Challenging Dogma - Fall 2007

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

Monday, December 10, 2007

Small steps, small vision: a critique of the US Department of Health and Human Services SMALLSTEP campaign to reduce childhood obesity – Jean Kelley

Obesity has become a major public health concern because it is associated with the development of many chronic, difficult to treat conditions such as hypertension, diabetes and heart disease. In addition to individual morbidity, these chronic conditions account for a large portion of health care spending and as such are an important area for research in etiology and prevention.

Rates of obesity in the US have reached epidemic proportions. In 2005, NHANES prevalence statistics for obesity, defined as a BMI greater than 30, show that about a quarter of US adults are obese. What is very concerning is that the NHANES data show that the prevalence of overweight in US children, defined in 2005 as a BMI greater than the 95 percentile, has steadily increased from 1971 through 2004, from 5% to 13.9% in the preschool age group, from 4% to 18.8% in the elementary-school age group, and from 6.1% to 17.4% in the middle- and high-school age group. (1) Of additional concern is that, according to results from an NIH funded study last year, children who were found to be obese at least once during the ages 2.5 years to 4 years old were five times more likely to be obese at the age of 12 years old than children who were never obese during these ages. (2) In the US, there are currently over 9 million children over age 6 who are obese. (3) Studies have shown that childhood obesity increases the risk of obesity in adulthood. Obesity in children over 3 years old is an important predictor of adult obesity, independent of parental obesity. (4) In recognition of the importance of addressing obesity in children, pediatric weight classification has recently been revised. In 2005, children with a BMI greater than the 95 percentile were classified as overweight; in 2007 they are classified as obese. (5)

The SMALLSTEP campaign is the US Department of Health and Human Services’s obesity prevention program. Using primarily television ads and its SMALLSTEP website, the program targets obesity prevention through education about nutrition and exercise. This campaign will fail to make an impact on childhood obesity because of its poor use of the media (TV ads and web site), its limited overall vision, and its failure to address some of the more fundamental causes of the obesity epidemic. This paper will propose three reasons for the failure of the SMALLSTEPS program, and discuss an alternative approach with a more comprehensive vision that appears much more likely to succeed.

The SMALLSTEP TV ads are poorly executed.

The TV ads that form a major part of this campaign are boring and confusing. These ads are aimed at school-age and younger children, and must compete for their attention with the far more exciting action-packed ads put out by the food industry, which sell such items as sugary-cereals, pop-tarts, and hi-fat microwavable pizzas. One of the SMALLSTEP ads (Birds) depicts two pre-teen boys slouching on some stairs, looking bored and depressed, eating ‘healthy’ sandwiches, their skate boards lying by unused. (6) An Eeyore-like voiceover makes some factual statements about healthy food and then one of the boys burps, scattering a flock of pigeons. The final flat-affect voiceover asks the question “Can your food do that?” This question appears in other SMALLSTEP ads and is supposed to impart the message that healthy food somehow makes you powerful. We know from advertising theory that a successful ad is all about promise: the greater the promise the more effective the ad. (7) This theory is used to great and lucrative advantage by the food industry. The promise of the power to scatter a flock of pigeons does not even come close to the excitement, fun and toys promised by the sugary-cereal ads.

Similarly, a large part of the SMALLSTEP resources has gone into developing a web site intended to teach children the facts about healthy food and exercise. However, after a child has been through the games and questions once, there is no particularly exciting incentive to return to the site. Most commercial home video games are much more fun and challenging. One of the exercise games shows a cartoon character and the name of an exercise, such as ‘jumping jacks’ or ‘sit-ups’, and then counts down from 10.(8) Theoretically, the child is supposed to stand next to the computer and do the exercises by himself. This is an example of a highly unrealistic classic public health approach to behavior change, which is to say to a child ‘here is a behavior we want you to do, now do it.’ A more effective approach would be to use what is known from marketing theory and find out what the child wants, then ‘sell’ that behavior to him in such a way that he thinks he is getting what he wants.

The SMALLSTEP campaign has a limited overall vision.

The SMALLSTEP campaign, which typifies the overall US public health approach to the obesity epidemic, is based primarily on the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA), two public health theories that focus on the primary role and responsibility of the individual in determining his or her health. Both are based on the premise that, given enough factual information, an individual will make a rational decision to change his or her health behavior to prevent a negative health outcome. The teen/adult web site of SMALLSTEP is a good example of this theory at work. The drop-down menus to choose from are the following: ‘get the facts’, ‘eat better’, ‘get active’, ‘learn more’, and ‘portion control’. (9) There is nothing on the website to address the fact that the teen lives in a world of many conflicting social pressures. It is extremely difficult to initiate, let alone maintain, a behavior change that requires eating radically different foods from your peers, or engaging in a physical activity level that is not reinforced by your peers or your social environment. In addition, it does not address some of the emotional, cultural or taste-preference reasons for eating “unhealthy” foods. The absence of this important aspect of food choice is evidenced by the list of recipes that is provided on the side bar. With the possible exception of ‘oven baked fries’ and ‘barbeque chicken’, none of the recipes is particularly geared to the types of foods that teens regularly like to consume and might consider trying to adapt. “Mediterranean Baked Fish” or “Green Beans Saute” do not compete with pizza or a Big Mac.

There is also nothing on the website or TV ads that addresses the problem of the role of the food industry in perpetuating the obesity epidemic. If the SMALLSTEP campaign had a more comprehensive vision, it could provide information about what is known about the effect of the food industry’s marketing on children’s eating behavior. A 2006 study by the Institute of Medicine (10) found the following: 1. more than $10 billion is spent yearly on marketing food and beverages to US children, 2. this marketing strongly influences children’s food preference and consumption, 3. food preferences in children develop very early and children as young as 2-3 years of age demonstrate brand recognition, 4. children under the age of 8 years cannot distinguish between commercial and non-commercial content, or understand the persuasive intent of an advertisement, 5. the primary focus of the food industry’s marketing is youth and children, and 6. the majority of products marketed to this age group are high in calories and low in nutrients. (10)

Information of this kind might ignite the kind of anger or rebellion that teens often feel if they perceive they are being lied to, manipulated or told what to do. It might prompt them to want to “get back” at the food industry by boycotting their products, for instance, or by telling their younger siblings not to let the food industry ‘tell them what to eat’. Tapping in to this kind of adolescent motivation was successfully employed in the Truth campaign against teen smoking in Florida. (11) The rebellious response elicited by the media portrayal of the tobacco industry’s manipulation of youth seems to have played a significant role in reducing youth smoking.

The SMALLSTEP campaign ignores the fundamental causes of the obesity epidemic.

Clearly, obesity is a result of caloric imbalance, and factors that directly impact this imbalance, such as diet and exercise, are excellent targets for intervention at the individual level. There are other social and environmental factors, however, that are risk factors that put individuals at risk for this caloric imbalance. These risk factors are not addressed by the SMALLSTEP campaign. Unhealthy diet and sedentary lifestyle are proximal causes of obesity. Social and environmental factors, such as socioeconomic status and community infrastructure, are “fundamental causes” of obesity, because these define the context in which individuals are put at risk of the risk of poor diet and sedentary lifestyle. (12)

Poverty, food insecurity, poor housing, community violence, poorly funded schools, and inadequate access to health care are all examples of social factors that can be considered distal but fundamental causes of obesity. (13) The effect of poverty on obesity can be seen when one compares the actual cost and availability of a ‘healthy diet’ with that of the USDA Thrifty Food Plan (TFP). (TFP is a USDA food plan used to determine food stamp benefits. It consists of “food lists and menus that serve as a national standard for a minimally nutritious diet at the lowest possible cost”. It has not been revised since 1999 and does not incorporate current nutrition guidelines.) (14) A study done in 2005 in Boston compared the TFP menu with a revised healthier version, incorporating current nutrition recommendations. The monthly cost of the healthier diet was almost $150 more than the maximum monthly food stamp benefit, and substantially more than the average monthly food stamp benefit received by most families in Boston. (13,14). The minority and low-income neighborhoods where the study was done were less likely to have supermarkets and more likely to have smaller grocery and convenience stores. Many of the healthy food items were missing from these smaller stores. Families in minority and low-income communities thus may not be able to achieve the recommended diet due to cost and lack of availability.

Food insecurity is related to obesity in a similar way. Food insecurity refers to the “uncertain or limited availability of nutritionally adequate and safe food or the ability to acquire food in socially acceptable ways”. (13,15) Families on limited income often replace the more expensive fresh produce and lean meats recommended for a healthy diet with cheap high fat, high sugar foods. These high-calorie, low-nutrient foods are the very foods that the SMALLSTEP campaign is telling families and children to avoid. Low income and minority neighborhoods also have a higher density of fast food restaurants compared to higher income, predominantly white communities. The increased availability of these restaurants leads to increased consumption of fast food in these populations. (13,16)

In summary, the SMALLSTEP campaign will fail to impact the obesity epidemic because it assumes that merely providing factual information will be sufficient to change individual behavior, it does not utilize effective advertising and marketing to deliver a successful public health message, and it does not address the underlying social causes of obesity.

An alternative approach: Robert Wood Johnson Foundation’s Obesity Program.

The Robert Wood Johnson Foundation (RWJF) has pledged $500 million over the next five years to fund programs that are focused on improving access to affordable healthy foods and increased opportunities for physical activity. The goal is to target the underlying environmental and policy factors that influence risk factors for unhealthy obesity-related behaviors, especially in communities with low-income children and families. The following quote by Dr Lavizzio-Mourey, president of RWJF, is a perfect example of thinking beyond the Health Belief Model: “Individual choice and behavior are important, but the world we live in plays a big role, too. We have to make it easier for kids to eat well and move more. That means more parks and safe places for kids to play, more grocery stores that stock affordable fresh produce, and improved school policies on nutrition and physical education.” (17) It is clear that this approach will address the fundamental causes of obesity and will have a much higher likelihood of success than the SMALLSTEP program.


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  1. Neault N, Cook JT, Morris V, Frank DA. The Real Cost of a Healthy Diet: Healthful Foods Are Out of Reach for Low-Income Families in Boston, Massachusetts. Report published August 2005 by the Boston Medical Center Department of Pediatrics. Available at:

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2000. Food Insecurity Institute. Available at:

    15. Block JP,Scribner RA, DeSalvo KB. Fast Food, Race/Ethnicity, and Income: A Geographic Analysis. Am J Prev Med 2004:27(3)211-217.

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