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
(1) Ikeda, Joanne P., Patricia B. Crawford, Gail Woodward-Lopez. 2006. “BMI Screenings in Schools: Helpful or Harmful.” Health Education Research Theory and Practice. 21, 6: 761-769.
(2) Centers for Disease Control and Prevention. “BMI Executive Summary.” Date Retrieved April 3, 2009. (http://www.cdc.gov/HealthyYouth/obesity/BMI/pdf/BMI_execsumm.pdf).
(3) Simsekoglu, Ozlem and Timo Lajunen. 2008 “Social Psychology of Seat belt Use: A Comparison of Planned Behavior and Health Belief Model.” Transportation research 11: 181-191.
(4) Ellis, Shmuel and Shaul Arieli. 1999. “Predicting Intentions to Repot Administrative and Disciplinary Infractions: Applying the Reasoned Action Model.” Human Relations 52: 947-967.
(5) Hagger, Martin S., Nikos L. D. Chatzisarantis, and Jemma Harris. 2006. “The Process By Which Relative Autonomous Motivation Affects Intentional Behavior: Comparing Effects across Dieting and Exercise Behaviors.” Motiv Emot 30: 307-321.
(6) Raybeck, Douglas. “Anthropology and Labeling Theory: A Constructive Critique.” Ethos. 16, 4: 371-397.
(7) Klein, Malcolm W. 1986. “Labeling Theory and Delinquency Policy: An Experimental Test.” Criminal Justice and Behavior. 13, 47: 48-79. Date Retrieve April 3, 2009. (http://www.jstor.org/stable/1685855).
(8) Strauss, Richard S. 2000. “Childhood Obesity and Self-Esteem.” Pediatrics. 105, 15. Date Retrieved April 3, 2009. (http://pediatrics.aappublications.org/cgi/content/full/105/1/e15).
(9) Tversky, Amos and Daniel Kahneman. 1981. “The Framing of Decisions and the Psychology of Choice.” Science, New Series. 211, 4481: 453-458. (http://www.jstor.org/stable/1685855).
(10) Wld, Johnathan. 2003. “McDonald's Obesity Suit Tossed U.S. Judge Says Complaint Fails to Prove Chain is Responsible for Kids' Weight Gain.” CNN. February 17. Retrieved April 24, 2009. (http://money.cnn.com/2003/01/22/news/companies/mcdonalds/).
(11) Truth Campaign. 2009.”About Us.” Retrieved April 24, 2009. (http://www.thetruth.com/aboutUs.cfm)
(12) Public Health Institute. 2006. “Junk Food Marketers Target Children, Survey Says.” Retrieved April 24, 2009. (http://www.phi.org/news_events/news-viewRelease.cfm?pressReleaseID=96&year=2006).
(13) Pure Facts. 2002. “A Different Kind of School Lunch.” Retrieved April 24, 2009. (http://school-lunch.org/wisconsin.html)
(14) Corn Refiners Assocaition.2009 “Sweet Surprise.” Retrieved April 24, 2009. (http://www.sweetsurprise.com/hfcs-and-your-family)
(15) Science Daily. 2007. “Soda Warning? High-fructose Corn Syrup Linked To Diabetes, New Study Suggests.” Retrieved April 24, 2009. (http://www.sciencedaily.com/releases/2007/08/070823094819.htm)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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