Challenging Dogma - Fall 2007

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

Sunday, December 9, 2007

Public Health’s Failure To Get Through To Fat America - Elizabeth Aron

A growing proportion of American adults are fighting the battle of the bulge. The trend towards an increasingly obese society has been seen over the past ten years. Overall, among adults in the United States older than 20 years, 65.1% were overweight or obese, 30.4% were obese, and 4.9% were extremely obese(1). The Center for Disease Control (CDC) has studied obesity trends in the United States for many years and the most recent data show a rapid increase in obesity throughout the United States. One of the main reasons that obesity poses such a problem is because of obesity’s contribution to chronic diseases and other health risks. For example, cardiovascular diseases increase significantly with increased obesity. Overall mortality from heart disease has a positive correlation with BMI (body mass index) levels greater than 25 kg per mm and the risk increases most dramatically when BMI levels surpass 30 kg per mm(2). The recent rise in the prevalence of overweight and obesity in the U.S. are reflected across all ages, racial and ethnic groups, and education levels(2). These factors, along with the increased economic cost of treating an increasingly overweight population has caught the attention of government and public health officials and prompted action(3).

Present public health advertising targets overweight and obese individuals. The ads are focused on changing the food intake of overweight and obese individuals. The American Medical Association’s advertising campaign directed towards physicians, has issued guidelines to help doctors identify at risk overweight individuals to help them develop an effective weight loss plans. In its current form, the plan indicates that a doctor should help in, “setting reasonable weight loss goals, selecting appropriate weight loss programs, referring patients to ancillary personnel when appropriate, and providing monitoring support and encouragement”(4). However, such recommendations provide an imperfect answer to the problem of obesity because they encourage individuals to consume fewer calories and increase their physical activity but do not deal with the emotions or cultures surrounding food.

As a society, the U.S. is becoming more aware of the potential health and economic implications as the rates of obesity continue to increase(5). Some researchers and health officials have highlighted obesity as the next serious epidemic and predict serious health consequences in the years to come(6). America is a nation that has access to a variety of unhealthy food options, consumes too many calories and is increasingly sedentary. Nevertheless, the current public health advertising campaign’s approach to halting and potentially reversing this epidemic is fundamentally flawed because it ignores both the social and cultural influences that surround eating behaviors in the United States. The current public health advertising campaign assumes that individual eating behaviors, separate from the social and cultural environments, are the main cause of the obesity epidemic.

The public health advertising approach to reducing obesity is directed towards marketing a healthier lifestyle based on the Health Belief Model. Public health’s current reliance on the HBM to alter eating behavior is a failing method. The HBM is based on the understanding that people will take a health-related action if they feel: that a negative health condition can be avoided, have a positive expectation that by taking a recommended action, they will avoid a negative health condition, and believe that they can successfully take the recommended health action. The HBM is created based on four constructs representing the perceived threat and net benefits: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. The combination of these concepts is hypothesized to account for people's ‘readiness to act’(7). Advertisements commonly seen on television and in publications use the HBM to provide information on how to make healthy food choices. The advertisements’ developers assume that people will take the information provided and adopt healthier eating behaviors.
Yet, these adds fail to make a significant difference in the eating behaviors of individuals or even change individuals’ motivations because they fail to account for the immense sociocultural obstacles. In the case of food behaviors, the assumption is that unhealthy food choices are perceived to have an extremely negative impact and therefore would be reduced.

Yet food has a more complex role in American society, because it is not simply a behavior but part of the pleasure of living(8). In ancient times food was a means of survival but modern times have transformed food into an integral part of culture and society. Food is part of celebrations, rituals, religions and customs. For example, families from Hispanic cultures believe that food is not only about consuming calories for daily sustenance, as the Health Belief model would suggest. Rather, in “some Hispanic cultures, the people believe that foods, herbs, illnesses, and bodily states are characterized by degrees of ‘hot’ and ‘cold’. A good meal will be balanced. Those who eat foods whose temperatures are wrong for them can get sick…[and] a good appetite is associated with good health”(9). The HBM does not take into account any of these or other cultural factors as it attempts to change peoples associated with food. For these Hispanic cultures food has a symbolic value as much as it has nutritional value. It would be illogical then to conclude that simply educating a person about the nutritional value of specific foods would cause a drastic change in their eating behaviors.

Aside from the lack of understanding about food and its relationship to various cultures, the current public health advertising campaign’s aim to change eating behaviors fails because it does not deal with the long term planning that is necessary to bring about lasting change. Public health officials have relied on physicians to promote healthy eating behaviors(2). Physicians who are already overworked are being asked to take more time with patients to instruct them about making healthy food choices. Reliance on physicians because it focuses on the short-term problem of people choosing healthy foods while failing to address the underlying issues associated with food in the U.S. This method of physician-induced behavior change does not provide time for follow up because people rarely see physicians on a routine basis(10). Lacking consistent follow-up, changes that are induced by physicians are likely to be short-lived because eating is an ingrained part of a person’s culture and cannot be easily changed. Thus, without continuous follow-up, reliance on an advertising campaign to get physicians to instigate changes in eating behavior will be unsuccessful.

Moreover, the public health advertising approach to changing eating behaviors is focused on a long-term goal that requires extensive amounts of time and dedication by individuals to change their own behaviors. This advertising approach is in direct competition with the 35 billion dollar per year diet industry, an industry which promises people weight loss without struggling with any long-term commitments or serious lifestyle modifications(11). Americans buy into these easy solutions, spending billions of dollars each year on programs, foods, pills, and exercise equipment aimed at making them skinner and more attractive(11). Thus, the public health approach to changing eating behaviors is a direct competitor with the very lucrative diet industry. The diet industry’s success is based on short-term gains rather than any real sustainable changes in behavior, and so far, their approach has been extremely lucrative. The public health advertisements do not promise speedy results but rather alludes to the goal of a healthier life. In a culture obsessed with instant gratification, attempts to instill long-term changes that require effort will be difficult and the public health approaches seeking his goal have failed.

Not only does the public health approach to changing Americans’ eating behaviors fail due to its competition with the diet industry, but also it fails because of its reliance on the Theory of Reasoned Action. The Theory of Reasoned Action suggests that people’s behavior is determined by their intention to perform the behavior and that this intention is, in turn, a function of their attitude toward the behavior. Therefore the best predictor of behavior is intention. The Theory of Reasoned Action assumes that people’s intentions are determined by three things: their attitude towards the specific behavior, their subjective norms and their perceived behavioral control so that only specific attitudes towards the behavior in question can be expected to predict that behavior(12). The Theory of Reasoned Action in public health advertising relies on a presumed interaction between the behavior intention and the behavior relationship related to eating behaviors. This approach is also a failure at reducing obesity because many people foresee the obstacles between themselves and changing their eating behaviors as too immense, hence the success of the diet industry. Basing public health advertising campaigns on the Theory of Reasoned Action fails because it does not take into account impulsive behavior that accounts for much of the ways in which Americans act. Much of the American culture is based around the idea that if a person wants something they should be able to have it immediately. To base a public health intervention on a long-term behavior-changing plan with no immediate rewards fails to account for the culture in which Americans live.

It is apparent, from the growing proportion of overweight and obese individuals in the United States that the public health approach to altering the eating behaviors of the American people has failed. A different approach to this complex problem needs to be proposed. A way to market the attractiveness of healthy eating behavior to shift public perspective is necessary. By creating public demand for healthier food options the social and cultural components of food behaviors can be altered. A new culture around food behaviors needs to come about in order to motivate people to make life-changing decisions about food and the role food plays in American’s daily lives. Changing the public health approach to advertising may bring about reductions in the number of overweight and obese individuals in the United States.

1: Prevalence of Overweight and Obesity Among US Children, Adolescents, and Adults, 1999-2002. JAMA. June 16, 2004—Vol 291, No. 23
2: American Family Physician. Obesity: assessment and management in primary care. 2001 Jun 1; 63(11):2185-96.
3: U.S. Department of Health and Human Services. The Surgeon General's call to action to prevent and decrease overweight and obesity. [Rockville, MD]: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; [2001]. Available from:
4: Elster AB, Kuznets NJ. Dietary habits, eating disorders, and obesity. In: AMA guidelines for adolescent preventive services: recommendations and rationale. Baltimore, Md. Williams & Wilkins. 1994: 41-57
5: Finkelstein EA, Fiebelkorn IC, Wang G. State-level estimates of annual medical expenditures attributable to obesity. Obesity Research 2004;12(1):18–24.
6: Mokdad AH, Bowman BA, Ford ES, Bowman BA, Vijnicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;285:1195–1200.
7:Glanz K., Rimer B.K., Lewis F.M. Health Behavior and Health Education. Theory, Research and Practice. San Francisco: Wiley & Sons. 2002.
8: Macht M, Meininger J, Roth J. The Pleasures of Eating: A Qualitative Analysis. Journal of Happiness Studies. 2005. 6:137-160(24)
9: Sanjur D. Hispanic Foodways, Nutrition, and Health. Allyn and Bacon. Boston. 1995. 42-45.
10: Center for Disease Control. Ambulatory Care Visits to Physician Offices, Hospital Outpatient Departments, and Emergency Departments: United States , 1999-2000. Series Report 13, No. 157. 78 pp. (PHS) 2004-1728.
11: Alfonsi S. Diet Industry Is Big Business: Americans Spend Billions On Weight-Loss Products. New York. Dec. 1, 2006. Available from:
12: Ajzen, I. From intentions to actions: A theory of planned behavior. Heidelberg: Springer. 1985.

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