Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Part I – Promoting Healthy Dietary Habits in Children: An Incomplete Approach from National Childhood Nutrition Programs – Abigail O. Isaacson

Childhood Obesity and Food Insecurity in America
Childhood obesity is a growing problem in America. Kids eat more and move less than they did 20 years ago, and childhood obesity has tripled since 1980 (5). Because eating behaviors in childhood are predictive of adult obesity, learning healthy patterns before age 5 can help prevent obesity and related disease in adulthood (20). In 2003–2006, 16.3% of children and adolescents aged 2–19 years were classified as obese (above 95th percentile BMI) according to CDC growth charts (5,20). This increasingly unhealthy behavior stems from a variety of factors, including the availability of cheap, energy-dense foods and popularity of TV and video games.
Most Americans know that obesity increases one’s risk of developing chronic diseases like diabetes, cancer, heart disease and stroke in adulthood, but they know much less about another dietary threat to child and adult health: food insecurity. Increasing in America and around the world, food insecurity occurs when a child or family cannot purchase enough food to enjoy an active and healthy lifestyle (14). The Child Sentinel Nutrition Assessment Program (C-SNAP) reports that 16.7% of American children under age 6 live in a food insecure household (14). Not only are these children more prone to nutrient deficiencies and hospitalization during illnesses, but they also suffer cognitive, motor and behavioral problems that affect their development and school performance.
National approaches to preventing obesity and food insecurity involve multi-level efforts from the United States Department of Agriculture (USDA) Center for Nutrition Policy and Promotion (CNPP), the U.S. Centers for Disease Control (CDC) Division of Nutrition, Physical Activity and Obesity, the National Institutes of Health (NIH) and others. These organizations are well funded and equipped to deliver trusted messages to the mass public and therefore deserve frequent critique. Current childhood health promotions center on breastfeeding, increasing fruit and vegetable consumption and physical activity, and decreasing sugar-drinks, high energy dense foods and TV viewing (10). While such recommendations certainly promote good health and identify what needs to happen to help prevent childhood obesity and disease, they fail to emphasize how such interventions will be made relevant at an integrated level. Specifically, national nutrition promotion programs tend to measure success by individual intention, inconsistently target appropriate decision makers and fail to reflect the realities of diverse sub-populations.
Keeping With Tradition
As with many health interventions, nutrition programs seek evidence from traditional health behavior change models, namely Theory of Reasoned Action, Health Belief Model, Social Cognitive Theory and Transtheoretical Model (12). These theories analyze how people make behavioral choices that produce valuable results by each individual’s judgment (16). Scientists admit to their appeal; for example, the Transtheoretical Model’s brevity, high face validity, and understandability, especially to the non-behavioral scientist, makes it highly appealing to the implementer (16). In terms of strong evidence, however, the model utilizes cross-sectional, observational studies in most cases rather than randomized control trials, which produce stronger results. Traditional behavior models emphasize individual cognitive processes and internal perceptions as determinants of behavior.
The CDC also holds conventional theories in an exemplary fashion: “state-of-the-art nutrition education uses many of the social learning behavioral change techniques used in other health education domains” (10). Critical outcomes include raising the value placed on health, taking responsibility for one's health and increasing confidence in one's ability to make health-enhancing behavioral changes. Similarly, a local nutrition pilot project at Boston Medical Center called Healthy Eating and Activity Today (HEAT) bases its outreach on models like Social Cognitive Theory (20). To elevate self-care in the homes of obese children, it emphasizes building knowledge, skills, reinforcement, rewards, self-awareness, social support, self-efficacy, goal setting, cues to action and modeling (20,21). Even these theories with added environmental-level components still encourage the common perception that individual, psychological factors are the primary forces in decision making. This approach unnecessarily limits the potential role that community and environmental changes could play in encouraging positive behavior change among individuals.
Health behavior research suggests that traditional approaches are out of style. A recent study looking at the relationship between these accepted variables and adult diet adherence found that theoritical factors such as self-efficacy, perceived barriers, positive attitude, goal-setting and social support became improved once patients were successfully adhering to a diet (16). However, none of the variables predicted successful diet adherence as the models suggest they should. Another study analyzing perception and dietary change found that groups who have positive attitudes toward a low fat diet do not necessarily take steps toward reducing fat in their diet, especially if they believe they are already eating a low-fat diet (3). Researchers agree that these models are great predictors of intention and motivation but not actual behavior (2,3). National interventions to prevent childhood obesity and food insecurity have traditionally followed an internal, cognitive approach aimed primarily at changing individual intention and less on external, environmental influences.
Overemphasizing Individual Intention
Current national campaigns fit with traditional models by measuring success according to intention. Following the example of the USDA Fresh Fruit and Vegetable Pilot Program in 2003-4, one Mississippi school distributed free fruits and vegetables among 5th graders to increase their perceptions and consumption of fruits and vegetables (9). The program evaluation cited attitudes toward, preferences for and intentions to eat more fruits and vegetables as indicators of success. Eighth grade students in the district reported increased preferences for and intention to eat more fruits and vegetables, and 5th graders’ preferences decreased (9). No information was reported on whether either group actually adopted healthier eating patterns; instead, judgment of 8th graders’ success and 5th graders’ consequent failure was determined by stated intentions alone.
Another program steered toward individual intentions is the CDC-sponsored “Fruits&Veggies – More Matters” program, which replaces the 5 (to 9) A Day campaign and includes new guidelines set forth by the U.S. Department of Health and Human Services and the USDA (8). More Matters targets children’s healthy eating using traditional behavior change beliefs: raising the value of good health and nutrition, identifying benefits and barriers, promoting physical appearance and capacity for exercise, improving sense of personal independence and control, modeling health eating, giving praise and prizes for successes, analyzing personal eating patterns, etc. (10). It presents interactive and age-specific activities, recipes and healthy recommendations on its website, and information is presented to and left up to the individual to act upon (7,8). Beyond its website and attempts at in-store packaging logos which minimally explain the program to the public, little community-level exposure to program involvement exists.
National efforts put enormous faith in individual intention and ability to consistently conquer emotion, avoid temptation and make good decisions. Left to their own choice and judgment, individuals do not always recognize their weaknesses or available tools to overcome them (2). Rather than being consistently rational beings, humans are prone to procrastination and inconsistency. We are not always capable of keeping logical goals and self-control, especially when it comes to permanent changes in diet and exercise. Forfeiting long-term goals for immediate gratification is common for all ages, especially children, who need external influences to help shape their improved behaviors (2). Most traditional theories of behavior place too little emphasis on the importance and success of such needs.
While national child health behavior campaigns heavily weigh individual cognition and intention, they do not entirely neglect environmental approaches. More Matters mentions policy and environmental change, health disparities, science, partnerships, access, education and research as variables of creating change (10). It includes goals of “enabling students to critically analyze socio-cultural influences, including advertising, on food selection, to resist negative social pressures, and to develop social support for healthy eating” (10). However, individuals remain the ones making the change, and few references to overcome complicated behavior change barriers are easily found. What about dealing with temptation and failure in relapse to previous habits? Emotions associated with eating? Cultural tradition? Lack of healthy food availability? More Matters and school programs need to target relationships between children and their surroundings in order to make behavior change more possible.
Who Really Makes Kids’ Dietary Decisions?
Since free choice is a factor in decision-making, it makes sense that traditional interventions target choosers (3). However, multiple choosers influence life of a child. The health decisions of pre-school aged children are generally made for them, and these early years are formative for healthy behaviors later in life (20). Parents’ involvement in their children’s eating and exercising choices become shared as kids enter elementary school. For example, a parent who is on board with a healthy eating plan at home may be able to prepare healthy lunches for her child to take to school. However, if all the child’s friends are eating in-school lunches because it’s viewed as cool, the child will likely find a way to neglect his healthier home lunch in order to fit in. Unless the school is also ‘on board’ with a healthy eating plan and limits unhealthy options at lunch, the child won’t receive consistent messages about healthy eating. Parents come to rely on school-based programs and community organizations to help shape healthy behavior adaptation.
While national nutrition programs make mention of this key interface, they still tend to target individual children as main influencers of their own health. In a Transtheoretical Model approach, the CDC’s child-focused campaign attempts to adapt nutrition education to children’s levels. Its Food Champs website involves children ages 2-5 with interactive click-and-drag graphics and games (7). Messages such as, “Corn: we like to eat corn on the cob, frozen or canned. It’s even used to make ethanol gas for our cars” are delivered to young children who make it onto the More Matters website. However, introducing ethanol gas to a 2-5-year old and sitting at a computer with him may not be as health-effective or realistic as taking him to the park or helping him taste healthy foods. Food Champs and More Matters must consistently emphasize lifestyle tools for parents or other decision-makers to initiate with their children to help shape their future choices.
The (HEAT) pilot intervention at Boston Medical Center described earlier also targets children as decision-makers through its automated weekly telephone interviews. As part of the data collection, which includes parental responses, the obese child is responsible to report his progress over the phone with a computer prompter (20). This direct, in-home approach values the child’s independence and self-analysis but may not control for emotional responses caused by feelings of failure, shame, embarrassment, or apathy. Involvement of both the pediatrician and the family is noted but limited.
Targeting individual children is not a bad idea when utilized in combination with an emphasis on community influence. In one Colorado elementary school, students are encouraged to ‘purchase’ fruits and vegetables with valuable tokens at a daily produce market setup by staff (11). This construct is praised for encouraging individual student responsibility, analyzing personal diet, and valuing of fruits and vegetables since they ‘cost’ earned tokens. However, the market could also encourage community thought in students by giving them a budget to buy for a proportion of classmates or their family at home for a day. By having them think for others, they might be more understand how others think with and for them.
Environmental change must involve the roles of a wide array of decision makers; parents, school management, grocery stores, and policy makers all determine part of the nutrition and physical activity environment of school children. The USDA's Team Nutrition positively “seeks to gain the support of many sectors of society for improving the diet of young persons by creating innovative public and private partnerships that promote healthy food choices through the media, schools, families, and community” (12). Tangible efforts and evidence of this environmental goal need strengthening. The USDA and partner organizations must implement a clearly defined, multi-level action plan among parents, schools, politicians, community organizations and children to create a framework within which healthy food choices can happen.
Not Everyone Fits Into Traditional Nutrition Intervention Models
Healthy diet promotion programs generally have a standard message catered toward a middle-class population. Communication targets two-parent, working families who spend 30% of their incomes on food (still based on 1964 poverty thresholds), rush to sports practice with their kids and have the ability to prioritize their future health (8,14). Considerations of sub-populations, regional differences, and ethnic purchasing patterns are missing or are supplementary rather than primary considerations, leaving vulnerable populations behind.
Current interventions excel at providing standardized recommendations but fail in providing ethnic or cultural tools to address differences in cultural beliefs. More Matters has created supplemental pamphlets for sub-populations but with little difference in messaging. For example, “Choose Smart, Choose Healthy” publication created for African American Women provides the same food example recommendations that the CDC provides for all populations on its website (8). The message is consistent, but perhaps using healthy foods common to the African American diet would be more helpful. The pamphlet emphasizes control and beauty: “It’s your life. You’re in control” and “Beauty. Inside and Out” are accompanied by pictures of African American women. While the pamphlet does list foods and corresponding nutrients that might be more common to an African American diet, the emphasis is not clear and cultural differences are faint. Instead of conveying a message that African American women can find a manageable way to eat a healthy diet that is still familiar to them, the pamphlet might be communicating that beauty and control are achieved by conforming to a standard diet created largely by white populations.
Instances of families who are setup for failure by these standard designs signify the need for continued development at environmental and social levels. The USDA Thrifty Food Plan gives recommendations that consider issues of disparity, affordability, and opportunity in achieving a healthier diet. However, the 25 million Americans relying on Food Stamp Program, now called Supplemental Nutrition Assistance Program (SNAP), are likely to have difficulty meeting the Thrifty Food Plan’s Healthier Diet Market Basket recommendations (14,17). For example, an average family of four who use Food Stamps would receive a maximum allotment of $497.39 a month for food, but most families receive an allotment far below the maximum (14). In Boston, the average Food Stamp allotment is only $159.95 (far from the maximum); the Thrifty Food Plan costs an average of $524.26 at the grocery store, and Healthier Diet for a Boston family of four costs $645.20 (14). Being able to purchase the recommended foods for such families is not a reality. Even though this federal assistance is meant to supplement other grocery money, many families rely on this as their only food budget.
Giving low-income families a guide on what to put in a ‘healthy food basket’ will not help them if recommended items are not on the shelves at their nearest grocery store or if their monthly wages are eaten up first by rent, childcare, or other pressing needs. Additionally, minority and immigrant families have a different definition of a healthy diet and may see little value in American recommendations based on the Food Pyramid. They may hold differing beliefs about food and its role in health, disease and emotional comfort for different ethnic groups that must be considered. Many families do not have access to health education through national nutrition program websites, lack basic finances even to implement available cost-saving strategies provided by the More Matters program, and are not in a position to prioritize their future health.
Looking Ahead
Children’s individual cognitive processes are certainly involved in choosing a healthy diet, but not to the extent that current programs project. Traditional behavior processes teach kids that they can make decisions independently of the people and influences around them. True human weaknesses complicate the apparent success of intention leading to behavior change, and the involvement of many decision makers is crucial. National nutrition interventions do not give enough recognition to the critical role of community in children’s decision making or to the complexities that culture, poverty and emotion add to standard nutrition approaches. Internal mechanisms continue as the main reliance of these interventions. Unless community environments are structured in a way that helps kids make healthy behavior decisions, we will continue to see childhood obesity and food insecurity, and their social consequences, rise in America.
National nutrition programs are not entirely missing the picture of successful childhood health promotion, but rising rates of childhood obesity and food insecurity demonstrate certain weaknesses in accepted, traditional approaches. A greater emphasis on environmental influences upon children, a more comprehensive strategy that includes all decision-makers, and action plans that consider ethnic and socioeconomic barriers and beliefs will strengthen existing national nutrition interventions.
Part II - Social Science and National Nutrition Program Reform: Improved Methods for Food Insecure and Obese Children and Their Communities – Abigail O. Isaacson

Dominating players of the nutrition world work tirelessly to create relevant and evidence-based diet recommendations for American children. Organizations like the Centers for Disease Control (CDC) and United States Department of Agriculture (USDA) own the resources and expertise to earn public trust when it comes to healthy behavior. Their current child nutrition interventions have focused on individual intention while limiting involvement of external decision-makers. They have also generally presented streamlined, monoculture strategies to instigate positive dietary change in children. With the support of social science theories, national health organizations will better combat childhood obesity and food insecurity by structuring programs at the environmental level, involving a greater variety of decision-makers, and creating regional program variations based on cultural preferences.
“Socialized” Nutrition Programs
The theoretical impetus behind national nutrition interventions has traditionally targeted children’s internal perceptions. Nutrition advocates need not neglect all the factors that theories like Health Belief Model and Social Cognitive Theory identify, but they should elevate certain elements to a community level. A push from intention to action in childhood obesity prevention will require a stronger application of theories based on social sciences to improve outcomes.
Several theories support healthy diet promotion among children. Labeling Theory and, to a greater extent, Stigma Theory, reveal layers of negative social classification inherent in certain program components (32,26). Labeling can create self-fulfilling prophecies among target populations, and federal assistance programs may stigmatize recipients by labeling them as low-income and thus exacerbate their situation. National nutrition interventions need to carefully contemplate their terminology and approach while raising societal value toward obese and food insecure children.
For the development of nutrition strategies, Social Marketing Theory and Framing Theory are helpful. Marketing theory suggests that the continuous emphasis on the tangible marketing of intangible ideas, lifestyle changes and behaviors improve the effectiveness of public health interventions (25). Framing Theory outlines how individuals can shape each others’ perceptions of reality by guiding certain cognitive processes (27). Knowing what food kids value, for example, and then ‘selling’ it back to them, perhaps in a “healthified” version, creates an emotional appeal toward healthy eating habits (24). Social science theories inform national programs to remove stigma and improve desirability of healthy foods to kids and their communities.
Strengthening the Environmental-Level Approach
National child nutrition programs have settled on children’s demonstration of intention to improve dietary behaviors, but additional factors such as acceptance and understanding of a program within the child’s community greatly enhance outcome achievement. The CDC’s More Matters program has designed creative interactions for children of all ages on its website, but they remain locked in a computer screen. Applying online activities at a non-cyber community level will expose more children to learning tools and foster community support of health decisions. To strengthen its approach, the CDC could employ more nutritionists to prepare its ‘food of the month’ in kids’ classrooms for tasting or at community farmers’ markets. The USDA has already sponsored initiatives like these in certain U.S. counties on a small scale, although participation is limited to low-income women and children who qualify for federal assistance (29,31). An enhanced, multi-level approach could omit income requirements (and stigma) and adapt suggestions to the preferences, food availability and cultural beliefs evidenced by community-level research. With Marketing Theory in mind, it could then advertise concepts and materials at local elementary schools to prepare kids for a times of shopping, tasting and learning that are both exciting and realistic.
While broader community support allows more children make the jump from intention to behavior change, barriers still exist. Economic, cultural and ideological variables hinder many kids’ progress toward healthy eating. One idea that incorporates a reduction of these barriers on an environmental level is the development of a healthy food coupon program. Newspaper food coupons often feature foods that are either unhealthy, undesirable, irrelevant to local diet or luxury item from specialty stores. Other coupons are only available online or might require the purchase of some other product first (23). Many coupon systems run the potential of excluding large portions of the populations that need the savings most. A healthy food coupon project would serve as a quasi-continuation of the USDA’s Farmer’s Market Nutrition Program (FMNP), which provides produce coupons at WIC offices in partnership with certain growers at seasonal farmer’s markets, but with added twists (31).
Instead of being available only during market seasons and to low-income women and children, coupons would be available year-round to anyone who wanted them. They could be strategically rotated through different locations where vulnerable populations are more likely to cross, such as day cares, elementary schools, grocery stores, pharmacies and community centers like the YMCA. These coupons would not distinguish participants by race or class or culture. Pilot projects would test the location, regional whole food preferences, local store selection and effectiveness of consistent versus rotating coupon availability.
The project idea is to provide children and their deciders with a set of tools at a community level in order to move past intention to actual adoption of a healthier diet. If children’s schools and home environments are not structured to help them achieve a healthier diet, then intentions alone will unlikely result in positive behavior change. Ideally, users would experience a sense of empowerment, pride, thriftiness and improved health. The CDC, USDA and NIH could collectively contribute resources, communication skills and multi-level support. Coupons would have limits, but they would frame healthy foods in a more attractive light, establish dietary habits that would continue when affordability and access allowed, and foster consistent national and community cohesiveness toward child food security and healthy eating.
A Team of Leaders
While children must maintain some freedom in determining their dietary preferences, community leaders are well positioned to shape kids’ choices toward healthy options as well. External leaders need to take more responsibility for the lives of children who are at risk for obesity and food insecurity. A commanding team of healthy promotion leaders includes parents, guardians, schools, doctors, community nutritionists, day care centers, public libraries grocery stores, advertising agencies, churches and many more. Nationally led support networks of vulnerable and food insecure children can make a huge difference in their success.
At a school level, along with classroom nutritionists preparing foods to expose kids to varieties of new and healthy tastes, students can plant vegetables in school gardens and monitor their progress. They can vote on class snacks, take recipes home to their parents, ‘eat the rainbow’ at farmer’s market visits or practice purchasing adequate fruit and vegetable servings for their family members with a school market budget. Schools would be an important recipient of real produce coupons that kids could take home and give to their parents to take grocery shopping.
Providing children’s decision makers with existing tools at a community level and apart from the Internet will improve accessibility and awareness. More Matters already provides online tools that include food sticker pages and Eat Your Colors worksheets (22). However, families that are not searching for healthy diet resources or lack access to the web or a printer are not going to utilize these tools. Worksheets could be available at participating grocery stores, which could also automatically give produce coupons at checkout if a customer does not purchase a minimum amount of whole foods. Day care centers could implement More Matters Food Champs activities during snack time. Many possibilities and variations exist for improved nutrition program implementation in different community locations, but it will take the involvement of multiple decision makers.
Population Preferences
National health organizations agree that more investigation is needed on environmental variables and their effects on obesity and food insecurity among children (30). They aim to study consumer behavior, but they do not place as much emphasis on cultural differences among these children’s communities. For diet recommendations to be realistically received, they must consider regional dietary beliefs, preferences and food availability. Anthropologists offer additional expertise for determining true community needs assessments: “they immerse themselves in the social life of the setting they seek to understand” (33, p.103). The definition of a healthy diet will differ between communities and among children. For CDC or USDA representatives to involve themselves at such an intimate community level would potentially transform their programs with a wealth of wisdom.
Specifically, research staff or nutritionists in local schools and community sites can talk with children, hold recipe competitions, or work with local chefs to identify preferred healthy foods that will be accepted by various ethnic groups besides Americans of European descent. A coupon project would need to take steps like these to first determine which foods to feature and at what price discounts. Incorporating anthropological tenants into nutrition interventions will alleviate some of the sub-cultural weaknesses of current program approaches.

Child Food Security
National organizations such as the CDC, USDA and NIH have contributed incredible work toward child nutrition, and even methods that are on the right track can still be improved. In their continued aims to reduce childhood obesity and food insecurity, national programs must draw on principles revealed by social science investigation. People enjoy free things, saving money, being independent, and not having to spend a lot of money on food staples (2). A healthy foods coupon project based on the knowledge of these preferences has potential to reach more food insecure and obese children and their families. Population-scale interventions will help nutrition program leaders structure community environments of children in an attractive manner without negative labels. Bringing national nutrition tools to the community-level, involving more decision-makers and considering sup-population preferences will provide more children with a structured environment within which food security is possible.

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