Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Tuesday, December 11, 2007

Individuals Alone Can’t Halt the Obesity Epidemic- How Obesity Prevention Focused on Personal Responsibility is Failing in America-Dailan Liu

The impact of obesity on health has been recognized for more than half a century, and weight reduction has been an American preoccupation for decades. Yet, the prevalence of obesity has increased sharply and continues to soar among U.S. adults and children, with no immediate signs of reversal. Nearly two-thirds of American adults are overweight or obese due to sedentary lifestyles and unhealthy eating habits (1). The rate of childhood obesity more than tripled from 1980 to 2004 (2-3). Approximately 25 million children are now either obese or overweight. In early 2000, Health & Human Services launched a small step campaign including hundreds of tips on food, eating, cooking and exercise which lead people to healthy lifestyles to control and prevent obesity. But the Obesity rates have increased by more than 60% among adults over the last 10 years. “Despite all of the emphasis focused on childhood obesity in our country during the last several years, many children and families are still not making the necessary changes to lead healthy lifestyles,” said Ad Council President and CEO Peggy Conlon (4).

Poor nutrition and physical inactivity are two identified factors that lead to obesity increasing Americans’ risk for developing major diseases, including type 2 diabetes, heart disease, stroke and some forms of cancers (5-6). According to HHS, obese and overweight adults cost the U.S. anywhere from $69 billion to $117 billion per year(7). Researchers and practitioners know a lot about nutrition and exercise. There are well agreed upon standards for basic nutrition and minimum levels of physical activity for sustaining good health (8-9). However, much less is known about how to effectively encourage people to make healthy choices. Individuals are often told to take personal responsibility and lose weight. Clearly, the strategy of focusing on personal responsibility alone is failing.

Why has obesity control failed? This is because individuals alone can’t halt the obesity epidemic. Most obesity prevention programs like the small step campaign target individual behavior change at the micro level (i.e. personal choices in relation to caloric intake, exercise, and diet composition). At the macro level, changing patterns in the global prevalence of obesity are explained in terms of broad social, environmental, and biological factors (e.g. food choice availability, occupational activity level, and biological predisposition). Obesity prevention at the international level will be most successful if they can simultaneously address both the cultural influences that motivate personal behaviors, and the macro level determinants of obesity over which the individual has little or no control. This is called the socio- ecological model (10). Using this model we can more fully understand and solve the obesity problem.

The Small Step Campaign Assumes Factual Information About Diet and Exercise Would Ignite Individual’s Behavior Change.
The small step TV ads are poorly designed, the website mostly focus on factual information with no fun. In the ad, a flat voice asks the question “Can your food do that?” which is boring and confusing. From the advertising theory we know that a successful ad is based on a great promise, which is effectively used in the food industry. Similarly the small step website is full of hundreds of tips to teach you what to eat, how to cook and how to exercise (11). People do not have an incentive to read all of the tips, let alone to return to the site again.

The small step campaign assumes that all the factual information about diet and exercise will be enough to change the individual’s behavior. The campaign is primarily based on the Health Belief Model and Theory of Reasoned Action. These two models focus on the individual’s role and responsibility to ignite behavior changes. The campaign does not address the individual’s taste preference, cultural and social economic reasons for eating unhealthy foods (12-13).
The small step campaign should have a more comprehensive vision. Clearly, unhealthy diet and lack of exercise are the two proximal factors directly causing obesity. Social and environmental factors like poverty, poorly funded schools, inadequate access to health care and community insecurity are considered distal but fundamental causes of obesity.

Personal Responsibility Strategy Lack Tools to Promote Self-Efficacy
Social Learning Theory is based on the tenet that people do not learn behaviors and make decisions in a vacuum, isolated from external interactions. They are influenced by their relationships with families, friends, neighbors, and colleagues; their home, workplace, neighborhood, and school environments; their economic limitations; and their genetics, physiology, psychology, and life stages (10). Considering the many aspects of American culture that promote obesity, the small step campaign focusing only on modifying individual behavior is not enough to reverse the current trend. Industry practices and technological advances have promoted obesity. Americans spend about half of their food budget and consume about 1/3 of their daily meals outside the home. Food eaten outside is higher in fat and lower in micronutrients than food prepared at home. There also tends to be more of it, with the standard serving sizes of certain foods increasing greatly in recent decades. For example, in the 1950s, coca-cola was packaged only 6.5oz.bottles; today single- serving containers are 20-oz. bottles.

Food promotions, pricing, packaging and availability all encourage Americans to eat more, not less. In 2000, the cost of advertising soft drinks reached $ 700 million, and for the McDonald’s restaurant chain the advertising budget topped $1 billion, dwarfing the National Cancer Institute’s $4 million annual investment in the educational component of its 5-A-Day campaign to increase consumption of fruit and vegetables (14).

Meanwhile, labor-saving devices, from automobiles to e-mail, are ubiquitous and have reduced energy needs, as has the shift of a large proportion of the workforce from manual labor to white-collar jobs that require little more activity than pressing keys on a computer. In addition, many suburban neighborhoods are geared towards automobiles, with few, if any, sidewalks to encourage walking, running and other forms of transportation and exercise. Taken together, such changes in the food and lifestyle environment help explain why it requires more than just willpower for Americans to balance their intake and output of energy.
There are hundreds of tips in small the step campaign to change the individual’s behavior, but it is not easy to stick to even some of them. The small step campaign does not address the above distal but fundamental causes of obesity assuming American live in an environment they can control very well in a life style instructed by small step tips. The outlined measures in the small step campaign cannot alone eliminate obesity from the American landscape. A possible effective method is levying small taxes on energy-dense foods or activities that could generate big revenues to be used to promote health, such as a 2/3 cent tax per 12 ounces on soft drinks (15). Without a national commitment and effective new approaches to making the environment more favorable to maintaining healthy weight, the obesity epidemic will be almost impossible to halt.

Personal Responsibility Strategies Fail to Consider the Social Economic Factors- Like Poverty, Cultural and Safety Issues
A 2005 survey of low-income children ages 2 to 5 called the Pediatric Nutrition Surveillance Survey found that 14.7% of these children are overweight (16). Thirty-nine states and Washington, D.C. participated in the survey. Obesity rates also appear to have some relationship with poverty rates in many states. Eight of the 10 states with the highest rates of poverty are in the South, where obesity rates are higher, and many of the states with the lowest poverty rates are among the states with the lowest obesity rates. Eight of the states with the highest poverty rates are also in the top 15 states with the highest obesity rates (17).
Many tips in the small step campaign emphasize ordering a small serving of food, and the use of honey instead of sugar. However low income families prefer getting large potions of food to save money. In addition these low income families do not want to pay to go to gym for exercise.

For many households, the lack of money can contribute to both hunger and obesity. Households that lack the funds to purchase enough food often have to rely on cheaper, high calorie foods than prudent diets based on lean meats, fish, fresh vegetables, and fruit. These families try to maximize caloric intake for each dollar spent, which can lead to over consumption of calories and a less healthy diet. Mini-marts packed with chips, sodas and candy bars are often more common in low-income areas. “We didn't have enough to really go shopping, so we'd go to McDonald's," "We just got junk food because it was so much cheaper and it was filling and it tastes good (18)." While obesity rates are climbing among all ages, races and incomes, evidence shows that the poor are more likely to be overweight than wealthier Americans. This is a population we want to help, but telling them to eat fresh grapes and play a bit of tennis is not going to be effective.

Lower income Americans have less access to information from health professionals, and consequently, less knowledge about how to maintain a healthy lifestyle. Immigrants from poor countries believe obesity is a sign of health due to the culture difference. People who don't know where their next meal is coming from tend to splurge when food is available. They do not want to change their behavior and life style. In addition unsafe playgrounds, community violence and poorly funded schools may also discourage physical activities.

The Social-Ecological Model (SEM) could be thought of as an onion, with one level wrapping around another. At the center of the model is the individual. At this level, we consider the internal determinants of behavior, such as knowledge, attitudes, beliefs, and skills. This is the foundational level, but the model recognizes that many external forces (interpersonal, organizational, community and society) influence these individual determinants. In order to facilitate behavior change it is important to address these external forces. This model serves as a reminder to look at all levels of influence that can be addressed to support long-term, healthful lifestyle choices (19).

Despite the obesity epidemic in the low-income group, the small step campaign focused on middle class, which is one of the reasons these interventions can not reverse or even stop the obesity epidemic. The small step campaign does not address any above fundamental social factor of obesity.

A possible approach is to create ways to distribute free or inexpensive fruits and vegetables to low-income community. An on-going program addresses this: The Robert Wood Johnson Foundation is the nation's largest philanthropic organization dedicated exclusively to improving health for all Americans. One of the programs is trying to reverse the childhood obesity epidemic by 2015 by improving access to affordable healthy foods and increase opportunities for physical activity in schools and communities across the nation (20). The Foundation's major efforts are trying to changes the policies in the community and school environments that are most effective in increasing physical activity and improving nutrition for kids. This is a good example of thinking about the obesity problem beyond the Health Belief Model and implementing the socio-ecologic Model. One good example: how this program makes healthy food available to the low-income families. The Foundation is working with The Food Trust, a Philadelphia-based advocacy organization whose mission is to ensure that everyone has access to affordable, nutritious food. The Food Trust has achieved tremendous success in bringing supermarkets back to underserved communities in Pennsylvania.

This article criticizes the small step campaign for obesity prevention, proposes three arguments that small steps failed to increase the public self-efficacy, ignored the fundamental causes of obesity, discuss the more effective methods to prevent obesity by implementing the social-ecologic model, which requires focusing on strategies that will work on a wide scale. 1) Individuals: Addressing obesity begins by changing everyday behaviors that relate to eating and physical activity. That means changing people’s knowledge, attitudes, and beliefs. 2) Interpersonal Groups: an important way to encourage more healthy behaviors, and give individuals the knowledge and support they need. 3) Organizations: include schools, places of employment, places of worship, sports teams. Organizations can help members make better choices about healthy eating and physical activity through changes in organizational policies and environments 4) Communities: like large organizations, able to make changes to policy and the environment to give residents the best possible access to healthy foods and places to be physically active. This means implementing changes to zoning ordinances, improvements to parks and recreation facilities, and creating ways to distribute free or inexpensive fruits and vegetables. 5) Society: This all-encompassing category involves individuals, organizations, and communities working together for change. New nutrition and physical activity legislation, statewide school policies, media campaigns, and partnerships with business and industry are just some of the ways a comprehensive strategy to address obesity and other chronic diseases takes shape on a large scale (21). If we embrace comprehensive views for the obesity problem by addressing the fundamental social factors, hopefully we can take a big step to control or even reverse the obesity epidemic (22).

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14. National Cancer Institute. Cancer Trend Progress Report: Fruits and Vegetable Consumption 2005 Update. Bethesda,
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Comparison,” American Journal of Public Health 95, no. 3 (2005).
17. Low-income preschoolers prone to obesity at
18. “The Regulation to Phase Out: Artificial Trans Fat,”
19. The Social-Ecological Model at
20. The Robert Wood Johnson Foundation at
21. U.S. Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System Survey Data (Atlanta, GA:
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2006).
22. T.A. Wadden, K.D. Brownell, and G.D. Foster, “Obesity: Responding to the Global Epidemic,” Presentation, 8 January
2004. From an article originally published in Journal of Consulting and Clinical Psychology 70, no. 3 (June 2002): 510-

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