Challenging Dogma - Fall 2007

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

Sunday, December 9, 2007

Knowledge Only Goes So Far: The National Cholesterol Education Program's Failure to Consider Social and Behavioral Science Principles-Cynthia Glennon

The National Cholesterol Education Program (NCEP) fails to account for basic social and behavioral science principles. NCEP takes a rational-empirical approach to try to encourage behavioral change at the individual level (1,2). Education is just one approach to a public health problem, and its appropriateness for different interventions should be considered carefully (1). This paper presents evidence that NCEP does not consider at least several social and behavioral principles.

NCEP attempts to reduce cholesterol levels in Americans and thus reduce national levels of coronary heart disease (3). NCEP interventions include education of health care professionals, education of Americans to have cholesterol levels tested, and education of Americans to lead a heart-healthy lifestyle by choosing food low in fat and cholesterol and exercising (3). This paper will discuss NCEP’s failure to consider social and behavioral principles in regard to education of Americans to choose healthy foods and exercise.

It is clear that Americans are not following guidelines for choosing healthier foods and exercise to reduce cholesterol. Despite NCEP’s inception in 1985, heart disease is still the leading cause of hospitalization in 2001 according to the Centers for Disease Control (CDC) (4). Cholesterol reduction is an important factor in reducing coronary heart disease rates in America. Heart disease contributes to many premature deaths and much health care spending (3). According to the CDC, 654,092 deaths were due to heart disease in 2004, accounting for 27% of deaths (5). After 22 years of educational measures, heart disease is still the leading cause of death in America. It is time that NCEP redesign their approach to cholesterol intake intervention.

NCEP Overlooks Theory of Reasoned Action

One reason NCEP’s education program fails is that it does not account for the two important factors making up the Theory of Reasoned Action (TRA): perceived norms and attitudes (6, 7). According to the TRA, perceived norms and attitudes predict intention, which in turn predict behavior (6).

Foods high in cholesterol and fat may be the norm for many groups. For example, studies show higher cholesterol intake amongst Hispanic and black participants than in white participants (8,9). A study looking deeper into the broad classification of Hispanic ethnicity studied that Mexican-Americans who adhere to a traditional Mexican diet have high cholesterol levels (10). Since foods high in cholesterol are a cultural norm for some groups, the rational-empirical approach that NCEP uses is not enough to change individual high cholesterol food consumption. A whole cultural norm may need to be changed in order to reduce cholesterol intake in some groups.

A second piece of the TRA that NCEP does not account for is an individual’s attitudes. Individual attitudes about changing diet or exercising may inhibit intention to change behavior (6, 7). An example is an individual’s previous failed attempt to lower cholesterol by healthier eating. A person may feel that he or she is taking action to reduce intake of high cholesterol foods but not see significant reduction of cholesterol levels at the next test. A disheartening experience like this may lead a person to give up or not try so hard if results are not apparent.

NCEP Ignores Modeling in Social Learning Theory

NCEP fails to account for modeling, which is a component of the Social Learning Theory (SLT) (7, 11). According to this theory, an individual will model himself after a role model, which predicts behavior (7, 11). The fast food industry exhibits powerful advertising, spending $11.26 billion in 2004 (12), and uses sports stars and celebrities to promote high cholesterol products. A few fast food chains and celebrities seen in advertising are mentioned here:

McDonalds: Jason Alexander, Charles Barkley, Kelsey Grammer, Michael Jordan, Yao Ming
Pizza Hut: Queen Latifah, Ringo Starr
Burger King: Shaquille O’Neill
Taco Bell: Shaquille O’Neill, Jacoby Ellsbury (13, 14).

Currently, Burger King uses the “King” icon as a model of manliness and links high cholesterol products to machismo. The range of celebrities shows the fast food industry’s attempt to influence a variety of target audiences to buy their products.

Studies have shown that sports stars and celebrities are role models for children (15, 16). The many sports role models promoting fast food products that are high in cholesterol would induce increased consumption of these products by children, according to SLT. Additionally, research shows that childhood obesity often continues into adulthood (2). NCEP is up against the fast food industry in trying to win over children to make healthy food choices in both their younger years and into adulthood.

Sports stars and celebrities are not the only role models for children, as parents can set an example as well. According to a news summary of a survey by the American Dietetic Association Foundation, children ages 8-12 say their top role models are mother (23%) and father (17.4%) (17). If parents are eating unhealthy high-cholesterol foods and not exercising, according to SLT, children will model these unhealthy behaviors. As I will explore further in the next section, educating parents does not solve the issue of unhealthy behaviors for families.

NCEP Does Not Consider Socioeconomic Status

NCEP fails to take into consideration the impact of socioeconomic status (SES) on affordability of and access to healthy foods and exercise. There are at least two potential barriers to a reduced cholesterol diet for people of low SES, affordability and access to healthy foods and practicality of exercise (18).

Low-income parents may not be able to afford healthy foods consistently, instead finding that processed foods or fast foods are filling and cheaper, even if high in cholesterol. In addition, choices of healthy food are limited or non-existent in some low-income neighborhoods (19).

Exercise may be difficult for people of low SES if they cannot afford a gym membership. A single mother, for instance, may work long hours to bring in income for her family, and even if she can afford membership, spending time at the gym would mean higher child care costs and additional time away from her family. Alternatives to the gym are outdoor activities such as running, walking, or biking. However these activities are dangerous if crime is a problem in a low SES neighborhood, and residents of low SES neighborhoods have lower physical health (20). An individual’s SES impacts availability of healthy foods and safety and practicality of exercise.


NCEP does not account for many social and behavioral science principles, which is a reason for the failure of the program to reduce cholesterol intake of Americans and thereby reduce heart disease. NCEP does not consider norms, such as traditional diet of some cultures, or attitudes, which are key pieces of the Theory of Reasoned Action. NCEP also ignores modeling as part of the Social Learning Theory, a theory that the fast food industry has successfully used to their advantage. As a final example, NCEP has not addressed Socioeconomic Status (SES) in its programs, and is failing to address the fact that people of low SES face many barriers to healthy food choices and exercise. Cholesterol reduction is an important factor in reducing coronary heart disease rates in America. Heart disease contributes to many premature deaths in America and greater health care spending (21). After 22 years of minimal progress in reducing Americans’ cholesterol intake, it is time for NCEP to rethink its rational-empirical approach and take more effective measures towards a heart-healthy America.


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