Challenging Dogma - Fall 2008

Wednesday, December 17, 2008

A Review of the "Balance First" Diet and Exercise Campaign and Recommendations for Improvement – Kristen Binau


Diet and exercise make up a large part of physical health and well being. They also are two of the biggest health issues in industrialized countries like the U.S. Poor decisions regarding diet and exercise can lead to many cardiovascular and respiratory problems and can cause obesity (1). Choices about diet and exercise tend to be life long so many public health campaigns concentrate on influencing young people. Ensuring that adolescents have proper diet and adequate exercise may be the key to reducing the incidence of many negative health outcomes (2).

One campaign that focuses on young people is balance first. Balance first is a diet and exercise campaign aimed at adolescents in the sixth, seventh, and eighth grades. The campaign has an overarching theme of personal energy balance. Energy input from food must be proportional to energy output from exercise to maintain health. Balance first takes place within junior high schools and relies on a series of five lesson plans to teach students about diet and exercise. Each lesson requires one to three class periods and consists of several activities. Many of the activities involve engaging the students in discussions regarding diet and exercise and many focus on giving more information on what healthy diet and exercise entail. Along with the lesson plans, a four page magazine is distributed to students with information on diet and exercise and examples of good diet and exercise. At the beginning of the implementation, a letter is also sent home to parents explaining that their child is participating in the program and directing them to several resources to learn more about diet and exercise (3).

Balance first is severely flawed in a few ways. First, the format in which it is implemented is not effective. The campaign is taught to junior high students like any school subject and requires multiple class periods. This is problematic for students in an age group where testing academic authority is popular. Teachers also may not be able to implement the entire program in a tight schedule. The second problem in the campaign involves social factors and personal feelings. The program does not account for the social context of junior high where students can get singled out for being overweight and it also does not engage the families in diet and exercise change to a large extent. Lastly, the balance first campaign assumes that when presented with information on why and how to change, the students will rationally decide to change and then follow through with their decision. Rational behavior and intention leading to change should never be assumed.

Campaign Format

Schools can be very effective environments for public health campaigns to change behavior (4). However, the format of the campaign has to be well thought out. Balance first’s format is designed much like a school subject to be taught to children in lesson plan form. Some of these lessons plans even include the students doing their own research on diet and exercise. Each lesson plan takes between one to three class periods meaning the total class time the program requires is between ten and twelve periods. Balance first is designed for sixth through eighth graders. This age group is often characterized by the transition from children into adults (3).

The format of balance first fails to consider several potential problems. First, the age group of the students could affect the campaign. Students in middle school tend to begin to reject the norms of the school learning format. It is a very important time for students because they are going through puberty and their beliefs about the world are beginning to solidify. They are maturing. While this may seem like a good point in the life cycle to implement a behavior change, it may not be that easy. The students in grades six through eight mature by testing authority. These include school and classroom boundaries. Students may not pay attention to the campaign as an act of rebellion against the norms of school learning. It is important for adolescents to work through this phase of maturing so instead, the campaign should be considered for a different age group. Balance first also should be used within another age group because of the activities themselves. Some activities such as the adapted activity charades game in Lesson Plan 3 could come off as a bit juvenile to middle school students. Certain activities may be more suitable for younger students such as those in elementary school.

The lesson plan setup is another problem. Students in general may not pay attention to the campaign if it is designed like a school subject. Some of the activities in the campaign like the ‘beneath the surface’ activity in Lesson Plan 3 even have the students conducting research. This creates an academic atmosphere for the campaign which may lead the students to treat it as such. They will look at it like they would a math class or English class. This causes the campaign to lose much of its effectiveness because the uniqueness is gone. The campaign also requires between seven and eleven class periods for its five lessons. Teachers may not be able to dedicate this amount of time to the campaign and there is no abridged version to fall back on. They may opt to not participate in the campaign at all rather than try to cut certain activities out themselves. The length could also cause the students to become bored with the topic as the lessons become repetitive. The campaign needs to stand out against the academic backdrop and it can’t do this by a drawn out step by step process.

Social Factors

The balance first campaign tries to include families in its campaign. At the beginning of the program, a letter is sent home to parents about the program. The letter gives facts about problems associated with poor diet and little physical activity. It also goes on to explain what the balance first campaign involves. Finally, it lists a couple of websites that parents can visit to learn more about energy balance and health decisions. Within the program, certain activities are done in a discussion or one on one format. In the third lesson plan, students pair up and discuss their diet and physical activity level. They also create diet plans for each other.

The aspects of balance first listed above leave out the issue of social factors. This is because the campaign has a large basis in the Health Belief model where a person makes decisions based on simply weighing perceived benefits against perceived barriers to behavior change (5). However, no one decides to make a behavior change in a vacuum. The people in that person’s social circle affect how they live and therefore their behavior (6). A major social group that must be considered in the balance first campaign is the family of the student. At the middle school age, young people are still greatly influenced by their parents. This is especially true with diet. For most middle school students, there is no choice when it comes to food. They eat what their parents buy them. This is why it is so important to involve the parents in the behavior change. The campaign cannot rely on the students to teach their parents why and how to change either. Balance first uses a letter sent home with the student at the beginning of the program to get its message to the parents. However the impact the letter will have is small. While the letter does give some statistics about obesity and physical activity level in America, it does not include any particular ways to change behavior. There are no diet or exercise suggestions anywhere in the letter. The only advice given is to visit two websites that have more information. The letter does not even ask the parents to discuss with their children different ways to stay healthy. Because of the lack of useful advice in the letter, most parents will disregard it and make no changes. Those who would like more information need to have an internet connection. This cannot be assumed for all families for a successful campaign. The letter should also be made available in different languages. It is currently only available in English and Spanish.

After parents have read the letter, the ones who have and then use their internet connection may learn important information and advice about diet and exercise. Regrettably, knowing what a healthy diet entails is one thing doesn’t automatically lead to implementing one. For some families, it may just not be possible. Two full time parents or a single full time parent may not have time to cook or even grocery shop. Instead, they may choose to get fast food or pizza. Other families may just not have the financial means to change the family diet. A two liter of Coke is cheaper than a gallon of milk and soft drinks hold little nutritional value. Families that are busy or in a low socio-economic class will not change their behavior because of a newsletter.

Even with a letter full of useful information, parents may not change their food buying choices. Another public health campaign for healthy eating in teens sent home family newsletters to help families change to better food choices. They found that there was not significant change in buying habits of the parents receiving newsletters (7). The family unit is hard to change with only newsletters.

Social factors also come up in the classroom teaching of the program. With many of the activities, students are expected to talk about their diet and exercise habits. This can become a problem with students who do not feel comfortable discussing their habits with peers. Students who are overweight specifically would probably participate in the discussions less than other students. However, these students would probably benefit the most from the discussions. Middle school can be especially hard for students who are different from their peers such as those who are overweight. Overweight children are often treated differently (8).

Subsequently, overweight students may fear taunting by their peers if they speak up in class to talk about what exercise means to them. The program could in fact target the overweight children itself. In one activity, students pair up and discuss how much exercise they get regularly and how much and what they eat (3). An overweight child could be judged by the other students based on what they eat. The students who are overweight may not be honest during the lessons and then as a consequence, reject the behavior change of diet and exercise. Overweight students would not get the best experience from the campaign.

Social circles greatly affect the behavior of a middle school student. Without a campaign that effectively accounts for the social factors that act on students’ decision-making, students will not actively change their habits.

Rational decisions and intention to act

The main focus of balance first is giving students information about diet and exercise. They are given information on the MyPyramid serving of food. They are given information on different forms of acceptable exercise. They are even given some information on why the balance between food intake and exercise output is important. The idea behind all of this information is that when they are given all of the information, they will make the choice to get the appropriate diet and exercise and will proceed to do it. This idea follows the Health Belief model (5). Unfortunately, this way of thinking does not take into account major aspects of the human decision making process. Rational behavior should never be assumed and the intention to change does not always amount to change.

Balance first focuses on giving students facts. Each lesson plan gives students more and more information about keeping diet and exercise in balance. This approach creates a problem though. Listing off the reasons why students should change their behavior and explaining how to change behavior does not necessarily lead to behavior. The campaign assumes that students will take the information they have on the subject and then make the decision to change or not change rationally. This does not happen in real life. Human beings do not always act rationally. Young people in particular will not rationally consider the harmful effects of heart disease to the instant gratification of fast food. Part of this is because they won’t care about health problems they will have when they are fifty. Many of the health problems associated with bad diet and little exercise take time to create. Heart disease and type II diabetes are some of the health problems related to obesity and they don’t usually occur until middle age (9). For students between the ages of twelve and fourteen, that can seem like a far off time. Young people also tend to feel invincible when it comes to health in general.

The campaign also makes another major assumption about decision-making. It trusts that once the student makes the rationalized choice to get more exercise and eat healthier, the student will then just proceed to do it. However, intention does not always lead to action. Many times, a person will decide to make a behavior change but then fails to proceed. This is just another part of human nature that should be considered for a public health campaign.


The balance first campaign created some considerable errors. The format of school learning is flawed because it pushes the students to associate diet and exercise with math class. It also requires too much classroom time for its lessons. The campaign also makes mistakes based on a common public health model. With little regard to social factors, the campaign follows the Health Belief model. This model also makes the mistake of assuming rational behavior and the idea that intention leads to action.

These missteps make much of the campaign ineffective for students. One option they might have considered though for most of the campaign, was the input from students. In the past, student opinions have created very effective campaigns. The Truth campaign in Florida took contributions and ideas from teens about smoking to create an effective anti-smoking ad campaign (10). Input from middle school students would have stopped the campaign from being taught to students in school subject form. They also may have come up with new ways to get the ideas of diet and exercise out to the students and families. In any case, the balance first campaign as is does not give much reassurance that our nation’s children will start becoming more healthy.

Calling for a new diet and exercise campaign

The balance first campaign contains several errors in its planning. First, the format of the campaign is not well thought out. Balance first is implemented in a middle school age setting which is a difficult age group for behavior change. It is also planned out in lengthy lessons which can be boring and too long for the students and teachers. Next, the campaign forgets to account for the social factors that affect a student’s decision making. Parents can have strong effect on behaviors of the family, and school social circles can impact a single student’s feeling and attitudes about behavior change. Finally, the campaign relies completely on rational decision making and follow through. The straight information from the campaign does not necessarily lead to health behavior change. All of these problems can be fixed by redesigning the diet and exercise campaign. The new campaign would need to take into account the format, social factors and decision making and follow through. I propose that a diet and exercise campaign should be redesigned into a one time, comprehensive, learning experience called Family Fun Night.

Family Fun Night

Family Fun Night is a one time per year, after school health fair where parents and students get together to learn more about diet and exercise. It is implemented at an early elementary school age group and focuses on engaging the parents as well as students. The program uses games and activities to teach parents and children health lifestyle activities. Different stations are set up in a school gym or other open space where the parents and children move through the activities one at a time. The stations would include a variety of challenges and activities that the parent-student teams complete. One station might have participants learn how to make some delicious but nutritious snacks. Another station might involve a jump rope tournament. Yet another might involve high school athletes demonstrating different ways to get exercise. All of the activities teach children and parents about healthy lifestyle choices regarding diet and exercise but would not use facts and statistics. Learning happens instead through direct participation in activities. Station leaders lead groups in healthy decision making but don’t push numbers and details. Emphasis is put on learning by doing. Prizes are also given out to participants for completing the activities. These will also encourage healthy lifestyles. Free admission passes to a local, public pool or coupons for healthy snacks would be given out to every participant after each station. These rewards are handed out regardless of how well a parent-student team completes a station. Winning the activity is not important. After the Family Fun Night, parents and students will have new ideas and creative ways to embrace healthy diet and exercise.


The Family Fun Night addresses all of the format problems in balance first. First, the middle school age groups of sixth through eighth graders is changed to a younger audience. The middle school age group is too difficult to implement an effective behavior change campaign. Students at that age might be more set in their lifestyle choices than elementary school children. Elementary school children are very receptive to public health campaigns (11). This age group tends to be more impressionable so the campaign would be more effective. Children at this age group are also still close with their parents. Middle school age students sometimes rebel against their parents and may not want to attend a social function with them.

The other major format issue in balance first was the lengthy, lesson plans. This format would be changed to a one-time event that is after the school day has ended. This shortened time period will make the campaign more interesting for students and keep the campaign’s message in the front of the student’s mind. It will not be treated like any other school subject. The after school event is also helpful for teachers who cannot sacrifice academic time for the campaign. It requires no more classroom time than a brief announcement about the event.

Social Factors

Family Fun Night would also correct the balance first campaign’s ignorance of social factors. The fun night actually implements social networking theory. This theory explains that individuals are directly influenced in behavior change by the social networks surrounding them (12). One of the most important social networks is the immediate family of an individual. Especially for young children, parents are one of the largest influences on behavior (13) and involving them in a diet and exercise campaign can increase effectiveness (14). An example of the influence parents have on a child’s behavior is seen in the purchasing of groceries for a household. Children eat what their parents buy for them. Parents then, are entirely responsible for their young children’s diet and they must be at least partially responsible for their exercise behavior. Because of this, Family Fun Night incorporates parents into the intervention. Parents are actually a main target for the campaign. The idea is that by changing the behaviors and ideas of the parent, the child’s behavior will change also.

The campaign also tackles the social factors among peers of the student. Family Fun Night changes the way children learn about diet and exercise. There is no emphasis on direct communication between the participants. Students don’t have to talk to other students during any of the activities. In fact, the activities are designed to bolster the relationship between parent and child, not among children. The campaign is designed this way because of the effect peers can have on behaviors. Peers have been shown to affect the behavior of an individual. For example, an individual with peers who partake in a risky behavior such as smoking are more likely to partake in that risk also (15). Peers can also affect behavior change in a public health campaign. In balance first, students had to participate in discussions. For some students, this could be a very difficult task. Overweight children could be singled out by their peers for their remarks in discussions. In one study by Blote, Kint, and Westenberg (16) students with social anxiety were met with poor classroom behavior when giving an oral presentation. Students in the classroom did not respect the students with social anxiety. This kind of singling out might lead the socially anxious to not participate in classroom discussions. This example could be applied to overweight children in a discussion of diet and exercise. They may not participate in discussions where their remarks are poorly received. Family Fun Night contains less direct peer interaction. The students participate together but are not required to measure themselves against each other. In fact, Family Fun Night rewards everyone for participating which makes for a more positive environment.

Rational decision making and intention

Finally, Family Fun Night attacks two of the most common problems involved with campaigns based on the Health Belief Model (5). Rational decision making and follow through are pitfalls that the Health Belief Model automatically assumes. Since rational decision making does not work in reality, Family Fun Night instead implements marketing theory. Marketing theory pushes a good or service onto consumers by convincing them that they want or need it (17). It does this by associating the product with something people enjoy. For Family Fun Night, the name alone pushes the idea that children will have fun. The name of the campaign does not mention diet or exercise or anything health related. Elementary school students will think the campaign is actually an event dedicated to fun.

Follow through is one of the most difficult challenges in public health campaigns. Family Fun Night however, tries to promote follow through in two different ways. First, the campaign involves actual exercise and nutrition planning. Participants are already following through to a certain degree and beginning the behavior change in the intervention which may lead to better long term compliance. Family Fun Night also uses rewards that encourage follow through. Admission to a public pool or coupons used towards health foods cause the participants to follow through on the behavior change. This extra push towards the behavior change will help the participants maintain better diet and exercise.


Family Fun Night should be considered as an alternative to balance first. The campaign accounts for the problems that balance first failed to address. The format is changed to a shorter, more action packed event for both students and parents. Social factors regarding parents and peers are explored and then manipulated to promote easier behavior change. Several methods are finally used to convince students and parents to change behavior and follow through on that change. With all of these improvements to the campaign, students and parents will be more likely to change their diet and exercise habits.


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