Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Analysis of Boston Public Health Commission’s Boston BestBites Restaurant Program to Fight Obesity – Lindsay Flaherty

Introduction to Obesity and BestBites
As public health practitioners are very aware of, obesity is a major problem in the United States. In Massachusetts, the obesity rate for 2007 was 21.3 percent, which is lower than most states in the country (1). The obesity problem persists in the city of Boston as well, and five years ago, the Boston Public Health Commission created the Boston Steps program to address it, along with diabetes and asthma in eight Boston neighborhoods with the highest prevalence of these conditions. In this focused area including Chinatown, Dorchester, Hyde Park, Jamaica Plain, Mattapan, Roxbury, South Boston, and the South End, 33 percent of residents are overweight, while 20 percent are obese (2). One of the programs created as part of Boston Steps is called the Boston BestBites program.
Boston BestBites is designed to help Bostonians make healthier food options when dining out in the city. With all of the tempting restaurant choices in Boston, it is not surprising that that 40 percent of residents’ food dollars are spent while eating away from home (3). Restaurants that are interested in participating in BestBites submit potentially healthy recipes to nutritionists from Brigham and Women’s Hospital for analysis. The hospital nutrition department has developed guidelines constituting a healthy meal, outlining total calories, saturated fat, trans fat and sodium. Maximum allowances in these categories are outlined for an appetizer, entrée and a dessert. The guidelines fit in with the Dietary Guidelines for Americans 2005, which recommends a 2,000 calorie per day diet for the average American adult (4). Restaurants then work with the nutritionist to meet the guidelines, if they do not pass originally. Once the recipe meets the criteria, participating restaurants are given window decals, coasters, and table tents branded with the BestBites logo and are included in campaign advertising. Healthy menu items are designated in some way so diners know what they are choosing (5).
Boston BestBites launched in August of 2006 with 12 participating restaurants. It sent out 600 packets of information to garner restaurant participation (6). As of April of 2007, there were 21 participating restaurants, spanning some of the targeted neighborhoods, but not all. Information about the program after April of 2007 is difficult to find. It appears as though the program is no longer running, or doing so with minimal support. This could be due to a number of reasons, from lack of funding, to lack of restaurant support, or even poor outcomes.
This approach to fight obesity in restaurants taken by Boston BestBites is not unique. There have been other similar approaches developed. I developed a program that precluded BestBites called The Boston Heart Party Restaurant Program in which we garnered local Boston restaurants to develop heart-smart dishes to complement our free CVD screenings. Some national chain restaurants have created healthier options on their menus for those individuals who are dieting. One example of this was when Applebee’s teamed up with Weight Watchers in 2003 to create a menu that fit the Weight Watchers criteria and was offered alongside other menu choices (7). It is easy to understand the logic of such programs. By providing healthy options on a menu, it allows people to participate in the dining experience of eating out while staying true to their diet. It could even encourage non-dieters to choose healthy, good-tasting options. In reality, the people who have obesity issues may not have the willpower to make the healthy choices when they eat out, or else they may eat and drink other things along with the healthy option that wipe out the positive effects after all.
Critiques of the Intervention
While the Boston BestBites campaign and those like it are innovative and logical, this paper will examine how this program and others like it are flawed for three main reasons. The first is that the campaign as it stands is focused on the individual and does not account for several other options that affect dining choices. Second, it does not take into account social and cultural influences on changes in behavior that can be explained through sociology and anthropology’s influences on the field of public health. Finally, while the campaign had visually appealing collateral materials, it was not supported by a strong communications program, which could have helped to solidify consumer awareness adoption.
Argument #1: Insufficiency in an Individual-Based Model
The Boston BestBites campaign is based on the Health Belief Model (HBM). In the HBM, health behavior is motivated by the following thought processes: perceived susceptibility to an outcome, perceived severity of the outcome, perceived benefits of an action, perceived barriers of taking that action, cues to action and self-efficacy (8-10). When patrons take their seats in a restaurant with a menu to decide what to order, they are presented with an array of choices. They essentially go through the thought processes presented by the HBM as they decide what to eat. Specifically, some of the questions they may consider are:
· Should I choose the lasagna or the baked chicken BestBite option?
· Would the enjoyment of the lasagna be worth breaking my diet for the day?
· If I get the lasagna, will I have time to put in an extra long session at the gym tomorrow?
· Will the BestBite option make me feel good enough to pass up my favorite meal?
Unfortunately, the limitations to the HBM apply to the Boston BestBites campaign as well. One of the main limitations of the HBM is that it is an individual-based model and assumes that people make decisions in a vacuum. However, it is important to consider that other people may be part of the decision-making process and experience of dining in a restaurant. In reality, most people seldom dine out alone. When dining out in a group, people most likely discuss options of what to get with others at their table. Besides engaging others in their decision-making process while eating out, people often share food with others they dine with. Even if they order the healthy dish, they may still be going over their allotted caloric intake for a “healthy” meal because of sharing, sampling, or ordering appetizers and drinks.
Another limitation of the HBM model is that it is based on the assumption that people make rational decisions. The idea of ownership as it relates to rational behavior is discussed by Dan Ariely in his book Predictably Irrational. He uses an example of highly coveted Duke basketball tickets to show that if a person owns something, he puts a higher value on it than a person who does not own it but would like to (11). This concept can be applied to the experience of dining out for new dieters. For people who have been accustomed to unhealthy eating habits, their entire lives, then it will be more difficult for them to give up what they are used to and choose the healthy option. Consider the hypothetical example of a man named Joe. Joe is overweight and grew up in an Italian household that traditionally ate homemade lasagna every Sunday. This lasagna was not a new-fangled version of the dish containing low-fat, soy-based cheese, an abundance of vegetables and whole wheat noodles. Joe is accustomed to gooey, cheesy lasagna with ground beef and sausage loaded into it. Lasagna is comforting and nostalgic to Joe, as well as delicious. When he dines out at an Italian restaurant for the first time and sees the lasagna on the menu next to the BestBites baked chicken, he will think about how enjoyable and comforting lasagna is to him. The decision to choose the chicken would be more difficult for him than someone who has never eaten lasagna before, in the same way that the Duke basketball tickets are more valuable to someone who possesses them. The man in the example will be strongly focused on what he is losing when choosing the chicken over the lasagna, as opposed to the health benefits of the chicken and may act irrationally.
Argument #2: Lack of Consideration for Social and Cultural Influences
Boston neighborhoods are extremely diverse and different from one another. A comparison of the demographic make-up of two of the neighborhoods focused on in the Boston Steps program shows this. According to 2000 Census data, Roxbury has 63 percent black people, 24 percent Hispanic people, and five percent white people. Twenty-two percent of people speak Spanish at home (12). In contrast, South Boston 85 percent white people, 7 percent Hispanic people, and two percent black people. Only six percent of people speak Spanish at home (13). In the Boston BestBites program, a simple solution was applied to a range of ethnic restaurants in neighborhoods with culturally and ethnically diverse backgrounds. But addressing the needs in Boston’s diverse neighborhoods cannot be met by a one size fits all solution.
By considering and applying sociological and anthropological theories and research methods in the development of the BestBites program, a more effective program could have been created. Sociology incorporates a focus on social groups, hierarchies, structures and the nature of social interaction into public health programs. Anthropology emphasizes the role of culture in human behavior and public health problems and takes into account a holistic approach to behavioral decisions (14).
As described above, dining out is highly social and culturally unique. Companions, surrounding, and a person’s background can have a strong influence on the decision-making process at a restaurant and needs to be considered in the BestBites program. Additionally, a person’s cultural background and beliefs might play an important role in how he or she views dining out and what types of dining choices are typical. This must be considered in order to understand how to best influence behavior in a restaurant setting.
It is unclear what, if any, research was done to develop this intervention. Research methods common to sociology and anthropology could have been helpful in developing a successful program. Sociology typically utilizes both qualitative and quantitative research methods, while anthropology focuses mostly on using highly qualitative methods alone. Some of the research tactics that would have been helpful in the development of the program, include surveys, observation, one-on-one interviews, focus groups and experimentation. Data collection could then be used to generate theories about behavior and inform an intervention that could be more effective (15).
Argument #3: Failure to Support Program with Extensive Marketing Program
Finally, the Boston BestBites campaign did not thrive, because it was not supported by strong communications tactics resulting in visibility for the campaign. Even though the campaign had strong collateral materials, they could not serve to hold up the campaign’s success alone. As has been described in this analysis, the BestBites public health intervention is built in a setting that is greatly influenced by social factors. In order to have a greater impact on people’s decision-making, the campaign needs to be accompanied by a higher volume of social marketing, advertising and public relations. When searching for resources about BestBites, there are a couple of pages on the Boston Public Health Commission (BPHC) website, a press release for the launch, a couple of news articles from the launch, and a couple of website commentaries on the program. Other than that, it is impossible to find information about the program before walking in the doors to one of the few participating restaurants.
There are various studies and papers that outline how advertising and marketing can affect people’s actions. One such model is William J. McGuire’s Information Processing Model (IPM) (16). The IPM culminates in a communication/persuasion matrix including the thirteen steps in information processing. They are: exposure, attention, liking, comprehension, cognitive elaboration, skill acquisition, agreement, memory storage, retrieval, decision making, acting on a decision, cognitive consolidation, and proselytizing (16). The IPM model has received criticism that it reduces the decision-making process to a succession of steps which is too orderly. However, it outlines the importance of reaching audiences with messages in various ways and at various times in order to get the consumer through this long list of thirteen steps. The BestBites program is accompanied by clean and practical collateral materials (i.e. table tents and coasters); but if a person has not heard of the program before walking in the door to the restaurant, he or she will most likely not make it past steps one and two (exposure and attention) on the matrix hierarchy. This would most likely not be enough to choose to make a behavior change and order a healthy dining option.
Other communications theories also underscore the effectiveness of using message dissemination as a means to influence consumer thought and opinion. Diffusion of Innovation Theory says that the media can be used to influence and encourage people to help further a message (17). The Agenda-Setting Theory similarly contends that the media can be used to help and direct people on what topics to think about (18). Through better utilization of message distribution by the media and other means, the BestBites program may have been a higher priority in the minds of Bostonians. By hitting audiences with the BestBite messages in various ways – even low budget ones – the campaign could have gained more energy and momentum. This may have helped to influence more people to make the healthy menu item choices and encourage more restaurants to sign on to participate.
In summary, the Boston BestBites program that was developed as part of the Boston Steps program by the BPHC seems like an innovative and catchy idea on the surface. However, by considering the campaign through the lens of a knowledgeable public health practitioner, it is clear that it contains flaws that might limit its effectiveness. Restaurant patrons do not make their decision of what type of food to order while dining out on their own. They are influenced by their companions, surroundings, and cultural background. Such influences need to be taken into consideration in the development of an effective intervention. In addition, a program with flashy collateral materials cannot stand on its own without a full scale communications program to help disseminate messages repeatedly to restaurant patrons so they are more likely to make healthy choices while dining out.
A New Intervention
On the surface, the Boston BestBites program is a fun and innovative way to fight obesity in the Boston neighborhoods with the biggest disparities. In order to create a new and better intervention to help Bostonians make healthier choices while dining out, it will not be necessary to completely overhaul the program. Instead, I propose to renovate it using what we know about more effective – and often unconventional – methods of addressing public health problems. The revamped BestBites program will need to incorporate social and environmental factors into the decision-making process; be constructed based on sound qualitative research so that it will uniquely meet the needs of patrons who live in certain neighborhoods and frequent certain restaurants; and be supported by a strong communications program to not only build awareness, but also supplement the decision-making process.
The revised program will be called Boston BestBites Nites. The campaign will run for a year, and will offer two unique BestBites Nites per month, each at a different restaurant located in one of the neighborhoods targeted in the Boston Steps program. There will be a total of total of 24 “nites.” The restaurant participating at each BestBites Nite will be required to have two appetizers, two entrees and two desserts pass through the nutritional analysis developed by Brigham and Women’s Hospital. In addition to this requirement, restaurants will be given autonomy to add additional elements to their Nite in order to help to customize it to their own patrons. Public health professionals will be available to help develop these ideas based on both traditional and nontraditional models for behavior change. Examples of activities unique to a specific restaurant include offering the meals at a discounted price as a way to entice lower income patrons; a physical activity component such as dancing that is typical in a particular culture and could help garner attendance; or the development of “mocktails” to help teach people how to adopt other healthy lifestyle changes.
All of the Nites will incorporate an educational component as well. The BestBites collateral materials will be expanded to include educational materials. A nutritionist from Brigham and Women’s Hospital Department of Nutrition will be present to answer any questions that patrons have about healthy eating and meal creation. Restaurants will also be free to suggest and develop other educational components based on their customer base. Following a certain restaurant’s BestBites Nite, it will be required to leave at least one of the healthy options on its menu for the future, and continue to distribute educational materials and other campaign literature throughout the duration of the program.
Counter-Argument #1: Moving Beyond an Individual-Based Model
Dining out at a restaurant is not an individual experience, and so an intervention that is based on an individual-based model simply will not have the intended impact. There are several ways that BestBites Nites is more incorporative of social factors. First, the BestBites Nites program is based on the ecological model. This model considers that individual factors are only a small contributor to a person’s behavior. Other factors that affect behavior include social/cultural/group, socioeconomic and structural, political and environmental factors. All of these factors would work together to influence behavior, not work individually (19).
In the BestBites Nites program, the decision-making process shifts from one that is individually focused, to one that is group focused. Family and friends will decide together that they want to attend the BestBites Nite at a certain restaurant, and so one person will not be isolated in trying to choose a healthy menu option amid other temptations and social pressure. Social, cultural, socioeconomic and group factors are already built into the experience. The individual need only decide which of the healthy options he or she wants to eat when after arriving at the event. An evening shaped around healthy restaurant dining and fun removes the pressure from an individual to make a healthy choice while under the influence of environmental surroundings or social pressures. Dancing or entertainment will make the evening more appealing as a group activity. The educational component will arm diners with ideas on how to maintain healthy eating habits in everyday life or while dining out in the future. Since at least one of the healthy menu items will stay on the menu after the BestBites Nite at that location, diners will be more likely to choose it on an individual basis in future visits to that restaurant now that they have experienced it in a group they are comfortable with.
The BestBites Nites also take into account that people do not always make rational decisions. As discussed above, diners know what they are giving up when they choose a healthy meal. For example, patrons at Poppa B’s in Dorchester are accustomed to traditional soul food dishes such as BBQ ribs, fried chicken and sweet potato fries (20). The BestBites Nite at Poppa B’s should not exclude these soul food favorites, but update them into healthier options. Patrons who may be tempted to make an irrational decision will remember how good these items are and not necessarily be satisfied with a menu that does not include them. An example of a renovated, healthy, soul food menu could include BBQ chicken, oven fried chicken and oven baked sweet potato fries. The patrons will not feel like they are giving anything up.
Counter-Argument #2: Strong Consideration for Social and Cultural Influences
As mentioned above, Boston is an extremely diverse city, and it is hardly possible to create a one size fits all obesity intervention that would have an impact on the city’s diverse population. Since BestBites Nites will take place at one location at a time, it will allow the program to be more tailored to accommodate the unique diners who typically frequent those restaurants, based on common characteristics of local residents. In this way, a BestBites Nites held at Poppa B’s in Dorchester will be very different from a BestBites Nites at Centre Street Café in Jamaica Plain.
The public health practitioners who are tasked with development and implementation of the BestBites Nites program will be instrumental in helping restaurants to develop a unique evening at their restaurant that will specifically help to encourage healthy dining among their patrons. By utilizing data collection methods more typical in the fields of sociology and anthropology, a more precise and focused understanding of each restaurant’s customer base can be gathered. Therefore, for each of the 24 restaurants that participate in BestBites Nites, two customer focus groups, at least 200 surveys, and at least five one-on-one interviews will be conducted with restaurants and patrons. Some of the questions that can be posed through these qualitative research methods include:
· Why do you dine at this restaurant?
· What is your favorite menu item at this restaurant, and why do you choose it?
· Who do you typically dine at this restaurant with?
· Do you maintain a healthy diet at home?
· What do you think of when you hear “health food”?
· What does eating a meal with family and friends mean to you?
· How is the food at this restaurant different or similar from the food you eat at home?
· Are there any activities – such as dancing, games, or demonstrations – that you would find entertaining while dining at this restaurant?
The research will be compiled into a report including recommendations for unique tactics to meet those patrons’ needs. The public health professionals will then meet one-on-one with the restaurant owners to design the evening.
Counter-Argument #3: Development of a Strong Communications Program
As mentioned above, Boston BestBites is a creative idea accompanied by a strong base of sharp collateral materials. The campaign’s development of restaurant-friendly items such as coasters and a recognizable logo is an important first step in building recognition of the campaign. However, the program received practically no media attention, has an outdated website, and seems to have fizzled out soon after its inception. In order to drive attendance to BestBite Nites and provide education to people that will hopefully have a longer term impact on people’s dining choices, the campaign will need to be supported by a strong communications program. The existing materials should be used as a basis for this, and additional materials should be developed to build upon and expand them.
The communications program will need to include public relations, advertising and community relations components. It should be creative and wide-reaching. By repeatedly getting the BestBites message in front of residents of target neighborhoods, it should follow that the campaign will have greater adoption based on William J. McGuire’s Information Processing Model (IPM) (21) and the Agenda Setting Model. More specifically, some or all of the following tactics could be included in the communications campaign:
· Advertising in community media publications, such as the Roslindale Transcript, Brighton Tab, South End News, and Jamaica Plain Gazette.
· Hanging flyers at neighborhood libraries, coffee shops, book stores, grocery stores, etc.
· Working with a local healthy food store (such as Trader Joe’s) to have them distribute flyers for BestBites when bagging groceries or giving receipts to customers.
· Generating feature stories in regional, local and community media about participating restaurants.
· Place a news story in Brigham and Women’s weekly newsletter, as well as other Partners institutions – possibly even offering a promotion for all Partners employees.
· Scheduling a “chat” with one of the nutritionists from Brigham and Women’s on, where users can write in questions about the program.
· Signing on a campaign “spokesperson” to help educate and influence consumers to eat healthy while eating out with the BestBites program.
In addition to these communications tactics, a strong and up-to-date website should be developed as a core information source of campaign information in addition to collateral materials. A catchy web address can appear on collateral materials, in advertising, or in news articles. When a user visits the website, it will have a detailed schedule and description of upcoming BestBites Nites and participating restaurants. Healthy dining tips and a blog by a Brigham and Women’s nutritionist could also be strong additions to the website. The online communications strategy could even incorporate the use of social media, where appropriate. For example, a Facebook group could be created for BestBites Nites to build buzz. For communities that do not have a high usage of the Internet, extra collateral materials and community relations tactics will be utilized to reach audiences in the most appropriate way.
In conclusion, Boston BestBites is an innovative program with a strong and established base. By tailoring and renovating the program to be more in tune with all of the factors that affect the decision-making process for diners at participating restaurants specifically, the intervention can have a greater impact. An improved intervention that is built around an individual-based decision-making model should also be strongly supported by a highly visible communications campaign that will help to foster a greater participation rate and, with hope, ultimately help improve the health of residents in the Boston neighborhoods facing the most disparaging obesity statistics today.
1. U.S. Obesity Trends 1985 – 2007 – 2007 Obesity Rates. Centers of Disease Control and Prevention. Accessed on 11/15/08.
2. About Boston Steps – Boston Steps Project Area. Boston Public Health Commission Website. Accessed on 11/15/08.
3. Boston BestBites. Boston Public Health Commission Website. Accessed on 11/15/08.
4. Dietary Guidelines for Americans, 2005. U.S. Department of Health and Human Services. Accessed on 11/15/08.
5. Boston BestBites. Boston Public Health Commission Website. Accessed on 11/15/08.
6. “Mayor Menino, Public Health Officials Kick-off Boston BestBites.” News & Press Releases. August 18, 2006. Accessed on 11/15/08.
7. “Applebee’s and Weight Watchers Announce Plans to Co-Develop New Menu.” Business Wire. July 25, 2003. Accessed on 11/15/08.
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12. Roxbury Data Profile. Department of Neighborhood Development, Policy Development and Research Division. US Bureau of the Census. May 1, 2006. - 2006-05-01.
13. South Boston Data Profile. Department of Neighborhood Development, Policy Development and Research Division. US Bureau of the Census. May 1, 2006. - 2006-05-01.
14. Edberg, Mark. Essentials of Health Behavior. Chapter 3, pages 31-32. Jones and Bartlett Publishers. Sudbury, MA. 2007.
15. Strunim, Lee. Disciplines of Social Sciences. Presentation Given to SB721 on November 6, 2008. Slides 12, 34.
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20. Poppa B’s Website. Menu. Accessed on December 9, 2008.
21. McGuire, W. J. (1999). Constructing social psychology: Creative and critical processes. Cambridge: Cambridge University Press.

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