Challenging Dogma - Fall 2007

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

Monday, December 10, 2007

Massachusetts Food Police: Micromismanaging Massachusetts School Menus through a Power-Coercive Approach – Catherine W. Saltus

In the state of Massachusetts, 25% to 30% of 10 to 17 year olds are overweight or obese (1). These children are at higher risk for a number of health outcomes, including heart disease, stroke, certain cancers, gallbladder disease, asthma, diabetes, depression, and low self-esteem (1). In August of 2007, the Massachusetts Legislature passed “An Act to Promote Proper School Nutrition”. The bill’s goal is to “promote healthy alternatives in public school food programs” (2). These new guidelines pertain only to “competitive foods or beverages”, which include all foods and beverages sold a la carte in school cafeterias, school stores, snack bars, or vending machines, but do not include foods sold as part of the National School Lunch Program, School Breakfast, Child Care, and Adult Programs (2). Under this new legislation, competitive foods will be limited to non-fried fruits and vegetables, whole grains, low-fat and non-fat dairy products, and will be trans-fat free. Competitive beverages will be 100% fruit juice, low-fat or non-fat dairy drinks, caffeine-free, and without flavoring, additives, or carbonation.

The state of California recently passed a similar legislation to limit the consumption of certain food items in public schools. In response, snack food companies rapidly found a loophole: they have reformulated many products to make portion sizes and amounts of trans fats to meet the requirement of the Food Nutrition Standards Bill. The program has proven ineffective thus far – some schools are simply not complying while others have students who are making meals out of multiple snack products, as the bill does not place a limit on how many snack items a student is allowed to purchase. The Massachusetts legislation will face similar failures.

The proposed Massachusetts public school soft drink ban, mandate of low-fat lunches, and restocking of vending machines with healthy items only is a flawed intervention for reducing childhood obesity in the Commonwealth’s public schools because it inappropriately uses the power-coercive approach, discounts the need for autonomy and individual control over behavior, and fails to consider behavior change as a process.

Ineffectiveness of the Power-Coercive Approach

The power-coercive approach is a behavior change strategy that uses the element of power, in this case political power, to mandate behavior change (4). Its use in a health setting, specifically in a sensitive area like childhood obesity, is questionable. Passing laws to mandate personal health behavior limits individual rights and freedom. It is unlikely that such legislation would be passed for adults. The fact that children are assumed unable to make appropriate health choices has allowed the law to be put in place. Parents and guardians may not agree with the standards set by the state of Massachusetts. This legislation forces choices that should be personal choices for the child or for the parent on the child’s behalf.

The power-coercive approach is not intended to educate children about healthy habits, nor does it teach the consequences of unhealthy eating behaviors. In addition, barriers to obtaining these healthier selections may still exist. These include cost of healthy food options for families of lower socioeconomic status and lack of culturally-appropriate menu alternatives.

Further, there are a number of practical issues with using the power-coercive approach to address the childhood obesity epidemic that will lead to its failure. The legislation does not provide any type of financial support for the newly mandated healthy options. The burden of increased costs for healthier options falls on the school or school lunch consumers. If schools need more funding to make healthier options available while keeping costs reasonable, they may turn to city or state officials for help. This could potentially translate into increased taxes for the school district, city, or state; or a “redirection” of funding within the school’s budget at the expense of other programs. This legislation also targets only those students who purchase school lunch. Perhaps these students are part of families with higher socioeconomic status (since the nationally subsidized programs are not affected by the legislation) and are not the students most in need of this legislation. Similarly, this legislation will not necessarily improve access for the proportion of students who bring unhealthy snacks from home. Furthermore, the ability to enforce these healthy eating habits through this legislation is limited. Kids may have access to unhealthy foods at home or the ability to purchase them outside of school hours. Also, once students leave the public school system (eg. transfer to private school, move to college), they will no longer be reached by this intervention. Finally, kids with more spending money have the ability to purchase multiple servings of foods. In such cases, the law’s ability to control the amount of trans fat or sodium a child consumes is lost.

Chin and Benne assert that political power plays an important role in bringing about change and that using “political power carries with it legitimacy…” if those who are using a power-coercive strategy are indeed in control of some social system (4). An obvious issue with the Act to Promote Proper School Nutrition is that state government has assumed some level of control over eating behavior. It may not be taken seriously by schools, parents, or children if they feel the state is inappropriate in trying to control eating behavior. Another potential concern with this approach is that policy makers often assume that the desired change has been made (4). Adequate enforcement, maintenance, and follow-up are necessary so that these assumptions do not undermine the effectiveness of this legislation. In other words, success should not be assumed until it is proven. The Act to Promote Proper School Nutrition provides little objective guidance for such procedures. The importance of political actions should not be discounted, but rather combined with normative-re-educative and rational-empirical strategies to be effective in changing behavior (4).

Autonomy and Individual Control

Legislation limits autonomy and individual control and instead attempts to force behavior change at a group level. This intervention removes any sense of control that a student may have over his or her dietary choices and ignores a fundamental need for a sense of freedom and individuality among school-aged kids (12). Two social psychological theories, the theory of planned behavior and reactance theory, demonstrate the importance of autonomy and control on behavior change. Research in this area has shown that when individual choice is eliminated, research subjects tend to behave in a “rebellious” manner (11).

The importance of perceived control is a major aspect of behavior change, as stated in the theory of planned behavior. “Perceived control” is a person’s belief that he or she can take action to change behavior (3). The Act for Promoting Proper School Nutrition may eliminate unhealthy food options, but it does so in a way that also limits an individual child’s ability to act autonomously. In other words, the control lies with the academic institution rather than with the individual. If a child senses this loss of control, he or she may resist behavior change.

Reactance Theory is another social psychological theory for looking at reactions to threatened or eliminated freedom (8). “Reactance” describes the motivational state that follows a threat to a person’s freedom (8). Studies have shown that elimination of a free behavior causes future resistance to the subject, which may lead to a behavioral relapse (10). Furthermore, if it is not possible to reestablish the behavior (eg. eating junk food), the eliminated behavior subsequently becomes more attractive (11). As it pertains to the Massachusetts legislation, reactance theory predicts an increased attractiveness of eliminated cafeteria items, potentially leading to increased consumption in other settings or time periods. Though a child may be forced to eat healthy foods at school, increased consumption outside of school will negate the legislation’s effect.

Behavior Change is a Process

The Act to Promote Proper School Nutrition fails to consider behavior change as a process. Developing healthy habits is a long-term change and not the result of a single legislative action. The Act to Promote Proper School Nutrition is a short-term fix rather than a long-term solution. This intervention ignores the assertion that behavioral change occurs in stages over time as stated by the stages of change models. Two theories, the transtheoretical model and the precaution adoption process model both represent the theory that behavioral change occurs in stages over time (3).

The transtheoretical model was first described by Proschaska and DiClemente, who outlined a series of stages where behavior change may occur. The stages range from a state in which a person is completely unaware of a problem, to weighing of the pros and cons of an issue, to action and completion of behavior change (3). According to the transtheoretical model, a person can move between or cycle through these stages (forwards or backwards), for a number of reasons, including re-evaluation or substituting a new behavior for an old one (3). The Act to Promote Proper School Nutrition ignores the presence of the stages as an important component of behavior change. Instead, it uses a classic “point-in-time” structure. “Point-in-time” theory opposes the stages of change theories because it asserts that attitudes, beliefs, and decisions about behavior occur as a single process. (3).

Similarly, the Precaution Adoption Process Model outlines a series of stages that lead to behavior change. Most importantly, its creators noted that “variables and factors important at one stage are not necessarily the same as those that come into play in another stage” (3). Because kids may be at different stages of the continuum, using legislation to enact behavior change may prove to be virtually ineffective. If we assume that school-aged children occupy a variety of stages within these models, it is implausible that just one intervention method could be effective. Many children may not be aware of the consequences of unhealthy eating behaviors. Others may have awareness, but lack motivation to change habits. Still others may be weighing the pros and cons of changing eating behavior. Factors required for change from each of these stages are different. A child who is unaware of his or her unhealthy eating behaviors may need education. The child who is unmotivated may need a change in social norms or some other influential factor. A child who is weighing the pros and cons of an issue may simply need time to make an autonomous decision for him or herself. None of the previous scenarios were considered when this legislation was used to elicit behavior change. Though legislation may change behavior temporarily, in this case it does so artificially, as children have not been allowed the opportunity to progress through the stages of change.

Furthermore, intervening at the wrong stage may actually be detrimental to the development of new behaviors (5). Multiple smoking cessation studies have illustrated the importance of matching treatments to a person’s stage of change. These studies show significantly reduced compliance when behavior change is attempted at a pre-contemplation stage (7). Therefore, the Act to Promote Proper School Nutrition may actually have an effect opposite its intended effect. If school-aged children are in the pre-contemplation stage, the likelihood of long-term behavior change is greatly reduced when proper eating habits are mandated.

Recommendations for Future Interventions

Combining this approach with a normative-re-educative and/or rational-empirical approach may be a more effective model for behavioral change. These behavior change strategies should instead empower kids to feel “in control” of their eating habits and the choices they make about health. Educating school-aged kids and offering healthy alternatives in addition to their less healthy counterparts allows for informed decision-making. A normative-re-educative strategy may change the social norms within a school such that kids conform to these norms for acceptance. If kids feel like it is socially acceptable to eat healthy foods, they are more likely to do so.

More effective interventions may also consider the stages of change models and perform targeted interventions at particular stages instead of assuming that everyone is at the same stage. Ultimately, in order to appropriately address the issue of poor childhood eating habits in Massachusetts public schools, we must consider the broader social issues that cause kids to participate in unhealthy eating behaviors. These fundamental causes may include geographic differences in the availability of healthy foods in general, socioeconomic differences that allow or disallow a student from accessing healthy options at school and elsewhere, and perhaps cultural differences in food choices that are not considered when menu options are selected. Rather than using resources to establish and enforce policies, funding and effort should be targeting these fundamental causes. Interventions that strive to educate, change school norms, improve access, enforce availability of healthy alternatives, and subsequently allow for autonomy and individual control in decision-making will prove significantly more effective.


Until its re-evaluation in 2013, the success of the Act to Promote Proper School Nutrition in Massachusetts public schools will be unknown. During this review, a number of considerations will be assessed, including the proportion of public schools that have “successfully” implemented the guidelines, challenges or barriers faced by the school systems, changes in revenue and student participation in meal programs, and finally, recommendations for program improvement. A secondary assessment will include evaluation of obesity trends in children across the Commonwealth. Furthermore, access to obesity “treatment” will be assessed. At no point in this review will the commission evaluate individual barriers to access, preventive care, or the permanence of behavior change – some of the supposed goals of this legislation. Therefore, the planned program evaluation will be unable to identify its shortcomings.

An Act to Promote Proper School Nutrition is a small step in the right direction. If used appropriately in conjunction with education and empowerment techniques, and evaluated objectively in relation to its goals, it has the potential to serve as a backbone for a very effective public health intervention. As it exists currently, this program is absorbing a large portion of available resources and funding that could utilized elsewhere to yield longer-lasting effects of greater magnitude. Public health efforts must be allocated to the most time and cost-effective interventions for the benefit of the largest number of individuals.


  1. Massachusetts Public Health Association Issue Priority: Childhood Obesity.
  2. Massachusetts Public Health Association: House – Bill No. 4199. August 2, 2007.
  3. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
  4. Chin R, Benne K. The Planning of Change: General Strategies for Effecting Changes in Human Systems. United States: Rinehart and Winston, 1976.
  5. Prochaska JO, DiClemente CC. In Search of How People Change: Applications to Addictive Behaviors. American Psychologist (1992): 1112-1114.
  6. Weinstein MD, Sandman PM. A Model of the Precaution Adoption Process: Evidence from Home Radon Testing. Health Psychology (1992): 170-180.
  7. Ockene J, Ockene I, Kristellar J. The Coronary Artery Smoking Intervention Study. National Heart Lung and Blood Institute (1988).
  8. Clee MA, Wicklund RA. Consumer Behavior and Psychological Reactance. Journal of Consumer Research (1980): 6, 389-405.
  9. Dickenburger D, Grabitz-Gniech G. Restrictive Conditions for the Occurrence of Psychological Reactance: Interpersonal Attraction, Need for Social Approval, and a Delay Factor.
  10. Finz S. Some Schools, Students Make Hash of Anti-Junk Food Law. San Francisco Chronicle: September 29, 2007.
  11. West SG. Increasing the Attractiveness of College Cafeteria Food: A Reactance Theory Perspective. Journal of Applied Psychology (1975): Vol. 60 (5), 656-658.
  12. Chao RK. Beyond Parental Control and Authoritarian Parenting Style: Understanding Chinese Parenting through the Notion of Training. Child Development (1994), Vol. 65, No. 4 , 1111-1119.

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