A Failed Intervention - Critiques of the Sargent Healthy Choice program and Suggestions for a More Promising Intervention--Samir Bhalla

Introduction

The prevalence of obesity is an extremely significant public health problem in today’s society that has increased dramatically over the past three decades. Obesity is the result of poor, unhealthy eating patterns, in conjunction with a lack of physical activity. Analyses of Americans’ dietary patterns show that Americans on average consume large amounts of protein and fat, and too few servings of fruits and vegetables (1). The combination of these dietary issues, with decreased physical activity and increased sedentary lifestyles, has led to the overall rise in obesity. In an attempt to combat obesity and unhealthy eating habits on a college campus, Boston University developed and promoted the Sargent Healthy Choice program. This intervention represents a collaborative effort between BU Dining Services and the BU Sargent College nutrition program (2). The goals of the Healthy Choice program are to offer a variety of food options that are both nutritious and satisfying, while helping consumers understand good nutrition and make healthier food choices in their daily lives. With the help of dining services, the Sargent Choice program has increased the variety of healthy foods such as fruits and vegetables into retail and residence dining locations all across campus (3). Easy identification of food options that meet the 2005 Dietary Guidelines for Americans is achieved through the use of the Sargent Health Choice logo that is placed next to these foods (2). Furthermore, recipes for popular foods such as chocolate chip cookies and pizza have been modified to decrease sodium and fat levels, while still attempting to maintain flavor.

Yet, while designed and implemented with good intentions, the Sargent Healthy Choice program represents, in essence, another flawed and ineffective public health intervention. The basis for this intervention stems from blemished health behavior models; namely, the Health Belief Model. This model incorrectly assumes that all behavior is rational and planned, and does not account for social factors that influence behavior or group dynamics. Furthermore, the Sargent Healthy Choice program neglects to utilize non-traditional behavioral models such as marketing theory or stigma theory. Advertising for the Sargent Choice program at Boston University has been limited to simply using an uninteresting logo and motto. Conversely, however, fast food franchises that provide unhealthy food options effectively market their products and programs to effect group behavior. These franchises perpetuate the dilemma that the Sargent Choice program attempts to fight. Moreover, the Sargent Healthy Choice program does not consider the learned nature of behavior and the individual and environmental factors necessary to affect behavior. Without providing a model for behavior, social support, or reinforcements for behavior, the Sargent Choice program is rendered ineffective at yielding changed consumption patterns. These deficiencies, in summation, yield an unproductive intervention for changing eating habits.

The flaws of the Sargent Healthy Choice program, however, can be used as a learning tool to create a new, more effective intervention. The hypothetical BU Platters food establishment described below represents a public health intervention employing aspects of Social Expectations theory, Advertising theory and Social Learning theory to design an effective intervention against unhealthy eating habits on college campuses. This program analyzes the underlying, fundamental causes that result in the predicament of unhealthy diets of college students. By taking into consideration the social environment and norms that result in unhealthy eating habits among college students, a more valuable intervention is created that utilizes the characteristics of college life to promote healthy behavior. Furthermore, by employing the principles of Advertising theory and Social Learning theory, the new BU Platters intervention makes use of the predictably irrational behavior of college students to promote the consumption of a balanced diet, thereby building upon the flaws of the Sargent Healthy Choice program.

A False Assumption

The Sargent Healthy Choice program is based on the Health Belief Model. Through the Sargent Healthy Choice program, dining halls on campus offer healthy food options that often include portions of whole grains and cooked vegetables (2). Furthermore, the dining halls offer salad bars that offer freshly prepared fruit salad, and a fruit stations with various fruits, including apples, pears, bananas, and oranges. The developers of the Sargent Choice program reasoned that by making healthier food options available to students, students will, in turn, choose to consume more wisely and to balance their diet with grains, vegetables and fruits. On average, the Warren Towers dining hall will serve 3000 students a day, all of whom will subsequently have access to the plentiful selection of fruits and vegetables offered in the dining hall. This reflects the Health Belief Model, as the Sargent Choice program aims to promote healthy consumption of food by providing easy access to healthy food options. By removing this barrier, the Health Belief Model argues, people are more likely to eat healthier.

The Sargent Choice plan, and the model on which it is based, assumes that individuals rationally weigh benefits and costs before decision making; thus, by providing greater access to healthier food, a barrier/cost to eating healthy is diminished and individuals will rationally decide to eat healthy (4, 5). This assumption is the central limitation of the Health Belief Model, as individuals do not always act rationally (6). Rather, people often make irrational decisions based on habits and desires. While there may be increased access to healthier food, students are still very likely to choose to eat pizza or burgers, or other unhealthy foods instead. This is an irrational behavior that the Health Belief Model and the Sargent Choice program cannot explain. Simply increasing the availability of healthier food options does not directly correlate to more people eating healthy. Individuals who do not hold their health in the same high regard that practitioners of public health do will not be fazed by this program. Moreover, decisions to eat healthier are influenced by social factors and group dynamics, which are not accounted for by the Sargent Choice program. People do not make the decision to eat healthier in a vacuum, and are not in absolute control of their decisions. Rather, the food choices that friends and close family members make will strongly influence the eating habits of an individual (7). This theory is represented by the Social Network theory, which, in short, states that the main determining factor of people’s behavior is the behavior of the people in their social network (8 and 9). Thus, while individuals may intend to eat healthy as a result of the greater access to healthy foods, these intentions do not always to come to fruition due to the influence of others. Furthermore, the Sargent Choice Program does not account for the self-efficacy of individuals. Individuals with low self-efficacy, and lack the confidence that they can change their eating pattern and maintain this habit are also not affected by the Sargent Choice program. For these selected reasons, the Sargent Choice Program is flawed in its design, for it only targets to change individual level factors, which will not result in a change in health behavior. The assumption that increasing the access to healthy foods across campus and in dining halls will result in healthier eating patterns is false. To alter the eating behaviors of an entire population of college students, social and group level factors must be also be addressed.

Ineffective Advertising

In addition to its flawed design, the marketing campaign for the Sargent Choice program has handicapped the effectiveness of this intervention. The advertising for this program has been restricted to the use of a circular logo on fliers and posters in food locations. Posters within these facilities advise students to maintain a balanced diet and how man servings of each food group to consume within a day. The posters, similar to the program’s website, offer eating tips, and other resources regarding nutrition classes. Occasionally, outside of dining halls, the Sargent Choice program will have tables set up offering samples of new recipes, in attempt to show students that Sargent Choice food options are not diminished in flavor or taste. Yet, these advertisements have been restricted to dining facilities. As a student in my fourth year at Boston University, I have yet to view an advertisement for the Sargent Choice program outside of a dining hall or the student union.

Conversely, however, fast food establishments near the Boston University campus such as McDonalds, Burger King, and Taco Bell have been marketing their unhealthy foods for years using the principles presented by Advertising theory (10). Traditional public health interventions that have been developed in the field of public health such as the Sargent Choice program have tried to explain and change individual behavior. Alternatively, the implementation of Advertising theory by fast food establishments has affected the behavior of a large mass of people (11). Through formative research, advertisers seek to assess the motivations, interests and aspirations of the target population. The aspirations and goals of the target population form the basis of Advertising theory, as this theory maintains that people will behave in desired ways if a promise is made to people that their aspirations are attainable. In other words, people will engage in a particular behavior if they are promised that their dreams can become reality. The product, or food in our case, is then packaged and presented in a way that appears to promise the targeted population that they will achieve their aspirations. Food establishments have produced commercials employing Advertising theory that are filled with promises of wealth, success, health, and popularity utilizing visual images. McDonalds for instance has ran an entire campaign based on the logo of the “McDonald’s smile” which is reinforced by visual images of happy children and young adults consuming McDonald’s food, often times in large groups (12). These types of advertisements convey to the target population of youths that consuming McDonald’s food will yield happiness and popularity (12 and 13). Consuming McDonald’s in pursuit of happiness and popularity is a completely irrational behavior, yet Advertising theory utilizes the fact that individuals act irrationally to affect the behavior of large groups of individuals.

The Sargent Healthy Choice program has not made any such efforts to advertise the program, taking advantage of the fact that people act irrationally. Rather the program’s advertising efforts have been based on the assumption that people act rationally, and by reading posters in dining facilities or participating in recipe tasting events, people will rationally choose to eat healthier food. The Sargent Healthy Choice intervention continues to use data, scientific recommendations and bullet points for evidence and support of behavior change. Yet, time and time again this methodology has proved to be ineffective. People know the risk factors and consequences of smoking; likewise people know that eating pizza and fried foods is unhealthy, but they continue to irrationally engage in this behavior. In opposition, food establishments have used visual images and catchy slogans and mottos to reinforce the promises made in their advertisements. Which slogan is more likely to yield a behavioral change – the “I’m Loving It” motto of McDonalds, reinforcing the promises of happiness made to their target population, or the Sargent Choice motto of “Where Nutrition Science Meets Culinary Art”? It can be argued that public health programs, such as the Sargent Choice intervention, do not have the same level of resources to research and ultimately produce commercials and advertisements. However, new filming and editing technology has decreased the costs of production of advertisements. Advertising theory represents a powerful and widely successful model that has been used by food, candy, and soda companies alike to sell their products and to create, albeit unintentionally, the problem of obesity in the first place. If such methods created the problem, then they should also be used to solve the problem. Furthermore, an individual’s self-efficacy, or their confidence that they can perform the action and overcome any barriers, is also important in predicting behavior.

Neglecting Social Learning Theory

As stated earlier, the basic premise of the Sargent Healthy Choice program is that by removing a barrier to eating healthy, individuals will rationally choose to change their eating habits. Yet, behavior can be described as a learned process that is affected by the environment and direct observation. The Social Learning Theory states that behavior is learned through observation of other people in a social context (6). The positive and negative reinforcements that are given to individuals can respectively encourage or discourage the learned behavior (14). Aside from the internal influences, behavior is also a function of the environment, social support and access to resources as well. Through this model, behavior change requires individual self-efficacy, positive reinforcement of the behavior, a model for the behavior, and social support. These requirements for change are not met by the Sargent Healthy Choice program, as no reinforcements, social support, or models for behavior are provided.

An example of the effectiveness of Social Learning theory on producing behavioral change is the series of commercials launched by the Subway franchise starring Jared Fogle (15). The commercials detailed how Jared lost over 240 pounds by walking to his nearby Subway restaurant and consuming their sandwiches for lunch and dinner every day. While these commercials were intended to build up sales for Subway, they also acted as a public health intervention against obesity. Jared’s commercials promoted increased physical activity (walking to Subway) and healthier, well-balanced diet (eating Subway sandwiches). This represents the Social Learning Theory because these commercials promoted healthy behavior through the presentation of Jared. The goal of the commercials was to encourage individuals to use Jared as a model for behavior. Jared received enormous praise through the media for losing 240 pounds, and this served as positive reinforcement for overweight individuals seeking to model Jared’s behavior. The commercials promoted individual self-efficacy through its slogan “It worked for Jared”. By stating that this behavior of increased physical activity and eating healthier food (Subway sandwiches) worked for Jared, the commercials are developing the self-efficacies of other overweight individuals that this plan could work for them as well, and that they could achieve significant weight loss like Jared. Thus, although Subway intended these commercials to increase sales and revenue, they also served as a public health intervention by promoting increased physical activity and healthier diet through the Social Learning Theory.

Unlike Subway, however, the Sargent Healthy Choice program makes no such efforts to provide direct observation of people that have successfully changed their eating habits. No reinforcements are provided to individuals that are contemplating change, or are in the action of behavioral change, which limits the effectiveness of this intervention. A central concept of the Social Learning theory is self-efficacy (14). Individuals who lack self-efficacy find no resources through the Sargent Healthy Choice program to develop the confidence within them to change their behavior. As a result, individuals will simply just not change due to the belief that they are unable to. Without providing these central requirements for change as described by the Social Learning theory, the Sargent Healthy Choice program is rendered ineffective at producing behavioral change. Thus, increasing the access to healthier foods, thus, does not directly relate to increased consumption of these healthy foods on a regular basis. One of the most productive public health interventions against obesity and eating patterns was launched by a fast food franchise, but yet, public health practitioners fail to utilize the same methodology in the design of interventions.

BU Platters – A New Intervention for an Old Problem

Poor eating habits on college campuses has been a well documented public health issue that makes up one subset of the overall obesity epidemic that our society currently faces (16,17). Boston University developed the Sargent Healthy Choice plan, which aimed to provide students with greater access to healthy foods in order to increase their consumption of such foods (2,3). While created with benevolent intentions, the program was poorly designed as it failed to contextualize the risk factors behind the poor diet of college students. This program did not take into account the social environment and norms of college life that causes the poor eating habits of students. This is the biggest flaw of the Sargent Healthy Choice program as it incorrectly assumes that people act rationally, and will choose to consume healthier foods when the barriers to this health action are minimized. The program makes no attempt to understand why college students maintain poorly balanced diets, and how this relates to the culture of life on a college campus. Furthermore, the Sargent Choice plan has displayed ineffective advertising that has handicapped the program, utilizing scientific data, bullet points, and boring logos and slogans when compared to the fast food establishments that the intervention attempts to counteract.

Conversely, a new intervention that would prove to be more effective in the battle against obesity and proper diet on a college campus is to open a school sponsored food establishment named BU Platters, located in the center of campus. This new establishment would remain open until at least 1am on weekdays and 3am on weekends. The menu will include healthy food options such as salads and fruits, while still providing meal entrees including sandwiches, pasta, in addition to coffee and other snacks for students as they study at night. BU Platters will accept dining and convenience points that are a part of students’ meal plans, and will increase the access to healthy food late at night. Typically at night, the only food options available on campus at Boston University is greasy, fried food in the dining halls via the Late Night Cafes, or ordering pizza from the local Dominos or Papa John’s establishments. It is extremely difficult to eat healthy when you can only choose between mozzarella sticks, chicken fingers, or pizza. Most of BU’s dining facilities, including campus dining halls and the student union, close at 8pm, which is ironic since the Sargent Healthy Choice plan only operates through these dining facilities (18). Thus, at night, these students are left with little to no variety in the types of foods they can consume, making it extremely difficult for them to maintain a well balanced diet. The BU Platters establishment will remedy this problem by providing students with a variety of relatively healthy food choices that appeal to all students, throughout extended hours of the day.

In addition to enhancing the availability of healthy food options to BU students, this new intervention builds upon the flaws of the Sargent Healthy Choice program by addressing the fundamental causes of unhealthy eating habits among college students. As Link and Phelan described, a fundamental cause of disease cannot be eliminated by only addressing the mechanism that appear to link these causes to disease (19). These fundamental causes often involve social factors such as social norms or socioeconomic status, which can have profound impacts on disease. The Sargent Choice program represents the traditional epidemiological mindset that focuses on proximate, individual based risk factors. Yet, these risk factors that result in unhealthy eating on college campuses must be contextualized to determine the true fundamental causes of poor eating habits among college students. This is the greatest strength of the new BU Platters intervention, as it effectively contextualizes the risk factors for unhealthy eating and subsequently, and utilizes the true fundamental causes to promote healthy diets.

One of the fundamental causes for the poor dietary habits of college students is the environment, culture and social norms of college life. As stated by the Social Expectations theory, people act in mass based on the current social norms (20). The social norms of college students are to go out with friends, party and consume alcohol, and study late at night to prepare for exams (20). It is in these three situations where unhealthy eating habits flourish. Under these norms, junk food establishments (under junk food establishments I include all fast food places as well as BU’s Late Night Cafes and Rhett’s diner located in the Student Union) thrive exacerbating the problem of unhealthy eating on campus. Students staying up late at night drink large amounts of coffee and soda to stay awake. After a night of partying and consuming alcohol, college students want to eat, and this tendency is why the T Anthony’s pizzeria in West Campus has been so profitable. Furthermore, groups of friends order food in when hanging out together to study or to watch a movie. These are the true underlying, fundamental causes for the dilemma of unhealthy eating habits among college students, and these are the causes that the new BU Platters intervention attempts to rectify.

By staying open late at night and offering a variety of foods from healthy snacks to full entrees, the BU Platters program utilizes the social norms of college life to promote behavioral change. Understanding that college students will go out partying and will stay up late to study allows the BU Platters program to be a more effective intervention. Providing healthier food options in a convenient location allows inebriated college kids to eat something healthier than greasy pizza or Chinese food. A significant percentage of the business earned by pizza and Chinese food establishments that deliver at late hours of the night is through college kids that order food after coming home from partying and drinking. This is especially true during finals period, where students are up studying all hours through the night. Boston University accommodates students during finals period by keeping the Mugar library open 24 hours a day, and by providing shuttle service from the library to student dorms at late hours of the night as well. Despite this, there are no food establishments open to provide healthy food for students while they are studying. The student union, for some reason, closes earlier at 7pm during finals period. BU Platters would thus serve these students late at night, providing them with healthy food options to consume. If fast food establishments can utilize the behavior of college students to earn profit, why shouldn’t public health also utilize these behaviors to promote healthier eating habits? Some restaurants close to campus are not open in the late hours because they do not want to deal with intoxicated college students. BU Platters will provide these students with healthier food alternatives to consume. While admittedly it may be unrealistic that drunken college students will eat a salad late at night, but even the transition to eating a sandwich over greasy pizza would represent progress. Furthermore, BU Platters also provides students with food options other than candy and soda to consume while they are up studying for exams. Moreover, the BU Platters program also caters to the needs and interests of its target population of college students by accepting BU Dining and Convenience points. It is characteristic of college students to resist spending their own money, as they would rather use their Dining points to order pizza from the local Dominos establishment. Accepting Dining points would result in increased business for BU Platters from BU students, and would allow for equal access to college students that live on campus. Thus, BU Platters addresses the social factors that produce unhealthy food consumption, and utilize the current social norms and expectations to promote healthier eating habits.

In regards to the Sargent Choice program, the BU Platters intervention builds off of the limitations and flaws of the Sargent program. Firstly, the Sargent Healthy Choice program, based on the traditional Health Belief Model, aims to promote healthy consumption of food by providing greater access to healthy food options. By removing the barrier of access to healthy food, the Health Belief Model argues, people are more likely to eat healthier (4,5). This is a central limitation of the program as people often do not behave rationally, but rather, act as a result of social and group level factors such as social norms and expectations. The new BU Platters intervention does not make this false assumption, as the program is based off of social factors that account for the irrational behavior of college students. In itself, the consumption of unhealthy food such as pizza and Chinese food while intoxicated can be seen as an irrational behavior, which the Sargent Healthy Choice program fails to explain. Yet, the new BU Platters intervention outlines the fundamental cause for this behavior, and utilizes this irrational behavior to promote change in the form of healthy eating habits.

Secondly, the BU Platters intervention will employ the principles of Advertising theory to promote the new establishment. The advertising for the Sargent Choice program has been restricted to the use of a circular logo on fliers and posters in food locations. Based on the assumption that people act rationally, Sargent Healthy Choice continues to use data, scientific recommendations and bullet points for evidence and support of behavior change. Yet, college students act irrationally, and continue to consume unhealthy food items. Through the use of effective advertisements based on the ideals of Advertising theory, the predictably irrational behavior of large groups of college students can be manipulated at once (10). The theory argues that people will engage in a particular behavior if they are promised that, by doing so, their dreams and aspirations can be achieved (11). Commercials advertising the new BU Platters establishment will display images of health and success to reinforce the achievement of individuals’ dreams, in conjunction with eating at BU Platters. The new program will utilize a colorful and flashy logo, along with a cool slogan, along with offering prizes and giveaways that BU students would actually be interested in, such as BU men’s hockey tickets. Through the employment of Advertising theory, the new BU Platters program attempts to promote the program to a higher degree than has seen with the Sargent Choice program. Also, through the commercials produced, the new BU Platters program will attempt to affect the behavior a large groups of college students at once, taking advantage of their predictably irrational behavior.

Finally, the new BU Platters program, unlike the Sargent Healthy Choice program, takes into account the principles of Social Learning theory, as social factors including the environment, social norms, support, and access to resources are considered (14). The intervention is designed based on the social norms of college life that yield the fundamental causes for the problem of unhealthy eating habits, accounting for the social environment that college students behave in. Furthermore, access to resources including healthy food is enhanced through this intervention by offering a variety of food options at a convenient location, at an establishment that also accepts BU dining points. All on campus BU students have meal plans, and thus students have equal access to these foods without any discrepancies based on race, gender, or any other convoluting factor.

Conclusion

The Sargent Choice program was designed with good intentions to tackle an ongoing problem of unhealthy eating habits among students on college campus. The consumption of largely unhealthy foods among college students is a documented problem that public health must address (16). Thus, it is commendable that Boston University attempt to focus on and resolve this issue through the initiation of the Sargent Health Choice program. As discussed, however, this intervention is severely defective. The design of the program was based on a simplistic model for behavior that describes individual behavior as planned and rational. This is not the case as many eating behaviors and habits are irrational, and are dependent on the eating patterns of others within an individual’s social network. Individuals do not make their decisions in a vacuum and are influenced by social constructs and the environment; these factors are not considered in the design of this intervention. In addition to this flawed design, the advertising campaign for the program has been ineffective. While fast food establishments have used the principles of Advertising theory to make promises of happiness and success that can be fulfilled by consuming their food, the Sargent Choice program has been limited to posters, fliers, and an uninteresting logo. Finally, the Sargent Choice program ignores learned nature of behavior. Rather than simply trying to coerce or convince people to change, Social Learning theory argues, a model for behavior, along with positive reinforcements, and social support resources are necessary affect behavioral change. The Sargent Healthy Choice program does not provide any of these so called requirements for change. While Boston University should be praised for attempting to address the issue of unhealthy eating on college campuses, the Sargent Healthy Choice program is not the solution. This intervention is critically flawed and is ineffective at producing changed eating patterns.

On the contrary, the BU Platters food establishment represents a multi-faceted public health intervention employing aspects of Social Expectations theory, Advertising theory and Social Learning theory to design an effective intervention against unhealthy eating habits on college campuses. This program analyzes the underlying, fundamental causes that result in the predicament of unhealthy diets of college students. The social norms of college life in conjunction with the lack of food establishments open to provide healthy options to meet the needs of college students has resulted in poor dietary behavior at BU. By contextualizing risk factors and determining the fundamental causes of a disease or problem, the BU Platters program will be able to take advantage of the social environment on campus, and utilize the predictable irrational behavior of college students to promote healthier diets. The development of the BU Platters program represents a movement away from traditional epidemiology that focuses on individual risk factors, to social epidemiology that studies the social context in which risk factors operate. Utilization of social epidemiology can result in the design and implementation of more effective public health interventions. For instance, people know the negative effects of unbalanced diets, but yet continue to consume unhealthy foods regardless. It is only through social epidemiology that interventions can be designed that adequately address the underlying social context and mechanisms that result in this behavior. The BU Platters program represents one such program in a time where many more are needed.

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