to change for motivation to change the child’s risk of obesity, key components of traditional approaches to health. The stigma the report cards attach to a child’s weight reinforces the flawed and ineffective nature of the program. Traditional models of behavior, labels, and the ranking and valuation of a child’s weight dictate the rationale behind the program. Society’s labels associated with health and obesity have far reaching consequences with regard to self-esteem and the child’s feelings of self-worth (7). Framing theory explains the influence over the child’s behavior based on the frame of the social norms and biases concerning health and obesity (9).
The alternative behavior models approach change at the group level with subtle suggestions for change based on aspirations and promises for a healthier life based on core values of beauty, wellness, and overall happiness reinforced with the help of visual images that further inspire a lifestyle. The traditional health behavior models are centered on the internal rationalization that an individual has for the costs and benefits of an action and the influences of society have on whether person feels s/he is capable of accomplishing an action. The Health Belief Model approach presents decisions as a combination of the rational decision process that involves the consideration of the perceived barriers and the severity of the action, and creates an individual’s intention, which is a direct antecedent of behavior. Susceptibility is the person’s belief that they are vulnerable to the action, and severity refers to the intensity of the possible consequences associated with the action (3). A Theory of Reasoned Action would focus on the social stereotypes associated with obesity; focusing on overweight individuals as opponents to the social norms and individuals who fit the BMI healthy rating as part of the larger collective majority (4). In 2003, a lawsuit was filed against McDonald’s accusing the company of making two girls obese. The case was thrown out of court based on a lack of substantial evidence. The judge asked “where should the line be drawn between an individual's own responsibility to take care of herself and society's responsibility to ensure others shield her?” (10) The blame was placed on the girls for becoming fat without regard for the larger social and environmental factors which may have contributed to the girls’ obesity. The logic behind this case and the BMI report cards assigns the blame and responsibility on the individual rather than explaining the obesity epidemic as a condition that must be combated not only on the individual level but at the larger, societal level.
The alternative approach to change would address behavior change at the group level rather than the individual level. This is one of its strengths compared to the traditional models. It also focuses on the multiple forms that influences can be presented to influence changes in behavior. The traditional models only address a few of the factors that influence action and not others such as spontaneity, society as an environmental context, and the frequency of irrationality in individuals, or a group mentality when addressing change. Groups of individuals with the inspiration for changes and images with which to aspire make the behavior appear more approachable so that individuals can overlook some of the hindrances that they may be prone to focus on with the other theories such as pre-meditation, costs, benefits and consequences. The alternative model further improves on the traditional theories through its approach and level of action. It considers the irrationally of individual and groups, by addressing the group mentality through the creation of a visual aspiration of a lifestyle and although the herd mentality can lead to irrational behavior, this attempts to steer the behavior by creating inspiration and promise of a lifestyle visually portrayed by models in commercial and print ads.
A combined approach to the presentation of a health lifestyle and nutritional foods, combined with physical activity would be an affective public health initiative when combating the influence of fast food industry and would lead to changes in school lunch programs and funding for physical education in schools. Therefore the changes will be based on the actions of the larger collective, which represents a distinct improvement on the traditional models of behavior which focus solely on the individual.
New Labels and Frames
The “Truth Campaign” focuses its message toward the youth by creating a rebellion again the large tobacco companies and their operation motives. The goal is to expose “an industry manipulating its products, facts, and advertising to secure replacement for the 1200 customers they ‘lose’ every day…To expose how the tobacco industry has been manipulating our generations and others before it.” (11) The campaign successfully frames the risks of smoking and tobacco so the industry is the guilty party and the American consumer, especially the youth, have the ability to change the way smoking is viewed and regulated. One of the advantages to the “Truth Campaign” is its use of the framing theory to show young consumers that “thinking smoking is rebellious is wrong and cigarettes are systematically marketed and sold a sign of rebellion.”(11) “Truth” illustrates the manipulative, misanthropic acts of the tobacco companies while emphasizing the power individuals and society have to combat tobacco companies’ influences.
A health initiative which framed unhealthy foods and the attempts of food manufactures and lobbyists to manipulate the consumer and appeal to children would change the ideology of weight and health in the US. Fast food, soda and candy companies market to children with colorful advertising and cartoon characters in order to sell their products while making a lasting impression on the children so they will become lifelong consumers. (12) Vending machines sponsored by candy and soda corporations in school combined with the elimination of physical education in schools are contributing to the obesity epidemic. Alternative approaches to behavior would not place the blame on the individual but incorporate weight in the context of the larger unhealthy lifestyle and culture of American society today, creating an effective initiative to combat the obesity epidemic in America. In Appleton, WI, the local school board contracted a natural food company to provide the school lunches and remove vending machine containing candy and soda, with a “a district-wide commitment to healthier eating and lifestyle in general.” (13) The results were healthier, more attentive and academically successful children (13).
Healthy Lifestyle Campaign
The campaign for healthier lifestyle and the fight against obesity is not without its challenges. The fast food industry and food special interest groups including the Corn Refiners Association are spending millions of dollars to convince the American public of the safety of their food while distracting the public form the unhealthy aspects of the foods they produce. The Corn Refiners of America sponsor the “Sweet Surprise” Campaign in which they promote the similar chemical composition to table sugar and state “sweeteners, such as high fructose corn syrup and sugar, make many nutritious foods taste even better, and can be part of a balanced diet.” (14) The manufactures downplay the negative health affects associated with high fructose corn syrup such as “an increased risk of diabetes, especially in children as well as an increased risk of obesity.” (15)
A healthy lifestyle imitative needs to appeal to the American consumer as much as the fast food industry does. Creating a revolution for health in which the fast food companies, lobbyists and manufactures were framed as the villains and deviants from the basic American values of health and happiness, the campaign would create a sensation for change in every generation. Framing the argument is the key to the determination of the perception of problems and will influence the shift in outcomes based on the definition of normal and deviant behavior. (9) An effective way to combat the millions spent in advertising would create a positive label for health and a negative stigma against the industry which bears some responsibility for the epidemic, while including not alienating those who are obese. (7)
The BMI report cards place a numerical value on health without supportive interventions for an overall lifestyle change for not only the child, but his/ her family and American society as a whole. Currently the report card implies a hierarchy within the children who are analyzed, and defines obesity as deviant from the social norm (7). The obsession with success creates a negative stigma in the report cards, children who are considered healthy, pass the test while the children who are obese or have the potential for becoming obese fail. Parents who are not educated about healthy food choices or the overall effects of unhealthy and/or obese lifestyles will not know how to address the BMI report card. Schools and communities need to create interactive programs that combine healthy eating habits, exercise, smart shopping tips, fast and healthy recipes, and an emphasis on physical activity in order to eliminate the stigma of the report cards.






















REFERENCES
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