Childhood Obesity: Characterizing the Failure and Potential Successes of Public Health Interventions on a Growing Epidemic—Lori L. Harrington, MD

Public health interventions over the years have been successful in improving the health and lives of children. However, there remains a growing and pervasive public health crisis amongst our children— obesity. Despite public health campaigns to intervene, childhood obesity continues to be an epidemic problem in the United States. According to two National Health and Nutrition Examination Surveys (NHANES), from the 1976-1980 survey and the 2003-2004 survey, the prevalence of overweight children and teenagers has increased substantially (1). For children aged 2–5 years, the prevalence of overweight increased from 5.0% to 13.9%; for those aged 6–11 years, prevalence increased from 6.5% to 18.8%; and for those aged 12–19 years, prevalence increased from 5.0% to 17.4%. This represents a 2-3 fold increase in the rates of obesity over a period of twenty-five years (2). This growing problem has grave health implication during childhood and as these children grow into adults. Obesity in childhood leads to hypertension, high cholesterol, increased rates of diabetes and cardiovascular disease, sleep apnea, asthma, exercise intolerance, osteoarthritis, as well as psychosocial consequences of obesity (2). Current public health strategies addressing this epidemic of childhood obesity narrowly focus on individual behaviors and these health risks of obesity, and are largely unsuccessful. Instead, a broader, more comprehensive approach, including other social and behavioral strategies to influence social norms, may be more successful.

A Current Public Health Strategy and the Health Belief Model
Public health prevention strategies to target childhood obesity narrowly rely on individual behavior, focusing on health risk and medical complications of obesity as an unsuccessful strategy of change. As a prime example, the highest federal authority of health in the United States, the US Department of Health and Human Services (HHS) and the Surgeon General have released a “Call To Action To Prevent and Decrease Overweight and Obesity,” with a focus on children and adolescents (3). The focus of this message is on the medical and health consequences of childhood obesity and addresses children and parents about the behavioral changes that should be made in order to avoid these consequences.

This strategy is clearly based on the Health Belief Model of change in behavior. It depends on the individual, the child or parent, to weigh their perceived susceptibility of developing the consequences of obesity and the benefits of avoiding those consequences, against their behavior including food and activity choices. This campaign then requires this individual to make a rational choice to decide to change their behavior and assumes change will come with the intention to do so, which is not accurate assumption. However, this campaign does not address any social or behavioral factors--economic, psychological, ethnic factors-- that may influence the decision to change or limit the ability of making that intention into an actual change. These limitations are barriers that the Health Belief Model falls short of addressing and are the likely reasons campaigns such as this one fail.

Social and Behavioral Factors
A more successful strategy for change in childhood obesity must identify behavioral, social, cultural and environmental factors that influence the increasing epidemic of childhood obesity. These strategies focus on a population-based approach to the problem, which may be more useful on this society-wide problem (4) (8) than an individual based approach. Anthropological changes such as activity level, technology, the built environment, family structure, and family activity; geographic changes in society; as well as sociologic factors including socioeconomic status, racial and ethnic influences are key factors in the development of the obesity epidemic and so must be considered in its prevention and resolution.

The progression of childhood obesity parallels the changing social norms of activity and diet change over the last few decades. Technological advances have come with the detriment of those changes including the immense decrease in activity level of children. Childhood entertainment, which used to be outdoor play and physical activity, has been replaced by the sedentary play of 300 cable channels, a myriad of video games, and the virtual world of relationships afforded by the Internet. None of these activities promotes physical fitness. An estimated 61.5% of children aged 9 to 13 do not participate in any organized physical activity during their non-school hours and 22.6% do not engage in any free-time physical activity (11). School support of physical activity has also declined, as school boards remove physical education from the curriculum and after-school sports programs require fees to participate, putting these activities out of the reach of some students. Only a small minority of children has daily physical education class time, and in those who do, active class time is far below 50% (10), even though this study by Datar et al. showed physical education classes were an effective intervention, especially for obese or at-risk girls. Changes in our built environment have also decreased children’s activity level (15). Most travel and transportation is by car; walking is no longer the mainstay of travel. As crime increases in neighborhoods, and as parents are out of the home more frequently for work, children spend more time indoors to avoid unsafe or unsupervised situations and less time in outdoor physical activity.

Along with decreased activity, changes in the diets of children and their families have worsened the obesity problem. In general, children’s diets have been influenced, to their detriment, by their parents’ diets, by unhealthy cultural norms, and by corporate America. Childhood obesity is a part of a greater problem of obesity in the general population, allowing children to recognize their adult role models’ weight as an acceptable social norm, a norm they are easily able to mirror. Children of obese mothers had double the odds of being obese compared with children of normal-weight mothers (5). A family based intervention strategy reported by Rodearmal et al (7) in which a family, with at least one obese child, decreased calorie intake and increased physical activity showed significant decrease in body mass index (BMI) of the target child. This finding suggests that a family strategy to incorporate both children and adults could be useful in obesity prevention.

Race, ethnicity, and socioeconomic factors are societal factors that must be considered in approaching the prevention of childhood obesity. In the United States, prevalence of obesity rose more than twice as fast among minority groups compared with white groups (2). A study by Kimbro et al (5) of overweight toddlers showed that Hispanic children were twice as likely as black or white children to be overweight or obese. Haas et al (6) identified black and Latino children as twice as likely of being overweight compared with white children, and Latino adolescents as more likely than whites. Kimbro’s study (5) identified factors such as culturally determined food intake patterns, less avoidance of fat containing foods, and greater consumption of whole milk compared to whites as factors contributing to the racial disparity in childhood obesity. An additional racial disparity was also identified by Kimbro: black and Hispanic mothers frequently do not identify their overweight children as overweight. Hispanic mothers, especially those who are less acculturated, are more likely than women in other groups to hold the common cultural belief that chubbier children are healthier. These disparities decreased only slightly when controlling for other child and maternal factors, suggesting that underlying cultural factors influence childhood obesity. Other social factors identified by Hass et al (6) include children from families in which parents had lower educational levels, lower income, and lack of health insurance as having a greater risk of being obese. The results from these studies suggest the need for tailored interventions to include social and cultural differences when approaching obesity.

Community and Industry Factors
Identification and incorporation of stakeholders from corporation and industry, down to the family and community level is essential in changing social norms to focus on eradication of childhood obesity. A broad societal strategy, rather than focusing on the traditional individual responsibility, (13) and a population based action plan is necessary. This action plan must focus on both public and private sectors in our communities.

Focusing on family, school, and community level interventions transitions the focus from individual level factors to group level factors. The model of social expectations theory in which social norms, values, and social roles affects people’s behavior supports this population focused approach. By slowly transitioning social expectations to no longer encourage or accept obesity, just as was successful in smoking in public places, public health may be able to change social norms. An approach focusing on families (7), community, and schools may be a first step. Interventions could include designing communities to encourage physical activity, increasing community access to nutritional food sources, and decreasing the ease of availability to fast food (8). School interventions that have been successful include implementation of physical education classes (10) and implementation of coordinated healthier eating programs (9).

A large component of community intervention must also include a focus on private industry and their part in the growing obesity epidemic. The food industry has been very effective through marketing and advertising in reaching extensive segments of the population and making their products household names. Household income spent on away-from-home foods rose from 25% of total food spending in 1970 to nearly one-half in 1999 (11). Using the same theories of branding in social marketing and making promises in advertising theory, industry can be instrumental in constructively addressing childhood obesity prevention by developing and promoting healthful products, consistent healthy messages, and creating a healthy eating environment. Public health practitioners should implement marketing research used by industry in order to understand peoples’ preferences, attitudes, intentions, and behaviors, which may be helpful in devising strategies for long-term behavioral changes (12). In addition to using industry strategies to make public health change, the food industry needs to make changes of their own.

Today’s food marketers spend an estimated $10 billion annually to reach children through measured media—television, radio, print, and Internet—with additional expenditures for promotions, video games, and text messaging (14). Children and youth aged 11 to 18 years visit fast food outlets an average of twice a week, and those who ate fast food consumed more total calories and fat, sweetened beverages, and fewer fruits and vegetables, and less milk than those who did not consume fast food. Fast food consumption is associated with a diet high in calories and low in nutrients and served in large portion sizes (11). The Institute of Medicine (IOM) (11) has made suggestions to the food industry including: expanding healthier meal options, decreasing serving sizes, and providing the nutritional information of their products at the point of purchase. The IOM has also called on companies to change their practices on targeting children and has asked Congress to enact legislation to this end (14). McDonald’s, the largest food service company in the world, has actually begun instituting some of these recommended changes including removing the “Supersize” option, adding more nutritional options to their menu, promoting these options in the media, and making available nutritional information on their product packaging. However, they continue to undermine these options and promote unhealthy eating by pricing differences and continuing directed advertising to children (14). The food industry has an incredible amount of popularity and therefore power and should consider using their name to help in addressing the problem of childhood obesity.

Conclusion
The current public health approach to childhood obesity erroneously focuses on the individual and their behavioral choices to combat obesity. These strategies have not been successful in preventing or reducing childhood obesity. Instead, a new public health approach must be directed toward the many other social and behavioral factors that influence the development of obesity in the approach toward reducing obesity including racial and ethnic disparities, insurance status, and socioeconomic status. In addition to focusing on these identified social disparities in a new action plan to combat obesity, public health should use the food industry as an ally to combat obesity and consider taking advantage of their successful marketing strategies in the action plan approach.

References:
1. Centers for Disease Control. http://www.cdc.gov/nccdphp/dnpa/obesity/
2. Ebbeling CB, et al. Childhood obesity: public-health crisis, common sense cure. Lancet. 2002, 360: 473-82.
3. United States Department of health and Human Services. The Surgeon General's Call To Action To Prevent and Decrease Overweight and Obesity. January 2007. http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.htm
4. American Academy of Pediatrics Policy Statement. Prevention of Pediatric Overweight and Obesity. Pediatrics. 2003, 112 (2): 424-430.
5. Kimbro RT, et al. Racial and Ethnic Differentials in Overweight and Obesity Among 3-year Old Children. American Journal of Public Health. 2007, 97: 298-305.
6. Haas JS, et al. The Association of Race, Socioeconomic Status, and Health Insurance Status With the Prevalence of Overweight Among Children and Adolescents. American Journal of Public Health. 2203; 93: 2105-2110.
7. Rodearmel SJ, et al. Small Changes in Dietary Sugar and Physical Activity as an Approach to Preventing Weight Gain: The America on the Move Family Study. Pediatrics. 2007; 120:869-879.
8. Koplan JP, et al. Preventing Childhood Obesity: Health in the Balance. Institute of Medicine of the National Academies. Washington DC. National Academies Press. 2005.
9. Veugelers PJ, et al. Effectiveness of School Programs in Preventing Childhood Obesity: a Multilevel Comparison. American Journal of Public Health. 2005;95:432-435.
10. Datar A, and Sturm R. Physical Education in Elementary School and BMI: Evidence from the Early Childhood Longitudinal Study. American Journal of Public Health. 2004; 94:1501-1506.
11. Institute of Medicine of the National Academies. Industry Can Play a Role in Preventing Childhood Obesity. Fact Sheet. September 2004. http://www.iom.edu/Object.File/Master/22/613/fact%20sheet%20-%20industry%20finalBitticks.pdf
12. Institute of Medicine Regional Symposium. Progress in preventing Childhood Obesity: Focus on Industry. Beckman Center of the National Academies. December 1, 2005.
13. Burros, M. New Approach to Childhood Obesity Urged. NY Times. Oct 1, 2004.
14. Lewin A, et al. Food Industry Promises to Address Childhood Obesity: Preliminary Evaluation. Journal of Public Health Policy. 2006; 27: 327-348.
15. ICF International. Childhood Obesity Prevention. August 2007. http://www.icfi.com/Markets/Social-Programs/doc_files/childhood-obesity.pdf

Teens Getting Their Juice: National Campaigns Fail to Outmuscle Teen Steroid Use - Chris Blesso

Anabolic steroid use scandals in professional sports are currently at the forefront of every news channel. With the possibility of millions of dollars in rewards for athletic performance, many athletes are resorting to anabolic steroid use to enhance their abilities. Anabolic steroids are not allowed in any American professional sport, and are illegal without a prescription in the United States. They are also extremely physically dangerous if abused.

However, professional athletes may be damaging not only their bodies, but indirectly also their fans, as their influence as role models on youth in America is unassailable. It is widely known that youth tend to emulate their sports heroes, and recently, the sports world was shaken with steroid scandals. In December 2007, the Mitchell Report implicated more than 80 professional baseball players in the use of steroids (1). Olympic gold medal sprinter Marion Jones had her 5 gold medals stripped from her after admitting she lied about steroid use (1).

The Monitoring the Future survey, which is conducted annually on 8-12th graders by the National Institute on Drug Abuse (NIDA), showed that anabolic steroid use increased with age (2). The newest figures according to the NIDA represent increases since 1991 of approximately 75 percent among 8th - graders and over 50 percent among 10th - graders and 12th – graders (2). The Nutritional Supplementation and Anabolic Steroid Use in Adolescents study involved more than 3,200 students in 12 states and indicates that overall, 1.6 % of students reported using anabolic steroids (3). Now this number may be low, but it is a small survey and there may be bias in students that may sway them from reporting their steroid use. Higher levels of bias are observed among younger respondents and those with higher levels of drug use (4).
Methodological procedures, such as biological specimens, proxy reports (e.g., family member, peer), and repeated measures have been used to validate self-reported data, however these procedures are often impractical or too costly for community-based epidemiological studies (5, 6). Also, youth may be completely unaware that they are taking or have taken a steroid and this could attenuate self reported data on steroid use. There are several supplements on the market that include hidden designer steroids or pro-steroids in the ingredients, as they are not Food & Drug Administration (FDA) regulated (7). The University of California, Los Angeles (UCLA) Olympic Analytical Laboratory identified several designer steroids in supplements legally sold in bodybuilding stores and on the internet, which would potentially be available to teens (7).

Nevertheless, reported steroid use has increased to 6% in 12th grade males, which is a substantial increase (3). Not surprisingly, among students admitting steroid use, 57% said professional athletes influenced their decision to use the drugs and 63% said professional athletes influenced their friends to use them (1). Adding to the frightening statistics, 80% of users and 35% of non-users believed that steroids could help them achieve their athletic dreams (1).

With an increasing need to address teen steroid use, several public health initiatives will be examined, including The National Institute on Drug Abuse’s (NIDA) “Keep Your Body Healthy: Game Plan” and the Partnership for a Drug-Free America’s anti-steroid initiative. Let us first examine the NIDA’s public health campaign. While visiting the NIDA website, they provide several links to fact pages on various drugs that are abused by teens (including steroids). The link for anabolic steroids provides standard public health messages on steroids including: what they are, common street names, how to use them, prevalence, common side effects and details into more serious side effects including growth stunting, hormonal imbalances, mood swings, heart effects, and disfigurements (8). Besides a facts page, the NIDA website includes links for sections with information regarding true-life stories, question & answers, and parent/teacher educational information (8). The NIDA’s media campaign, entitled “Keep Your Body Healthy”, has a public service announcement for steroids called “Gameplan” (8). According to the NIDA, “Gameplan” is the “ latest installment in our "Keep Your Body Healthy" campaign (which) seeks to encourage young men and women to work with what nature has provided and not "cheat" by using steroids and thereby exposing themselves to the negative side-effects associated with these drugs” (8). Their media campaign involves a 60, 30, and 15-second PSA in both Spanish and English (8). It also includes a television special from their “In the Mix” series entitled “Steroids: The Hard Truth”, which debuted in 2002 on PBS and was hosted by celebrity Kevin Sorbo (8).

Now looking at the Partnership for a Drug-Free America’s anti-steroid initiative, we see similar to the NIDA, they have information on steroid education, although much less than the NIDA’s website (9). However, Major League Baseball (MLB) and the Partnership for a Drug-Free America joined together and developed an advertising campaign designed to educate America's youth and their parents about the dangers of steroids and performance-enhancing substances (9). They have several PSA’s which tell about the dangers of steroids on the body, and also show vivid images of destruction including a statue crumbling, and deflating sports balls (9). These PSA’s are aired on major networks including ESPN during the World Baseball Classic (10). No professional athletes or role models are present in these PSA’s; they feature sports related metaphors gradually destructing and are narrated mentioning the dangers of steroids (9)

A widely used psychological model called the Health Belief Model seems to be used in most public health campaigns, including the two described above. It attempts to predict behaviors by focusing on attitudes and beliefs (11). It involves an individual weighing the perceived benefits and costs of an action and then rationally deciding on an intention, which leads to a behavior (11). The perceived benefits are decided by weighing the perceived susceptibility and perceived severity. Perceived susceptibility refers to an individual’s perceptions regarding the possibility of a disease occurrence and perceived severity refers to the degree of seriousness of the given disease (11). These anti-steroid public health campaigns educate teens about their perceived susceptibility and severity of steroid use. However, The National Institute on Drug Abuse’s “Keep Your Body Healthy: Game Plan” and the Partnership for a Drug-Free America’s anti-steroid initiative have fallen short on preventing teen steroid use. By focusing on scare tactics and the dangers of steroids, with a judgmental tone, these campaigns have failed to make an impact on teen steroid use.

1. Failure to capitalize on branding
The anti-steroid campaigns are not effectively using the media to sufficiently communicate their message to teens. Campaigns need to target teens through multimedia that teens watch and create a brand for teens to recognize by employing youth marketing similar to the “truth” campaign (12). The “truth campaign is a large national youth-focused anti-tobacco education campaign which focuses on exposing tobacco companies as manipulators of teenagers (12). The “truth” campaign effectively reaches teens, because it is based on a brand name that youth identify and it is modeled after successful commercial youth brands (12). In a 2008 study that examined the three year impact of the American Legacy Foundation’s “truth” campaign and Philip Morris’s “Think. Don’t Smoke” campaign (13). Philip Morris’s campaign consists of a series of television advertisements entitled “Think. Don’t Smoke”, and has made them the focus of its anti-smoking campaign for teenagers telling children that they have a choice whether to smoke (14). The investigators found considerable evidence of influencing youth’s attitudes towards smoking and the tobacco industry (13). Study findings indicate that exposure to “truth” advertisements were associated with steady positive changes in teens attitudes, beliefs and intentions to smoke, whereas exposure to Philip Morris ads was associated with more favorable beliefs and attitudes toward the tobacco industry (13). This study shows that well-advertised anti-smoking campaigns can have an effect on youth’s attitudes on smoking, but tobacco companies are also crafting their advertisements in a similar style and being counterproductive towards anti-smoking efforts (13).

To be effective, anti-steroid campaigns must compete with the billion dollars a year supplement industry and illegal steroid dealers. The Partnership for a Drug-Free America has created PSA’s with a very cinematic and dramatic feel to them, but they fail to utilize the branding strategy that made the “truth” campaign so effective. The NIDA is somewhat branding their PSA’s with “Gameplan”, but media exposure is not widespread enough (outside of PBS), and therefore ineffective in changing youth attitudes.

2. Failure to take into account modeling theory
These initiatives assume that teens use steroids solely for sports performance and negate any aesthetic reasons. Campaigns need to incorporate Modeling Theory. Modeling theory argues that individuals learn to do specific actions by observation of others (models), and reproduce what they observe (14). Campaigns need role models like fit celebrities as well as professional athletes to speak out on use of steroids and publicly tarnish other individuals who use steroids. While the NIDA featured Kevin Sorbo, an actor who once portrayed Hercules, most teens do not know who that is (his most famous TV show ended in 1999) (15). The PSA’s for both campaigns did not include any professional athletes or celebrities. Reiterating, 57% of surveyed teens said professional athletes influenced their decision to use the drugs and 63% said professional athletes influenced their friends to use them (1).

3. Failure to account for teen attitudes
These campaigns assume that increasing knowledge of the risks of steroid use will lead to behavioral change (Health Belief Model). The temptation for teens to succeed in sports and make millions of dollars far outweighs the health risks, so a health risk based campaign is not relevant for teens. Campaigns need to utilize a normative-reeducation strategy and consider the Theory of Planned Behavior, which accounts for attitude and social norms of teens (16, 17). A study published in 2005 examined attitudes of teens towards the tobacco industry after being exposed to the counterindustry campaign of “truth” advertisements (18). Findings on teen attitudes were consistent with concepts from the Theory of Reasoned Action and Theory of Planned Behavior (18). The random-digit dial telephone survey found that in markets with higher levels of campaign exposure, teens had more negative beliefs about tobacco industry practices and more negative attitudes toward the tobacco industry (18). Findings also provided support for a social inoculation effect, a sort of “immunizing” of teens attitudes towards peer pressure and tobacco advertising (18). This social inoculation effect was shown by teens’ negative industry attitudes being associated with lower receptivity to pro-tobacco advertising (18).

4. Failure to utilize teen rebelliousness
The “Truth” campaign’s anti-manipulation strategy would be wise to employ by national anti-steroid campaigns. By explaining that steroids are dangerous, anti-steroid campaigns may be making steroids more appealing to youth (12). Campaigns need to target steroid dealers and also the supplement industry which are both preying on teenagers with dangerous untested chemicals and making outrageous performance claims. These supplement companies are putting teens and everyone else at risk with their hidden designer steroid ingredients (7). Teens then may think they are being manipulated; and a rebellion against steroid dealers could be an alternative to rebelling against authority.

5. Failure to market alternatives
Campaigns also need to market an alternative to using steroids, showing positive messages, results and success stories of someone achieving their athletic goals without steroids. The Health Belief Model campaigns are using invokes negative messages and teens will rebel against authority as they do not want to be indoctrinated.

In conclusion
Overall, these programs are effectively providing educational materials and PSA’s on the dangers and facts of steroid use. However, by not incorporating social & behavioral strategies that are fitting for teens specifically, teen steroid use may continue to rise and these programs may miss a key opportunity to make an impact during this recent onslaught of steroid scandals.
REFERENCES

1. Jacqueline Stenson. Kids on steroids willing to risk it all for success. MSNBC. http://www.msnbc.msn.com/id/22984780/
2. NIDA InfoFacts: High School and Youth Trends. National Institute on Drug Abuse. http://www.drugabuse.gov/Infofacts/HSYouthtrends.html
3. Hoffman JR et al. Nutritional Supplementation and Anabolic Steroid Use in Adolescents. Med Sci Sports Exerc. 2007; 40:15-24.
4. Fendrich M et al. Validity of drug use reporting in a high-risk community sample: a comparison of cocaine and heroin survey reports with hair tests. Am J Epidemiol. 1999; 149:955-62.
5. SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine Tob Res. 2002 May; 4(2):149-59.
6. Rosenstock IM. Historical Origins of the Health Belief Model. Health Educ Monogr.1974; 2: 84-91.
7. Shipley A et al. Designer Steroids: Hide and Seek. Washington Post. http://www.washingtonpost.com/wp-dyn/content/graphic/2005/10/18/GR2005101800648.html
8. Facts on Drugs: Anabolic Steroids. NIDA for Teens. http://teens.drugabuse.gov/facts/facts_ster2.asp#disfiguring_effects
9. Interactive Feature: The Steroids Story. The Partnership for a Drug-Free America. http://www.drugfree.org/Portal/Steroids/index.html
10. MLB and the Partnership Launch Second Phase of Anti-Steroid Initiative. The Partnership for a Drug-Free America. http://www.drugfree.org/Portal/About/NewsReleases/MAJOR_LEAGUE_BASEBALL_AND_THE_PARTNERSHIP
11. Chin R, Benne KD. General Strategies for Effecting Changes in Human Systems (pp. 22- 45). In: Bennis et al., ed. The Planning of Change. USA: Holt, Rinehard, and Winston, 1976.
12. Hicks J: The strategy behind Florida’s “truth” campaign. Tob Control 2001; 10:3-5.
13. Farrelly MC et al. Sustaining 'truth': changes in youth tobacco attitudes and smoking intentions after 3 years of a national antismoking campaign. Health Educ Res. 2008 Jan 17.
14. Socialization and Theories of Indirect Influence (pp. 202-227). In: Defleur ML, Ball-Rokeach SJ, ed. Theories of Mass Communication. White Plains, NY: Longman, 1989.
15. Biography. Kevin Sorbo Official Site. http://www.kevinsorbo.net/
16. Icek Ajzen. Theory of Planned Behavior. Icek Ajzen: Homepage. http://www.people.umass.edu/aizen/index.html
17. Novelli WD. “Don’t smoke,” buy Marlboro. BMJ. 1999 May 8; 318(7193): 1296.
18. Hershey JC et al. The theory of "truth": how counterindustry campaigns affect smoking behavior among teens. Health Psychol. 2005; 24:22-31.

The Strain on Low-Income Youth: A Critique of Violence Prevention Programs and Possible Alternative Explanations using Strain Theory – Mark Zocchi

Introduction
Youth violence is a unique public health problem and one that is not easily defined or treated by traditional epidemiological courses of prevention. Aside from public health, many different social scientists have attempted to explain motivation, causes, and circumstances under which youth violence occurs. The discourse on youth violence is deep in research into the ecological, sociological, cultural, and psychological contexts of society, with particular emphasis on urban society, where the vast majority of youth violence occurs. Unfortunately, most current public health interventions do not take advantage of these models and are mostly one-dimensional in their approach. The discourse offered by many social scientists can help the public health profession better understand causation of youth violence and create public health interventions to combat its root causes more effectively.

Most public health departments recognize the need to address violence in their communities. A review of any city’s public health department will usually find some information on violence prevention efforts. Healthy People 2010 identified violence and injury prevention as one of the 10 “Leading Health Indicators”. Despite Public Health’s attention towards violence prevention, the homicide rate has actually moved away from its Health People 2010 target (1).
Traditional violence prevention programs have focused on children considered “at risk” for violent behavior. Typical risk factors include those with prior histories of violence, drug or alcohol use, association with delinquent peers, a broken family, poor grades, and/or live in poverty. Typically, a violence prevention program will attempt to prevent violence by providing children with conflict resolution skills, peer leadership training, and mentoring. Some prevention efforts will also include parents and community leaders in the program as well (2). Each of these strategies are rooted in the belief that the most effective way to prevent youth violence is by improving social and behavioral skills of children in urban environments most at risk for committing acts of violence. These violence prevention initiatives, while effective in certain respects, are woefully inadequate in addressing the fundamental causes of violence. As such, the racial/ethnic disparities in violence remain high.

The unequal burden of Violence
African Americans are disproportionately affected by homicide in America. African Americans are victimized at a rate 6 times higher than whites are and African Americans commit homicide at a rate 7 times higher than whites (3) do. This disparity is even starker in for young African American males. African Americans age 18-24 are over 8 times more likely to be victim of homicide and 9 times more likely to commit homicide than whites of the same age group (4). Violence prevention must first and foremost address the causes behind this disparity instead of simply using this disparity to identify a population for intervention. While typical behavior based approaches may have a positive outcome for some (5), they do not address the primary source of the disparity. By examining factors beyond the immediate circumstances of the person who “pulls the trigger”, interventions would have more success at reducing the disparity.

Typical violence prevention programs virtually ignore the external conditions affecting the disparate populations. These programs do not address the economic, social, and environmental strains affecting communities disproportionately affected by violence. This duress culminates to produce a climate in which violence occurs at a much higher rate than in the general population.
Strain theory, as developed by sociologist Robert King Merton, reasons that deviance occurs when the prominent goals of the society are beyond the means to achieve them. Largely an economic theory, Merton attributes the deviance seen in low-income neighborhoods to inadequate means to achieve monetary and material success (6). In the context of violence, his theory can be applied to social and environmental conditions as well. The combination of economic, social, and environmental strain cause a high murder rate in the predominantly low-income areas of urban America.

Economic Strain
The socioeconomic status of those disproportionately affected by violence probably receives the most attention in public health. The Center for Disease Control lists poverty as a risk factor for violence (7). The promise of economic mobility (i.e. the ability to increase one’s relative income) is a fundamental tenant of American capitalism. However, the income gap between the rich and poor is growing without any corresponding increase in mobility (8). It is more than cliché to say that the rich have become richer while the poor have remained poor.

While poverty may be cited as one factor making someone “at risk” for violent behavior, violence prevention interventions stop short of looking at economic deprivation as a potential cause of violence. Several studies have shown that community assets and resources are positively correlated with lower levels of delinquent behavior, violence, and aggression irrespective of race (9). Increasing overall community resources and assets should be considered as mechanisms to reduce the violence occurring in these communities. Unfortunately, violence prevention has been limited to teaching high risk individuals how to cope with poverty instead of addressing the lack of community resources necessary to protect against violence from within.

While only a small percentage of youths in low-income neighborhoods join gangs, members of these gangs commit a significant percentage of violent crime (10). The function of a gang in contemporary urban society is largely an economic one. As industry moves out of the inner cities or outsources jobs oversees, the affluent move or commute to these jobs leaving everyone else to compete over what is left. As a result, substitute economies develop in these areas (10). Drug trafficking and the gangs they encompass are the largest and most profitable substitute economy. The connections it often has with the legitimate economy are a result of its size and profitability (as opposed to panhandling and street vending) (11). It is important to keep in mind however, that economic strain and gang activity is only one factor in the rate of violence and is not the entire picture. Indeed, there are other failures in the public health model of violence prevention that need to be deconstructed in order to move away from the one-dimensional behavioral approaches and to better understand the social and environmental factors as well.

Social Strain
Violence prevention does not address racism or class discrimination as a cause of violence. Employment discrimination, racial profiling, police brutality, and inadequately funded schools culminate into a harsh social existence for many inner city youth (12,13, 14). Because poverty can be seen as proportional to the presence of these structural barriers, social and economic strains are closely linked. For example, a mentoring program may be able to provide some level of social support, but the mentor cannot address the structural barriers that youth must overcome to emulate the mentor.

Similar to how gang and drug trafficking is a byproduct of economic strain, social isolation is a byproduct of social strain. Even if individuals in low-income urban neighborhoods do not join a gang (and most do not), the effect of being socialized into this isolation has a profound effect on the entire neighborhood. The effect of this isolation leads to a subculture of marginalized youth that feel they must “fend for themselves” and adopt a code of personal defense and a “survival of the fittest” mentality (15). Overall, the youth who adopt this subculture are identified as being the criminal element in a city. This label often has a self-fulfilling prophecy in that these youth believe that jail and/or death wait for them at a very young age.

These youth represent a small but tragic consequence of economic and social strain. Without the social isolation caused by racism and discrimination, violent crime is likely to be reduced because gangs would be less able to recruit people marginalized by their social circumstances. Similarly, without economic strain, violent crime is likely to decrease due to a reduced need for the violent alternate economies that a substitute for the mainstream economy.

Environmental Strain
The geographic location of where violence occurs is can give important insight into how violence prevention programs could better be designed. Violence is particularly concentrated in areas of high racial segregation, which places a disproportionate health risk on the residents of these neighborhoods. A better understanding of the effects of segregation will illuminate another fundamental cause of violence, one that is created by environmental strain. This particular type of strain has a profound impact on racial disparities because it obstructs the ability to manage or overcome the social and economic strains discussed earlier.

Racial segregation has a long history in the United States. Racist policy and prejudices geographically divided people by the color of their skin. African Americans were not offered the same housing or loans offered to whites, were paid less or not hired at all for jobs offered to whites, and were denied entrance to attend university and colleges in certain areas (16). African Americans, by a matter of policy, were denied these resources most necessary for economic mobility. The passage of the civil rights act of 1968 did not redistribute these resources concentrated in mostly white neighborhoods. African Americans and other minorities continue to face barriers to achieve what always had been available to those living in predominately white neighborhoods.

Today, predictably, areas with highest levels of racial segregation are characterized by having the poorest schools, fewest job opportunities, highest concentration of poverty, and, consequently, the highest rates of crime and drug abuse (17). The cumulative effect of this racial segregation has a direct impact on the violence experienced by youth in these neighborhoods. In this context, social norms are established that accept violence as a part of everyday life. With fewer legitimate options for employment, drug trade is established that creates economic motives to commit violence.

Conclusion
The majority of major violent crimes are committed by urban youths from low-income and minority backgrounds. While this fact may help public health initiatives identify the geographic location of violent crimes, it does not help to design interventions that address the economic, social, and environmental factors that surround violence. By reframing violent crime as a byproduct of environmental, social, and economic forces (and not acts of deviant individuals), initiatives will be more effective in reducing the violence that disproportionately burdens minority and urban communities.

REFERENCES
Centers of Disease Control and Prevention. Healthy People 2010 Midcourse Review. Injury and Violence Prevention. (http://www.healthypeople.gov/data/midcourse/default.htm)
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. “Best Practices of Youth Violence Prevention: A Sourcebook for Community Action”. Atlanta, GA, June 2002.
Homicide Trends in the United States: Trends by Race. http://www.ojp.usdoj.gov/bjs/homicide/race.htm
Homicide Trends in the United States: Trends by Age, Gender, and Race. http://www.ojp.usdoj.gov/bjs/homicide/ageracesex.htm
Mytton J, et al. School-based secondary prevention programmes for preventing violence (Review). The Cochrane Database of Systematic Reviews 2006, Issue 3.
Merton, R. Social Structure and Anomie. American Sociological Review. 1938; 3: 672-82.
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Understanding Youth Violence: Fact Sheet, 2006.
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PBS Frontline: Drug Wars. Do the Math: Why Illegal Drug Business is Thriving. http://www.pbs.org/wgbh/pages/frontline/shows/drugs/special/math.html
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Hoffman P. Police Abuse (pp. 115-126). In: Shapiro S, ed. Human Rights Violations in the United States: A Report on U.S. Compliance. Human Rights Watch, American Civil Liberties Union. 1993.
Alexander E. The Social Ecology of Youth Violence. Crime and Justice, Vol. 24, Youth Violence. 1998; 65-104.
Cable S. and Tamara M. Economic Imperatives and Race Relations: The Rise and Fall of the American Apartheid System. Journal of Black Studies, Vol. 34, No. 2. November 2003.
Atkins S. Racial Residential Segregation and Crime. Sociology Compass. January 1, 2007: 81–94,

Evaluating The Anti-Underage Drinking STOP Campaign-Vanessa Vazquez

Historically, in terms of alcohol control policies, the Minimum Legal Drinking Age Law (MLDA) has been credited with lowering the alcohol related morbidity and mortality rates in the United States (1). However, MLDA did not eliminate the ongoing problem of underage drinking itself. Underage Drinking continues to be a problem in all 50 states. Not only is underage drinking illegal, but it is also known to pose a threat to the individual and to society (2). Not surprisingly, alcohol is the most commonly used and abused drug amongst adolescents (3). A 2003 research study discovered that, on average, adolescents are 14 years old when they take their first drink (4). Age is of concern primarily because early initiation of drinking has been linked to alcohol consumption problems later in life (3).

In response to the escalating trend of underage drinking in the United States, Congress passed the Sober Truth On Preventing Underage Drinking Act or STOP ACT in 2006. The STOP Act has both federal and state provisions; the federal Interagency Coordinating Committee on the Prevention of Underage Drinking (ICCPUD) was established. The responsibility of (ICCPUD) is to ensure that the states are implementing laws and programs to counter underage drinking. As part of the STOP Act, the STOP media campaign was created to raise adults’ awareness of underage drinking through the use of information pamphlets, meetings, and other forms of advertisement.

The advertising campaign that accompanies the STOP Act shows promise with its focus on raising awareness in the community about teenage drinking. However, the campaign fails, because it relies on a rational model of behavior change, focuses only on increasing knowledge about risks, rather than dealing with the emotional and social reasons teenagers drink, and ultimately targets adults rather than teens.

1. Campaign Assumes Knowledge of Risk Factors Will Prompt Change
The STOP campaign tries to influence adolescent behavior by focusing on their intellect with facts, instead of focusing on their emotions, which can make more of an impression. The campaign uses a myth or fact pamphlet aimed at increasing the perceived risk of underage drinking intended to encourage adolescents to change their behavior. The campaign also assumes that people make rational decisions, not allowing the campaign to account for spontaneous teenage behavior and irrational decisions. Basically, the campaign is using the overused Health Belief model that focuses on behavioral change at the individual level and has been proven to be an ineffective model of behavior change (5). Some known determinants of behavioral change are perceived norms and self-efficacy, however the role of perceived risk is inconsistent to intention and behavior (6).

The STOP campaign further assumes that the causes of underage drinking are at the individual level instead of on a group level. By overlooking the impact of the social environment (peers, community, family) on behavior, the campaign is ignoring the role of others’ beliefs in shaping an adolescents’ own. The best method of sustaining prevention is not only to target the individuals but also their environment (7). Community involvement is also important in creating changes in institutional policies (schools, alcohol establishments, etc.) and public policies with regard to the underage access to alcohol (3).

The ineffectiveness of the traditional Public Health models should serve as a warning to the creators of the STOP campaign, who would be wise to use advertising models to reach their audience. In mass media campaigns, the group is more important than the individual. Considering a broad audience, messages are designed and audience segmentation, or targeting similar people, is ignored to achieve campaign objectives (8). Thus, the STOP campaign should not overlook the adolescents in delivering its campaign message of anti-underage drinking. Instead, the STOP campaign should try to incorporate framing theory, agenda setting theory, and social expectations theory to target teenagers.

According to agenda setting theory, “the media’s agenda sets the public’s agenda” and “the emphasis placed on issues in the mass media influences the priority [given to] these issues by the public” (9). The STOP campaign should use the media to influence what people think about, in this case, the problems facing America’s youth as a result of underage drinking. The STOP campaign can further use the media to put the issue of underage drinking on the public agenda. By doing so, the campaign will gain leverage by reaching out to the community, parents, and students themselves, helping to make everyone aware of the issue. Getting the underage drinking issue on the agenda and making society aware of the problem are the first steps to bringing about change in society.

Once the STOP campaign has made the underage drinking problem known to society, it is now time to target the teenagers themselves through the use of advertisements, such as commercials and print ads. Getting the message out to the public is important, but how the message is framed is what will determine whether or not adolescents will respond to it in terms of behavior (10).
Good framing will target the behavior that needs to be changed, in this case underage drinking, and frame the issue in a way that makes it look unfavorable for teenagers to do. Implementation of good framing will also require the STOP campaign to play on adolescents’ emotions with more images and fewer words or facts. In this arena, public health campaigns need to learn from the advertising industry in order to effectively reach teens.

Another strategy to consider is the use of social expectations theory, which says that people’s behaviors are affected by social norms, values, and roles. This theory defines how people are expected to interact with others in society and how to be integrated in the community (11). The STOP campaign should use this theory to advertise to teenagers that underage drinking is not the norm for people their age. For example, in a possible commercial, the STOP campaign can depict a fun party scene, but when one teenager brings alcohol in order to get the party started, everyone stops and looks at them in disbelief. Incorporating social expectations theory is vital because adolescents are primarily concerned with how others perceive them, which in turn is reflected in their behavior.

2. STOP Campaign Targets Adults Instead of Adolescents
Another flaw of the STOP Campaign is that the campaign is misdirected, targeting adults with the hopes that they will influence adolescent behavior, instead of targeting the adolescents themselves. Previous prevention programs have been successful by incorporating parents and the community, but ultimately targeting teens. One example of a successful prevention program is Project Northland, which is a multiyear youth intervention program. The program was first implemented in Minnesota in 20 school districts for three years from 6th to 8th grade, and was designed to address adolescent age appropriate concerns. In sixth grade, the program focused on adolescents’ skills to communicate with their parents about alcohol (12). Seventh grade education taught students to cope with peer issues and expectations about alcohol. Lastly, eighth grade taught students how to bring about community changes regarding alcohol programs and policies (12). A study later reported that at the end of the three years, when compared to the control communities, those in the intervention community reported a smaller percentage of students drinking or beginning to drink (3). The success of this anti-drinking program can be attributed to the fact that the program was designed specifically for teenagers’ needs during their adolescent years. Not only did the program try to change adolescents’ social environment, but also it allowed the students to be advocates of change by allowing them to write the newsletter “TEENSpeak.”

Another successful multiyear program is SADD, Students Against Drunk Driving or Students Against Destructive Decisions. SADD is an alcohol prevention program that primarily targets middle school and high school age adolescents. Chapters of SADD exist across the country and follow the philosophy “that young people, empowered to help each other, are the most effective force in prevention”(13). Therefore, it is the older SADD students who serve as mentors for younger adolescents in the group. Mentoring is vital to the programs’ success, because it is based on the idea that the most effective source for a message is the audience itself, in this case students educating other students about drinking. SADD also teaches students normative education, changing adolescents’ notions of peer alcohol use and provides peer discussion groups. The literature supports the use of such programs as SADD, stating, “the most effective programs utilize multiple years of behavioral health education, community-wide involvement and mass media complementing the school-based peer-led program” (14). Clearly, targeting teens is essential if the STOP campaign wants to promote behavioral change.

The STOP campaign’s insistence on targeting the parents of adolescents is ineffective because it ignores teenagers’ autonomy to make their own choices free of their parents’ beliefs. As stated before, the social environment does play a role in adolescents’ beliefs, but parental disapproval of drinking is not a key reason why teens abstain from alcohol (12). What the STOP campaign must consider is adolescents’ self-efficacy, or their confidence in being able to refuse the offer of alcohol and abstain from use. According to Bandura, it is perceived self-efficacy that influences behavior, from initiation of a new behavior to inhibition of another (5). One way to improve self efficacy is to change adolescents’ perceptions regarding their peers’ use of alcohol, making it known to them that it is not normal for kids their age to drink. By changing the adolescents’ norm perception, it will empower them to refuse alcohol, because they are not the only ones not drinking. The changing norm strategy relies on the value adolescents place on what others do and in turn how they are perceived.

Changing social norms, however, needs to involve parents of adolescents and, most importantly, how the parents perceive alcohol. Most adolescents report having been given alcohol by an adult or relative (15). Adults given adolescents alcohol might be explained by the fact that alcohol does not carry with it a social stigma like tobacco does, making it seem acceptable even for minors (1). Also, approval of underage drinking varies across households, primarily due to the difference in cultures and their acceptance of alcohol (15). Some cultures, such as the Hispanic culture, allow their children to drink wine at family functions or family dinners in order to share with the rest of the family. Cultural differences should not be shunned, but taken into consideration when planning alcohol prevention campaigns for youth in order to reach the broadest possible audience.

3. Interventions Will Be More Effective If Underage Drinking Is Viewed As a ‘Developmental Framework’
According to the Surgeon General, public health interventions will be more effective if they look at adolescents’ underage drinking through a “Developmental Framework” approach. The Surgeon General encourages campaigns to take a multifaceted approach to solve the underage drinking problem by focusing on adolescent development. Adolescence is a time when kids transition from childhood to a pseudo adulthood stage, in which time they are made to cope with ongoing biological changes, social changes, and behavioral changes. In the quest to find their identity and place in society, adolescents are known to increase their sense of risk taking in order to further state their independence. Research shows, that the puberty stage itself, or the shift to adolescence, has been associated with alcohol use (4). The brain, in particular, at this time begins remodeling itself and continues well into the twenties. The creation of new connections between nerve cells, and the pruning of some existing connections can in turn affect an adolescent’s impulse control, planning process and decision-making (16). Social changes will also occur, during which adolescents are placed in unfamiliar situations due to their peers, and since they lack experience, they often make unhealthy decisions. The STOP campaign should try to counter unhealthy decisions by educating teens about the changes they are undergoing and building their self-efficacy to resist making risky decisions.

Not only are teens likely to drink because of the changes they are undergoing, but also alcohol itself appears to have a different effect on adolescents than it does on adults. As a result of the brain’s remodeling, how adolescents respond to alcohol is altered as well. Studies have shown that adolescent memory is greatly affected and this cognitive impairment is lasting (16). Adolescents are also able to consume larger amounts of alcohol because they are able to stay awake longer and be mobile at higher blood alcohol levels as opposed to adults (4). The most common reason why alcohol has a different effect on teens than adults is because adolescents expect the positive effects of alcohol in social situations in order to have a good time and it is because of this ideal that they are inclined to drink more (4).

Identifying factors that predict alcohol use are not enough to change behavior. The STOP campaign should deal with the reasons why teens drink. The social environment, in particular, peer influence due to perceived norms of the American culture, might explain underage drinking. Adolescents want to be accepted by their peers and if they think that others are drinking, they want to do it too. However, adolescents’ perception of the quantity of drinking their peers do is skewed primarily because they overestimate the drinking habits of others (16). Overestimating is a problem because adolescents want to be like their peers and try to drink as much as they think their peers are drinking. The STOP campaign in this case should implement a social norming ideal to correct the misconceptions of adolescents regarding peer drinking. The Northland Project succeeded in this arena. By the end of the 8th grade, those in the intervention district had lower scores on the Peer Influence Scale (12).

Other reasons why teens might drink are because of their upbringing, its easy access, and the expectancies that teens have regarding alcohol. Beliefs regarding alcohol are established early in life. The positive expectancies that adolescents place on alcohol such as sociability and sexual attractiveness make drinking a pleasurable experience (16). Common sense indicates that those who associate alcohol with a pleasurable experience are more likely to drink. The most common reason teens gave with regards to drinking is because they enjoyed it and it got them in the “party mood” (14). Wanting to get in the “party mood” again plays on the notion that social acceptance influences teens’ behavior making them want to be perceived as cool by their peers. Easy access to alcohol makes adolescents not think twice about drinking, because no one is stopping them (1). Adolescents can get alcohol from adults or relatives in their families, older siblings, and older peers. These enablers do not think what they are doing is harmful to the adolescent, because they just see it as a way to help the teen out. In the college culture it is seen as, when I was underage an older peer bought me alcohol, thus, when I am of age I will do the same. Some bold teens even use fake IDs to purchase the alcohol themselves. The consequences of getting caught do not deter the use of the ID. On the contrary, students just try harder to avoid getting caught (1).

An adolescent’s upbringing is one factor that might affect their belief regarding alcohol. Family disruption, conflict, low parental supervision, and being a child of an alcoholic are factors that are well known to influence alcohol use among teens (17). These teens might see alcohol as a coping mechanism to deal with their less than picturesque life, of which they are victims.
If the STOP campaign seeks to address all the issues influencing a teen’s choice about alcohol use, a media campaign alone is not going to solve the problem. Instead, a multiyear prevention program will have to be considered to give adolescents the foundation to change their perceptions and encourage the community to realize that underage drinking is harmful to America’s youth.

Implications
By not addressing many of the previously mentioned factors, the STOP campaign will fail. Thus, future research needs to be done regarding other prevention methods for teen drinking. Incorporating Social Expectation theory to change existing norms in the community is one way to sustain behavioral change (18). Normative re-educative strategies should also be implemented to reinforce the fact that most teens do not use alcohol. Realizing that underage drinking is a group level problem, parents, the community, and the government need to act to change the escalating drinking trend among teens.

The community can try to incorporate the adolescents and make them feel useful by engaging them in positive activities such as volunteering, participating in local functions, and by creating more youth hang out venues (17). The government can set new underage drinking laws that will further enforce the STOP Act Law in local communities. If enough resources are devoted to the enforcement of the new policies, underage alcohol consumption will be reduced (1). State enforcement can be ensured if the government penalizes the state for not controlling underage drinking by threatening to withhold state funding.

Conclusions
Underage drinking is a national problem that has been escalating over the years, and an effective public health intervention is well over due. After considering all the reasons why teens drink, from the biological changes to the social factors, it only makes sense that the most powerful prevention programs will be those that implement a multiyear approach that can address adolescents’ changes first hand, much like Project Northland. Other public health campaigns should take this information and use it when creating alcohol prevention programs and anti-underage drinking media campaigns in order to target teens effectively. The STOP campaign cannot be expected to make an impact if it is just delivering a message to parents and then letting them fend for themselves. The STOP campaign must focus on their target audience, the teenagers, not their parents. Also, the STOP campaign will not change behavior simply by increasing knowledge of risk through a 3-minute media clip and a pamphlet. Behavioral change can only come about through a lengthy process of helping individuals change, by changing their belief system, and, ultimately, sustaining this change by altering social norms. Encompassing all these attributable factors is a whole system approach that looks at underage drinking as a “developmental framework.” The STOP campaign is failing, because it relies on a rational model of behavior change, focuses only on increasing knowledge about risks, rather than dealing with the emotional and social reasons teenagers drink, and, ultimately, targets adults rather than teens.

References
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Drinking Behavior Access to alcohol, and the Influences of Deterrence
Policies. Journal of American College Health 2002; 50: 223-236
2. National Institute on Alcohol Abuse and Alcoholism. Underage
Drinking: A Major Public Health Challenge. Bethesda, MD: NIAA.
3. Komro K and Toomey T. Strategies to Prevent Underage Drinking.
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4. National Institute on Alcohol Abuse and Alcoholism. Underage
Drinking: Why do Adolescents Drink, What are the Risks, and How
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Alcohol, Tobacco, and Other Drug Use: A Risk Factor Resiliency Based
Approach. Rockville, MD: Center for Substance Abuse Prevention, 1994.
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Hyperlinks
1. http://pubs.niaaa.nih.gov/publications/aa59.htm
2. http://pubs.niaaa.nih.gov/publications/AA67/AA67.htm
3. http://eric.ed.gov/ERICDocs/data/ericdocs2sql/content_storage_01/0000019b/80/13/d6/9e.pdf
4. http://www.sadd.org/value.htm

A Health Food Framing Fallacy: How the Public Health Promotion of Whole Grains Will Make Us Sicker - Michele Tassinari

The typical American diet has been identified as one of the reasons the US spends the most on health care yet ranks below other nations in numerous health outcomes. After two generations, immigrants develop the same rate of disease as Americans, evidence that “the chief cause of this health crisis is poor and imbalanced diets” (1-5). According to the Surgeon General, “your choice of diet can influence your long-term health prospects more than any other action you might take”. Heart disease, cancer, stroke and diabetes have been the leading causes of death in the US for decades. Sixty one percent of these deaths are attributable to diet (6-13).

Whole grains which are framed as health foods, are touted as being helpful in preventing cancer, cardiovascular disease, diabetes, obesity and several other diseases. However, for an estimated 42% of the population, whole grains have just the opposite effect and actually cause illness. An estimated 15% of the population has a wheat sensitivity (1 in 7 people) and an additional 30% react to gluten, a protein in wheat (14-15). The popularity of the Atkins diet was due to the elimination of bread-based carbohydrates. Atkins resulted in people discovering how much better they felt without wheat-based products, which were the underlying cause of their health problems (16). Overall, close to half of the population experiences negative health problems due to food products containing wheat.

The public health normative re-educative approach to promoting whole grains in place of refined grains for better health is misguided. It will aggravate and increase the morbidity and mortality rates whole grains are being advertised to ameliorate.

“Wheat between the lines”: What Health claims and the Whole Grain Council fail to mention

Research clearly indicates substances in whole wheat grains can interfere with not only animal but also human metabolism. Public health officials fail to take into account wheat’s tendency to aggravate body function among those with and without sensitivities (17-22). For those with wheat sensitivities, consuming wheat reduces the quality of daily life and eventually becomes fatal.

The symptoms of wheat sensitivities are vast and eclectic. They can be minor, annoying symptoms like runny nose, itchy skin, extreme fatigue, a feeling of insatiable hunger, mouth cankers, joint problems, stomach issues like bloating, cramps, gas, constipation or overly frequent bowel movements, depression, trouble concentrating, memory problems, headaches, general unwell feelings, and lactose intolerance. Children with wheat sensitivities tend to have behavioral problems, trouble in school, learning and concentrating problems, eczema, dental enamel defects, increased cavities, anemia and other nutritional deficiencies, continual colds or frequent sickness. Interestingly, children with autism and ADD have shown improvement when placed on a gluten free diet. Teens and adults, in addition to the issues children may face, may additionally experience acne/rashes, extreme mood swings and behaviors, migraines, anxiety and depression, eating disorders, blood sugar problems that can lead to diabetes, difficulty gaining, losing, or maintaining a healthy weight, circulation problems in hands and feet, and arthritis. Women may experience delayed menarche and cycle irregularities, frequent yeast infections, polycystic ovary syndrome, infertility, miscarriages, intrauterine growth retardation, low birth weight babies, and loss of bone mineral density (15,18,23-29).

Wheat may also be the culprit behind America’s large appetite. Wheat contains a protein called gluten. Digestion of gluten containing food produces exorphins, peptides with morphine-like activity that can interact with the central nervous system opiate receptors. Opiate peptides in the brain are involved in motivation, emotion, attachment, behavior, the response to stress and pain, and the control of food intake (30). Those with wheat sensitivities have a stronger opiate response during digestion, resulting in a feel- good “high” sensation, which leads to an urge for more. There is biological truth behind the phrase “comfort foods”. When not regularly consumed, fatigue, irritability, restlessness, a ravenous hunger, brain fog and other similar “crashing” withdrawal symptoms occur, ultimately resulting in a carbohydrate-based food craving/addiction. Many blame their inability to limit certain foods on a lack of willpower, but the true culprit may be an underlying wheat-induced opiate response.

The gluten protein is also found in barley, rye and often oats. The gluten content of products is increasing, in the effort to add more fiber and whole grains to food. Gluten is great for baking and manufacturing food. It has sticky and elastic properties that make products more heat resistant, malleable, and elastic. Gluten makes bread fluffier, gives pizza the right texture, and results in cakes, cookies and pastries that are moist, spongy, and aesthetically pleasing.

These sticky and elastic properties also make gluten difficult to digest. As wheat travels through the small intestine, the gluten particles can linger and adhere to the walls of the small intestine causing the body’s immune system registers the gluten proteins as invaders. The cells of the small intestine are attacked and killed in the process. The major function of the small intestine is to absorb macro and micro-nutrients. The presence of gluten leads to malabsorption of many nutrients, including the three most common supplements for women:iron, folate and calcium (31-36). Compounding the damage, undigested gluten can be absorbed into the bloodstream, eliciting a systemic autoimmune response injuring the tissues and organs throughout the entire body. Gluten can cause multi-system ailments “that affects not only the gastrointestinal tract but also the hematologic, endocrine, dermatologic, neurologic, reproductive, and orthopedic systems”. It is suspected as “the root cause of many cancers, autoimmune diseases, neurological diseases, chronic pain syndromes, psychiatric and other brain disorders, and premature death. There is also a clear causal connection with some cases of osteoporosis, epilepsy, learning disorders, attention deficit disorders, infertility, miscarriage, premature births, and chronic liver disease” (15,18) .

Whole Grain Havoc: The One-Sided Policy Perspective
"Diets rich in whole grain foods and low in total fat, saturated fat, and cholesterol, may help reduce the risk of heart disease and certain cancers". This phrase is commonly seen and heard today in newspapers, magazines, on tv, on food packages and from professional nutrition experts. “Whole grains” is a term used loosely by the general public and by officials to mean wheat. For example, the Whole Grain Council states that in one year whole grain flour production increased by 26%. In fine print at the bottom of the page, it is noted that the term whole grain flour is in reference to wheat flour (37). Public health officials are promoting the benefits of increased whole grain consumption on several levels, from mass media advocacy to policy changes

In 1997, the FDA first began to tout the health benefits of whole grains, from preventing heart disease and diabetes to helping maintain a healthy weight. Content claims, statements on food labels that proclaim a relationship between eating a food and that food promoting health or helping prevent disease (due to some ingredient or nutrient in it) were authorized. Health and nutrition claims are based on current published scientific statements from "a scientific body of the United States with official responsibility for public health protection or research directly related to human nutrition” and must not “exceed the disqualifying amounts of nutrients that may increase the risk of a disease or health-related condition in the general population” (38).

Yet, in the late 1980s, a similar effort was made to advocate low-fat products to aid in weight loss, control blood pressure and promote health. Food labels nationwide proclaimed reduced and low fat content and people avoided fat across the nation. A decade after the low fat campaign, the Center for Disease Control declared an “obesity epidemic” in America. The low fat fad employed downstream framing by only conveying the negative side of fats. The public, unaware that certain fats are beneficial and necessary for proper body function, avoided all fats, which was an unhealthy, erroneous and detrimental diet.

The same limited perspective downstream framing technique is being used to aggressively promote the consumption of whole grains. In 2005, the modification of the food pyramid was hailed as a major advance over the outdated version of the 1980s because it now boasts that “consuming at least three servings of whole grains per day can reduce the risk of diabetes and coronary heart disease and may help with weight maintenance. Thus, daily intake of three or more servings of whole grains per day is recommended, preferably by substituting whole grains for refined grains”. However, the pyramid still advocates 6 or more servings of bread products, ultimately remaining static in its recommended diet composition (39-40).

The perception of whole wheat as a wholesome, nutritious food is being pushed on the policy, economic and social levels. It is true that whole grains have more fiber, more nutrients and antioxidants and a lower glycemic index than refined grains. However, similar to the low-fat framing, this one-sided promotion of whole wheat will neither promote health nor healthy eating habits.

Wheat woes: The Bias in the Science
Public health is based on the logic that “it is better to err on the side of prudence even if it means persuading us all to engage in an activity, eat a food or take a pill that does nothing for us and ignoring, for the moment, the possibility that such as action could have unforeseen harmful consequences” (41). Public health officials are overlooking the negative evidence and avidly linking increased whole grain consumption to decreased disease outcomes.

The claim that whole grains reduced the risk of cardiovascular disease was announced in 1997 after a review of sixteen studies. Fourteen showed a reduced risk, two did not (42). However, sample size, retention rates, and other causes of bias and confounding were not carefully considered. Women in these studies with the highest intake of whole grains were shown to smoke less, exercise more, drink less alcohol, and were more likely to take Hormone Replacements, showing health conscious lifestyle and behavior attitudes (43). Moreover, whole grains often, but not always, have less sugar, hydrogenated fats, food additives and other chemicals than refined products, further confounding if the effect on the body is due to whole grains or due to the lack of additives. These observational studies cannot determine causation, as the one-sided media headlines often imply.

Forty case-control studies were used to establish the relationship between whole grains and a decreased risk of cancer. Seven did not support the association. One showed an increase in thyroid cancer(44). The effects of whole grains in the body are not understood. It is not clear if apparent protection is due to one or several nutrients in combination, indicative of a more health conscious lifestyle, socioeconomic status, or an interaction with body mass and composition (45).
Diabetes and whole grain studies show mixed results (46-49). However, animal models show an increased risk of diseases, such as diabetes, and early death when fed gluten (wheat) based diets (19-22).

Some studies, in lieu of the FDA’s eager promotion of whole grains, were sponsored by food companies. For example, one study entitled “The Importance of Promoting a Whole Grain Food Message” received financial support from Sara Lee Bakery and the Wheat Foods Council (50). The United States Department of Agriculture is a prominent sponsor of major nutrition research grants. The USDA’s purpose is to regulate and promotes agriculture. Considering wheat is a major money-making crop, there is a distinct conflict of interest.

Implications for a “glutened” society: The Celiac Iceberg
As wheat continues to be ingested over the years, celiac disease can develop. Celiac disease is the most severe and extreme reaction to the gluten protein. A tiny crumb of bread is enough to trigger a deleterious immune response. Celiac disease is more than twice as common as cystic fibrosis, Crohn’s disease and ulcerative colitis combined. However, many physicians misdiagnose it as another problem like irritable bowel, or dismiss patients as hypochondriacs or overly stressed. Patients don’t associate their symptoms with the food they ate. Currently about 1 in 133 people (approximately 1% of the American population) are thought to have celiac disease, but 97% of them do not even know they have it (15,18,23). The only treatment for celiac is life-long adherence to a gluten-free diet, which is extremely challenging and frustrating in today’s society. The whole grain enhancement of foods has made it even more difficult. Foods that once were gluten-free such as Rice Krispies, soy milk, salsa, and corn chips are now fortified with whole grains.

Untreated celiacs are twice as likely to die early from cancers, diabetes, osteoporotic issues, and liver problems. Diabetes tends to co-occur with celiac disease. Women are 2 times more likely to have celiac than men. Breast cancer in the families of celiac patients is twice as common as in the general population (15,18,51-54). Morbidity rates are much higher for cancers especially colorectal and gastrointestinal cancer: which are some of the most prevalent forms of cancer. Undiagnosed and untreated celiacs have a higher risk of death than smokers (26).The current prevalence of celiac is forty times that of what was thought only 12 years ago (23,29).

Conclusion: Wheat Whiplash
Knowingly or not, most Americans are eating larger quantities of whole grains because of the many products that are now whole grain enhanced, from Lucky Charms and Pringles to whole wheat pasta and 100% wheat bread. Over 600 million metric tons of wheat is eaten annually, making it the most consumed grain (15). Health officials have a one-sided, steadfast opinion that increasing wheat in the whole grain form is the solution to the nation’s health woes. Many Americans care about their health. According to the International Food Information Council, 75% of Americans are concerned about their weight and 70% modify their diet in hopes of losing weight, often switching to whole grains with hopes of better health (55). Framing wheat as a health food when close to half the population unknowingly has an adverse reaction to it is a deleterious public health policy. Wheat may be the fundamental cause of the augmenting American morbidity and mortality rates. Public health officials are either unaware of or are failing to acknowledge the evidence that wheat is not the health food it is widely perceived to be. Continuing to promote whole wheat as part of a healthy diet will continue to demote the health of the nation.

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Why our Nation’s Obesity Initiatives Fail in Producing a Healthy Population and Curbing the Epidemic - Megan Reeve

Obesity has been growing drastically in the United States over the last 20 years, among both children and adults. Childhood rates have actually tripled during this time (1). The government, along with the Center for Disease Control (CDC), has begun to label it as an illness or disease, rather than just poor eating habits (2). These higher rates are raising health concerns because of the consequences of heart disease, diabetes, hypertension, and several other health problems that are associated with obesity (1). The epidemic has only recently been identified as such, and focused initiatives to combat the problem have just begun to loosely be put into effect, such as changes in school lunches and more access to parks and bike paths (3), but they have yet to see much success. Since a large part of the epidemic is due to more than genetics and poor food choices, policies need to use tactics targeting behavior change and social constructs to see real transformations. Health practitioners and advocates also cannot expect change to occur overnight, this type of large-scale public overhaul will give very gradual results.

Currently, some states have enacted types of nutrition reform in schools, and others are promoting physical activity in communities to help alleviate the crisis (3). But so far there has been no solid federal involvement from the government, and some argue that is an important part of the battle against obesity that is missing (1,5). Clearly something still needs to be done, as obesity rates are still rising in all but a few states, mainly because it is not universally recognized as a large scale crisis, there is a lack of political will and funding to solve the problem, and throughout the country there is a lack of standardization among states to cooperatively get the nation to adopt healthy lifestyles.

Obesity is Not Accurately Recognized
Both the general public and public officials themselves have not correctly recognized and identified obesity for what it is: a disease and not simply poor eating habits or an unhealthy lifestyle. Many Americans believe in a culture of “quick fixes” and this terminology has begun to include diet and weight loss. Upon doing an internet search for weight loss or dieting, hundreds of different websites may appear offering pills or herbal remedies or new machinery promising a beautiful healthy body in very little time. Most Americans are not interested in long term approaches, nor do many of them think about the long-term effects their choices could have, as fast food establishments are as popular as ever, and young girls still suffer from eating disorders to keep their weight down. Both of these are examples of how busy daily lives can push the thought of a healthy diet and lifestyle to the bottom of the priority list, even though those choices can very well have a significant effect through old age. But since the importance of food choices and physical activity are mingled with ads about metabolism boosters, fat burning supplements, and cosmetic surgeries, the health consequences of high blood sugar and heart problems get lost as well.

The bias that exists among the public not only exacerbates the problem, but also means that many people are continuing to misidentify the obesity epidemic. Both the general public and healthcare workers judge people based on weight and/or appearance. This ignorant judgment can cause harm in all aspects of someone’s life, including home, work, school or their children’s school (4). In addition, it fosters blame and intolerance for those who are overweight, making them feel less and less adequate and more depressed (4). This often triggers binge eating, which is common among people suffering from feelings of inadequacy and depression, and continues their weight and health problems. Some people are predisposed to obesity because of genetics, some have metabolic disorders, and some may just have unhealthy lifestyles, or were raised only being exposed to the wrong types of foods, or perhaps are not sure what needs to be changed in their habits. By simply ignoring these people or being narrow-minded and cutting them off from society nothing is going to be solved. The crisis is simply going to continue and be perpetuated by those who think they are above the problem, and that those affected should take care of themselves.

Another problem in this facet of identification is the discrepancy that arises. As people are becoming more educated about the consequences obesity can have, nutritionists and dieticians are becoming more prevalent and available, but only to those who can afford them (6). Even the U.S. Surgeon General has said that 8 out of the top 10 leading causes of death, including coronary heart disease, stroke, some types of cancer, and diabetes mellitus, are all related to diet (6). Yet Medicaid and Medicare will only cover expenses due to nutrition and weight issues if it is absolutely necessary to the individual’s immediate health status. This limitation on coverage makes lifestyle changes very hard for those who cannot afford to pay out-of-pocket, and are not quite at the level where their lifestyle presents imminent danger to their health. But they may very well be at the point where revamping their way of life will take more than just a few thoughtful meal changes, and need assistance to achieve their goal. There are also discrepancies throughout the country, even though it is a widespread problem; the southern states are experiencing much higher rates than the rest of the U.S. (5). These kinds of issues need to be targeted without the ignorance that it is all individual choices and those in the south, or those too poor to pay for dieticians are not influenced by their environment. To be successful, the government and health officials need to understand the factors that contribute to these regional and socioeconomic disparities (1). By looking to make social changes instead of relying on personal changes, more success and less resistance will occur.

Lack of Political Will
There is a lack of politically driven initiatives to fight this dilemma. While looking at the whole picture, obesity may seem like a small challenge compared to war and the economy and universal health care, the problem has been gradually growing, and if it continues to grow at this rate, both American health care and the economy will be worse off because of it. Currently, there is a substantial lack of funding for obesity research and development, even though the impact it is having on the country (7). However, so many other diseases such as AIDS, Diabetes, and Heart Disease are considered higher priorities and are more well known, allowing for additional funding from smaller, private donors. Obesity is an underlying cause of both Diabetes Type II and many forms of Coronary Heart Disease. If additional funding were available for more research and education in these areas, it is likely that obesity rates would decrease, as would rates of adult onset diabetes and heart disease.

Funding also becomes an issue when it comes to children in this generation and future generations. Physical education classes in elementary schools and high schools are declining. Often schools are suffering financially and cannot afford gym teachers, or appropriate facilities that create an environment that promotes physical activity. The schools that do have classes are often too big with too many different age groups and skill levels with minimal supervision (8). There are loosely enforced requirements for both elementary and high school students to have a minimum amount of physical activity each week, but they are frequently not adhered to, and usually without consequence (9). Nationally less than 6 percent of high schools require physical education for juniors or seniors, according to the CDC (9). If funding is not the issue, schools have to deal with more demanding standardized test goals in fear of being closed if their students do not perform well. This added academic pressure often means that gym classes are the first to be deleted from the schedule when making space for a more demanding curriculum. Fitness advocates blame the state education departments for diminishing physical education’s importance by not enforcing the state’s minimum requirements for physical activity(9). Usually it is a combination of both of these situations, but simple federal funding to the schools that really need it, coupled with a more adamant insistence that physical education for children is necessary would easily assist in halting childhood obesity incidence.

There have been many state proposals to decrease obesity, but there needs to be a national commitment to fixing the problem. Researchers and scientists know all about nutrition and exercise, and how to live a healthy lifestyle, and normal standards of maintaining fitness. However, the problem lies in actually inspiring behavioral changes across the nation, and effectively empowering people to make those nutritious and fit choices by removal of barriers and complete access to what they need (1). Too much has been left to personal responsibility, which clearly is not the answer. People do not make decisions without input from others, and are constantly influenced by friends, school, work, and the media. In order to make changes at all of these levels, the government will have to at least engage at the macro level to help the changes and attitudes reach environments and communities on a more local level (1).

A few states are in the process of considering bills informally known as “fat taxes”, in an attempt to curb eating unhealthy and the purchasing of junk food. Controversies have arisen over the motives of this tax (10). Is it really about trying to help people to establish better eating habits, or is it just another way to squeeze more money out of the public and into the government’s pocket? It is similar to the tobacco tax, which forces people who smoke to pay more for their habit: Is a tax really the best way of addressing people’s eating habits? Often those who buy junk food do so because it is cheap and they do not have much money. To make junk food more expensive will not enable them to make healthier choices, but may force them to allocate more of their minimal funds to food (10). This idea also gives a different point of view regarding approach, as many opponents of these bills support the idea that personal responsibility is the best policy when fighting obesity (10).

Lack of Standardization Throughout the Country
Some states do a great job of building parks and walking paths and bike lanes, others have their schools revamping cafeteria food to offer only nutritious choices, while others do not even realize the magnitude of the obesity problem. Does this mean that those states with higher rates should be stricter about attacking the problem? Or that those already active states such as Colorado and Hawaii do not have much to worry about and can relax instead of rushing to form new bills and urging social change? The problem with tackling the epidemic on the state level like this arises when people move around the country, like many often do. Hypothetically, if children are conditioned in a school in New Mexico to drinking only milk and water and being exposed to only healthy food options, and their family moves to Mississippi, it is neither fair, nor helpful to allow them to revert back to soda machines and pizza rolls in their new school. If this issue is addressed state by state, the country will not see cohesive, positive results, and it will continue to be a disjointed balance of progress and failure. It is also difficult to convince national food and beverage corporations to make changes to their nutritional facts, or make national restaurant chains post nutrition facts unless the initiatives are unified throughout the nation (5). Without the federal government’s help, it is difficult to achieve consistency with new policies and effects that have the ability to change lifestyles.

Conclusion
The percentage of both the adult and child population that remains overweight or obese is still very high. If it is not addressed correctly in a short time, researchers suspect that it will be the first time children’s life expectancy will be shorter than adults (1,3). By properly addressing the epidemic as more than just personal choices for some states and cultures, and correcting stigmas that come out of the current weight bias, the problem can be corrected instead of just working to alleviate the symptoms for the fortunate few who can afford the treatment and nutritionists. Less focus should also be placed solely on weight loss. When thinking long term, it is more important to measure improved nutrition and physical activity than just pounds lost (5). The government will also need to admit that this is truly a public policy issue that they need to give attention to on the federal level if they want to see changes made on personal levels. Furthermore, the debate between government involvement and personal responsibility needs to be resolved. While personal responsibility is critical to adopting and sustaining healthy behaviors, many reports note that “individual change will not work in isolation” (5). Hopefully through this manner of thinking, American can turn the health of the nation around, instead of just lowering BMIs for statistics and losing weight for aesthetic purposes.

References

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