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

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

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

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

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

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

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

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

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

Unsatisfactory Implementation of the Policy

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

Training Issues

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

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

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

Staffing Issues

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

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

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

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

Inhumane Treatment

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

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

Recalls

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

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

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

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

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

The Limited Impact of Violence Intervention and Prevention (VIP) Among Target Neighborhoods in the City of Boston - Yuanyu(Emily)Lo

Introduction
Nationwide, we are seeing a surge in violence among the younger population, and youth violence has become a very important public health problem in recent years. Around the country, gang violence has spread to communities throughout the United States. At last count, there were more than 24,500 different youth gangs around the country, and more than 772,500 teens and young adults were members of gangs(1). From 1999 to 2000, youth-gang related homicides in Massachusetts rose more than 50 % (2), and the number of shootings started to climb: 268 in 2004 and 341 in 2005. Statistics show that Suffolk County Juvenile Courts handles approximately 2,275 cases annually for youths under 18 (3). According to the Massachusetts Youth Risk Behavior Survey, 2005: 10% of high school students were involved in a gang in 2004.

In 2007, Boston Mayor, Thomas Menino launched a Violence Intervention and Prevention (VIP) public health campaign in an effort to decrease the increasing violence in Boston neighboring communities. VIP used a canvassing approached and had volunteer go to four specific neighborhoods and knock on in order to distribute educational materials and survey the residents about violence concerns in their neighborhood. The volunteers worked in pairs knocking on residents’ doors and walked on the street in teams of six people per group. In addition the intervention put in place public safety officers (police and EMS) in each neighborhood to support the door-knocking team. Education materials were given in backpacks to each family filled with school supplies, giveaways for kids, and key information regarding city benefits and services such as educational flyers, youth service agencies and violence prevention agencies. When residents opened the door, VIP volunteers would ask the permission from the residents and spent 30 minute to an hour using the standardize survey to discuss about their concern in the neighborhoods. The goal of this campaign is to improve the safety of Boston residents living in high risk neighborhoods and to provide youths, and their families with the tools and strategies to address and resolve violence.

Failure of addressing social network issues
This campaign did not use social network to make it successful. According to the Greater Vancouver Street Gang Study, there are three types of gangs: criminal business organizations, street gangs and wannabe groups (4). These types of gangs must be distinguished in order to be able to tackle the major issues pertinent to the type of gang or gangs in these communities. Neighborhood implemented interventions need to understand this kind of range of gang difference in order to have a successful intervention. The VIP campaign had a good approach to visit residents in high risk neighborhoods between 4-8 pm however, most likely elderly and children would be home. The VIP intervention therefore needed to canvass the neighbourhoods and talk to community members that would know the difference between the kinds of gangs in their community to be able to get more information about what kinds of violence interventions the neighbourhood needs. Also, the educational materials did not offer the information that target different youth population, therefore, it may not deliverer the violence prevention message.

Most of the VIP volunteers were health educators and public health advocates, and most importantly members outside of the neighborhoods that were being canvassed. If we took social network perspective, neighborhood youth may think that talking to the volunteer is not “cool” since the volunteers do not belong to their peer group. Also, volunteers accompanied by EMT’s or the police. This may attract unwanted attention in the neighborhoods, and residents may feel intimidated talking to the volunteers because they don’t want to be associated with the police. According to social network theory, people’s behaviors are based on their social network. Using youth gang behaviors as an example, youth used violence to resolve conflict or seek revenge against their rivals. Failure to recognize the social network issue will lead to the inability to alter group behavior.

Failure to use “McGuire’s Communication Model”

Violence prevention interventions need to look at effective strategies that help people change behavior, like persuasive communication theory. Over the years, William J. McGuire has done extensive research in the area of attitude change and persuasive communication (5-8). He states when an individual is exposed to a message the information will be processed based on their individual personality and demographic (6,8). According to McGuire, there are several steps needed to alter the behavior including exposure, perception, comprehension, agreement, decision making, and action.

From the McGuire, it is critical to know who deliver the message. VIP campaign, messages were instituted by City Hall and delivered by public health advocates. Historically, young people tend to rebel against authority and do not like to be told what to do. They may rebel against their parents, teachers and public officials and do not want to listen to them. Who delivers the message and what messages are delivered are critical.

Even with exposure, attention is not guaranteed. The human brain can only process a small portion of the information it receives. When VIP volunteer handed over educational flyers and asking survey questions, it might overwhelm the residents with too many information which did not apply to them. It would be very helpful to select certain key messages to disseminate among the population with the hope that certain portions of the message will be retained. Personally, I think a backpack full of information will overwhelm residents. The backpacks would surely deliver the message, but it was not really a comprehensive means by which to do it. One thing to consider was that the residents might be less educated or limited in their English speaking skills. It might be hard for them to understand the message from the volunteers. Also, how they interpret the information might be very different from the message put forth by the campaign.

Self-efficacy issue
Self-efficacy is a person’s belief in his or her ability to succeed in a particular situation. Bandura described these beliefs as determinants of how people think, behave, and feel (9-12). Everyone can identify the goals and that which they wish to change to achieve these goal. However, young people who lack self-efficacy will believe that these tasks are too difficult or impossible to achieve. Therefore, they may just give up, or not follow through at all. Using adults showing up at their doors and telling youth the risk of street violence would not give them enough of a reason to change their behavior. Young people knew the risks of being in a gang and the amount of violence on the street. However, sometimes they believed that they had to join a gang to survive or to be part of the community. They had grown up in a gang culture, and it might be the only way of life that they knew. Gangs was a part of their lives and part of neighborhood culture. Failure to address these behaviors that were a direct result of their background would result in not being able to target the intended group.

Another obstacle young people might face is the inability to break away from the group or gang. Handing out surveys and fliers would not achieve the goal of preventing violence in the neighborhood. There needs to be tools and guidance to teach them how to break away or not join a street gang in the first place. Eventually, they will have to learn how to say “no” to the violence.

Conclusion
In order to have an effective public health campaign, we first have to identify and focus on our target population. One way to win over young people that we might consider is to use a previous gang member who could speaks their language. Other outreach methods that might influence young people are rap/pop concerts, basketball games or commercials to deliver the message rather than adults knocking on doors. For high risk neighborhoods, we should understand the culture of the communities and let youth know that there is another way to solve the problem besides violence. By understanding their background and the environment that they live in, we will be able to design a comprehensive plan to help residents and prevent future violence in the city.

REFERENCE
1. Howell, J.C. (1998). Youth Gangs: An Overview. Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention.
2. “Caught in the Crossfire: Arresting Gang Violence by Investing in Kids,” Fight Crime: Invest in Kids 9/14/04, available at http://www.fightcrime.org/reports/gangreport.pdf
3. Boston High-Risk Youth Network, “Needs Assessment of High-Risk Youth in Boston,” Sept. 2005.
4. Youth Justice in Canada Excerpt on “Youth Gangs”, 2003
5. McGuire, W. J. (1968). Personality and attitude change: An information-processing theory. In Greenwald, A.G., Brock, T.C., & Ostrom, T.M (Eds.), Psychological foundations of attitudes (pp.171-196). New York: Academic Press.
6. McGuire, W. J. (1976). Some internal psychological factors influencing consumer choice. Journal of Consumer Research, 2, 302-319.
7. McGuire, W. J. (1989). Theoretical foundations of campaigns. In Rice, R. E., & Atkin, C. K. (Eds.), Public Communication Campaigns (2nd ed.) (pp. 43-65). Newbury Park, CA: Sage Publications.
8. McGuire, W. J. (1999). Constructing social psychology: Creative and critical processes. Cambridge: Cambridge University Press.
9. Bandura, A. (1982). Self-efficacy mechanisms in human agency. American Psychology, 37, 122-147
10. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215.
11. Bandura, A. (1982). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.
12. Bandura, A. (1997). Self-Efficacy: The exercise of control. New York, NY: W. H. Freeman.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

REFERENCES
1. CDC National Center for Health Statistics. Health E-Stat. NHANES data on the Prevalence of Overweight Among Children and Adolescents: United States, 2003–2004. 28 Mar. 2008. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm.
2.Finkelstein EA, Zuckerman L. The Fattening of America. New Jersey: John Wiley & Sons, Inc., 2008.
3. CDC. Overweight and Obesity. 28 Mar. 2008. http://www.cdc.gov/nccdphp/dnpa/obesity/index.htm.
4. US Department of Health and Human Services, The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity (Rockville, MD: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001).
5. Ammerman AS, Cavallo D, Leung MM, Gustafson A. Farm, Food, Health: How Public Policy Affects Childhood Nutrition. Harvard Health Policy Review 2006; 7(2):152-165.
6. Winterfeld A. Overfed But Undernourished: Not will power, but purchasing power, may determine who eats healthy foods. State Legislatures 2005; April:34-36.
7. Smallstep Adult and Teen. 28 Mar. 2008. http://www.smallstep.gov.
8. Smallstep Kids. 28 Mar. 2008. http://smallstep.gov/kids/flash/index.html.
9. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
10. SB721 class notes, 14February2008
11. Institute of Medicine of the National Academies. Preventing Childhood Obesity. Washington, DC: National Academies of Science, 2005.
12. Gordon-Larsen P, Nelson MC, Page P, Popkin BM. Inequality in the Built Environment Underlies Key Health Disparities in Physical Activity and Obesity. Pediatrics 2006; 117:417-24.
13. Stanrock JW. Children, 5th edition, Boston, MA: McGraw Hill, 1997.
14. Birch LL, Fisher JO. Development of Eating Behaviors Among Children and Adolescents. Pediatrics 1998; 101:539-49.
15. Burke V, Beilin LJ, Dunbar D. Family lifestyle and parental body mass index as predictors of body mass index in Australian children: a longitudinal study. International Journal of Obesity 2001; 25:147-157.
16. Clark HR, Goyder E, Bissell P, Blank L, Peters J. How do parents’ child-feeding behaviours influence child weight? Implications for childhood obesity policy. Journal of Public Health 2007; 29(2):132-141.
17. Christakis NA, Fowler JH. The Spread of Obesity in a Large Social Network over 32 Years. N Engl J Med 2007; 357(4):370-379.
18. U.S. Census Bureau. Current Population Survey (CPS). Annual Social and Economic (ASEC) Supplement. Income Distribution Measures, by Definitions of Income: 2006. (INC RD-AEI 1).
19. U.S. Census Bureau. Race and Ethnicity: 2006. 3 April 2008. http://factfinder.census.gov/servlet/ACSSAFFPeople?_submenuId=people_10&_sse=on
20. U.S. Department of Commerce. Bureau of Economic Analysis. State Personal Income: 2006. (BEA 07-11).
21. Maty SC, Everson-Rose SA, Haan MN, Raghunathan TE, Kaplan GA. Education, income, occupation, and the 34-year incidence (1965-99) of Type 2 diabetes in the Alameda Country Study. International Journal of Epidemiology 2005; 34:1274-1281.
22. Albert MA, Glynn RJ, Buring J, Ridker PM. Impact of Traditional and Novel Risk Factors on the Relationship Between Socioeconomic Status and Incident Cardiovascular Events. Journal of the American Heart Association 2006; 114:2619-2626.
23. Schlosser E. Fast Food Nation. New York: Houghton Mifflin Company, 2001.
24. Pollan M. The Omnivore’s Dilemma. New York: Penguin Group, 2006.
25. Powell LM, Auld MC, Chaloupka FJ, et al. Associations between access to food stores and adolescent body mass index. Am J Prev Med 2007; 33:S301-7.
26. Galvez MP, Morland K, Raines C, et al. Race and food store availability in an inner-city neighbourhood. Public Health Nutr 2007; 1-8.
27. Harrison MS, Coyne T, Lee AJ. Leonard D, Lowson S, Groos A, Ashton BA. The increasing cost of the basic foods required to promote health in Queensland. MJA; 186(1):9-14.
38. World Health Organization. Global Strategy On Diet, Physical Activity And Health. 28 Mar. 2008. http://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf
29. French SA. Pricing Effects on Food Choices. The Journal of Nutrition 2003; 133:841S-843S.
30. Kaiser Family Foundation: The Role of Media in Childhood Obesity. February 2004.
31. Crespo CJ, Smit E, Troiano RP. Television watching, energy intake, and obesity in US children: results from the third National Health and Nutrition Examination Survey, 1988-1994. Arch Pediatr Adolesc Med 2001; 155:360-5.
32. Lowry R, Wechsler H, Galuska DA, et al. Television viewing and its associations with overweight, sedentary lifestyle, and insufficient consumption of fruits and vegetables among US high school students: differences by race, ethnicity, and gender. J Sch Health 2002; 72:413-21.
33. Proctor MH, Moore LL, Gao D, et al. Television viewing and change in body fat from preschool to early adolescence: The Framingham Children's Study. Int J Obes Relat Metab Disord 2003; 27:827-33.
34. Epstein LH, Roemmich JN, et al. A Randomized Trial of the Effects of Reducing Television Viewing and Computer Use on Body Mass Index in Young Children. Arch Pediatr Adolesc Med; 162(3):239-245.
35. ATTRA National Sustainable Agriculture Information Service. An Overview of Organic Crop Production. 28 Mar.

A New Discrimination For A New Millenium? – Elizabeth Gifford

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2. House Bill 282. Representatives Mayhall, Read, Shows. Regular Sesion; January 25, 2008.
3. Center for Disease Control and Prevention. Morbidity and Mortality weekly Report. September 15, 2006; Vol 55: pp.985-988.
4. Henderson L. Ebony Jr! and “Soul Food”: The Construction of Middle-Class African American Identity Through the Use f Traditional Southern Foodways. University of Wisconsin-Milwaukee. Melus [0163-755X] yr:2007; vol: 32 iss: 4.
5. Centers for Disaease Contro and Prevention. Behavioral Risk Factor Surveillance System Survey Data, 2005. unpublished data. Accessed April 23, 2008 at http://www.statehealthfacts.org/profileind.jsp?cat=2&sub=26&rgn=26
6. U.S. Preventive Services Task Force. The Nation’s Health 34(1), 2004.
7. Associated Content. Relating Eating Habits to Lifestyle and Values. Eric Loveday. Accessed April 23, 2008 at http://www.associatedcontent.com/article/152408/relating_eating_habits_to_lifestyle.html
8. Beaulieu L, Guillory F, Rubin S, Teater B. Mississippi: A Sense of Urgency. Southern Rural Development Center and MDC, Inc. 2002. Accessed April 23, 2008 at http://srdc.msstate.edu/publications/ms_urgency.pdf
9. U.S. Census Bureau. Income, Poverty and Health Insurance Coverage in the United States: 2006. Issued august 2007.
10. Felson DT, Zhang Y, Hannan MT, et al. Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum. 1997;40:728-733.
11.Vortmann M. BMI and health status among adults with asthma. Obesity. 2008; 16(1):146-152.
12. Felson DT, Chaisson CE. Understanding the relationship between body weight and osteoarthritis. Baillieres Clinical Rheumatology. 1997; 11:671-681.
13. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA. Jones and Bartlett Publishers, 2007.
14. Gallagher K, et al. Psychosocial factors related to physical activity and weight loss in overweight women. Med Sci Sports Exerc. 2006; 38(5): 971-980.
15. Renkow M. Population, Employment and Mobility in the Rural South. Southern Rural Development Center Policy Series. February 2004, No 3. Accessed April 23, 2008 at http://srdc.msstate.edu/publications/srdcpolicy/renkow.pdf
16. U.S. Census Bureau. State and Country Quickfacts. Accessed April 23, 2008 at http://quickfacts.census.gov/qfd/states/28000.html

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.
McMurrer, P and Sawhill, I. Economic Mobility in the United States. The Urban Institute. 1996. http://www.urban.org/url.cfm?ID=406722.
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Vigil J. Urban Violence and Street Gangs. Annu. Rev. Anthropol. 2003; 32:225–42
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.
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