Challenging Dogma - Fall 2009

Sunday, December 13, 2009

A Critical Analysis of Failed Nutrition Interventions – Leigh Simons

Increased fruit and vegetable consumption has been show to reduce the risk of stroke, various types of cancer, and type 2 diabetes and may result in weight loss (1). As a means to reverse, or even just to slow, physically and financially costly public health problems, many federal and state agencies have launched campaigns to promote healthy eating.
One such campaign was the “5 A Day” campaign which was launched in 1991 and implored the public to eat at least five servings of fruits and vegetables a day. It was replaced in 2007 by the “Fruits & Veggies: More Matters” campaign when the USDA guidelines for fruit and vegetable consumption were tailored to individuals and the units of measure changed from servings to cups (2). “Fruits & Veggies: More Matters” introduced a web site with health eating tips, tips for spreading your fruit and vegetable budget, and resources for health educators to teach kids healthy eating.
Despite the extended use of the “5 A Day” and “Fruits & Veggies: More Matter” campaigns and $4.5 million spent on communication in 2004 alone, the percentage of the population that eats 5 or more fruits a day decreased from 52% to 26% between1988 and 2006 (3,4). In fact, average consumption across the country, adjusting for changes in demographics, increased only from 3.8 fruits and vegetables a day to 3.9 vegetables a day between 1991 and 1997 (5). Not only did the population adhering to healthy eating guidelines decrease, but the marketing campaign was not particularly effective in informing the public about fruit and vegetable recommendations: in a 2002 survey by the Department of Health and Human Services, more than 50% of men did not know the “5 A Day” recommendations for fruit and vegetable consumption (6).
This summer, the New York Department of Health and Mental Hygiene launched a campaign aimed at reducing consumption of sodas, juice, and sports drinks. “Are You Pouring on the Pounds?” depicts a hand pouring either soda, juice, or a sports drinks into a glass overflowing with human fat (7). A health bulletin from the campaign includes the images from the ads and also includes various statistics, including the amount of sugar in the targeted drinks (8).
Typical nutritional interventions rest on the Health Belief Model and consequently fail to account for the ways that environmental factors affect accessibility and the ways social networks affect behavior. Nutritional interventions also use marketing campaigns resting on faulty assumptions about the public’s desires. An intervention that addresses these inadequacies must be developed using alternative health models.

I. Failures of Nutrition Campaigns
Interventions to improve the diets of Americans, including the “5 A Day,” “Fruits & Veggies: More Matters,” and “Are you pouring on the Pounds?” campaigns, have not substantially changed behavior because they fail to address three critical issues. First, as these campaigns are based primary on the Health Belief Model, they do not address environmental factors associated with poverty and location and how these factors influence the ability to pay for produce and the accessibility of produce. Second, diet campaigns do not take into account how social networks affect food decisions as these campaigns operate at the individual level. Finally, nutrition campaigns do not effectively use marketing theory, so the messages they employ do not resonate with their intended audience.

A. Nutrition Campaigns Fail to Address Environmental Factors
The “5 A Day” and “Fruits & Veggies: More Matters” state and national campaigns use the Health Belief Model to influence human behavior. The use of the Health Belief Model, however, fails to address how the environmental factors of poverty and location influence consumption of produce.
The Health Belief Model theorizes that an individual’s perceived susceptibility and perceived severity of a condition or disease will lead to a perceived benefit of taking a specific action to combat the condition. These perceived benefits are weighed against perceived barriers to the action. The outcome of weighing perceived benefits against perceived barriers is an individual’s intent. Intention leads, finally, to the individual performing the specific behavior (9).
The “5 A Day” and “Fruits & Veggies: More Matters” campaigns provide information to consumers so they can make rational decision about their food choices based on the Health Belief Model. One element of the “5 A Day” campaign, “California Children’s 5 a Day-Power Play! Campaign: Fruits and Vegetables,” aims to influence the perceived benefits of eating nutritiously by teaching children how to read nutrition labels and interpret the food pyramid and aims to reduce their long term risk of chronic diseases (10, 11).
The “5 A Day” campaign, however, does not adequately address the environmental factors associated with complying with fruit and vegetable consumption recommendations: fruits and vegetables in certain areas are either too expensive or not accessible, or both for some populations, and thus no amount of intent to purchase make it a feasible action. According to a United States Department of Agriculture (USDA) study, about 19 percent of low-income households did not purchase any fruits or vegetables in a given week, 10 percentage points higher than households with higher income (12). Several studies across the country have shown that there are fewer chain supermarkets in inner-cities and minority neighborhoods than in wealthier and white neighborhoods; the food outlets in inner-city and minority neighborhoods tend to be convenience stores and small grocery stores (13, 14). These smaller grocery stores are more expensive and carry far fewer products, including vegetables and produce (13). Further exacerbating the environmental factors that restrict access to more affordable produce is that fewer residents of poor and African American neighborhoods have access to private transportation, so it is much less feasible for residents of these neighborhoods to access chain supermarkets outside of their neighborhoods (14).
Publications like “30 Ways in 30 Days to Stretch Your Fruit & Vegetable Budget” from the “Fruits & Veggies: More Matters” campaign aim to reduce affordability barriers by providing tips to consumers such as buying store-brand forms of fruits and vegetables (15). Such a recommendation is likely not feasible for a consumer who only has access to food from a convenience store or small grocery store which do not have generic products like chain supermarkets do. There is evidence that the availability of fruits and vegetables increases consumption, even in children, as found in an intervention of British school children that provided students a free piece of fruit or vegetable in their first and second years of schools. Average consumption during the program increased by .5 servings a day, but when student were no longer eligible for the program, fruit and vegetable consumption returned to baseline consumption rates (16). It is access to produce that must be addressed, especially after considering evidence that when income increases among the lower-income population, they are less likely than high-income households to increase spending on fruits and vegetables (17). This research suggests there are strong environmental factors at work beyond the barrier of price.
The “5 A Day” and “Fruits & Veggies: More Matters” campaigns encourage the public to eat more fruits and vegetables by informing them about their nutritional value and how consumption can prevent disease. Attempts to address barriers like price fail to consider environmental factors that make compliance impossible.

B. Nutrition Campaigns Fail to Address Social Networks
As nutrition campaigns tend to be based on the Health Belief Model, they try to change an individual’s behavior. These campaigns fail to take into account how social relationships shape behavior.
Social Networks Theory says that people are influenced by others in their social network and those that are closest to them in their network (friends, spouse, friends of friends, etc) have more influence than people farther from them in the network. The actions of the people in a person’s network affects what that person will do and they are influenced by the social support, social norms, social engagement, and access to resources of the others in the group (18). Efforts to change behavior in a social network must be aimed at the entire group and not at individuals.
Obesity studies have shown that the likelihood of obesity increases if someone in your social network is obese. In the Framingham Heart Study, chances of becoming obese increased by 57% if the person had an obese friend, 40% if the person had an obese sibling, and 37% if the person had an obese spouse (19). The same study showed that geographical distance was less likely to affect obesity than distance in a social network, suggesting that the behaviors and decision of people you are close to affect obesity more than neighbors, coworkers, etc.
The “5 A Day,” “Fruits & Veggies: More Matters” and “Are You Pouring on the Pounds?” campaigns simply inform individuals of recommendations and fail to address entire networks. “T.A.S.T.E Tips and Information for Moms,” a publication from the “Fruits & Veggies: More Matters” campaign, is aimed at mothers as individuals because they are the likely food purchaser in the family. The publication offers ideas like bringing your kids to a farmer’s market or making meals as a family as a means to influence a mother’s, and consequently her family’s, behavior (20). While such a behavior change would likely alter a family’s behavior, the mom herself is unlikely to initiate such activities on her own. The publication fails to address the mother’s social network as a group, which likely consists of siblings, other moms that are friends, etc., who would have more of a collaborative influence on her purchasing and eating behavior, and consequently that of her family’s because of social support and engagement provided by networks.
Social norms in a network shape how people in the social network behave. The biggest changed in dining social norms in the last twenty years is the propensity of Americans to eat dinner outside of the house (17). This on-the-go eating behavior has a significant effect on produce consumption, according to the USDA. About one third of the average American’s daily caloric intake is from food that is not made in the home, but that portion of the American diet accounts only for 1 ¼ servings of vegetables and less than ½ a serving of fruit (17). These are dismal numbers for a dining option that has become a norm in American life.
Another norm of American food consumption is the propensity toward convenient, inexpensive food. Americans in 2002 spent only 10.1 percent of their disposable personal income on food, less than half as much as 1950 when Americans spent 20.5 percent of their income on food (17). It is not just a few people, but America as a population that has fundamentally changed how we eat.
“Are You Pouring on the Pounds?” tries to address the change in food patterns with an illustration in their health bulletin about how soda consumption has increased. Two graphics in the publication, however, only serve to reinforce what the social norms of the American public are. One graphic in the bulletin explains how many more calories a day Americans consume than they did 30 years ago, thus associating those extra calories to normal contemporary behavior. Another graphic shows how soda sizes have changed from what used to be a normal bottle at 6.5 ounce bottles. “Today,” the graphic explains, “12-ounce cans are considered ‘small’…and 20-ounce bottles are typical.” Consequently, the illustration validates the consumption of 20-ounce bottles, all the way down to the use of the word “typical.”
None of the campaigns take advantage of interactions within social networks as a means to influence behavior change. In order for a campaign to be effective, it must change the social norms within a social network. Individual behavior will not change without the support of others in the network as well as group interaction focused on new norms.

C. Nutrition Campaigns Fail to Adequately Use Marketing Theory

Nutrition campaigns use advertisement and marketing material to communicate their interventions, but these campaigns fail to resonate with the public because they do not adhere to the principles of marketing theory.
Marketing theory contends that formative research should be conducted in order to determine what the public wants. The product being sold should be packaged based on this research so that it appeals to the public’s desires using a promise that is constructed to demonstrate that the product fulfills these desires. The marketing must have imagery to illustrate how the product fulfills the public’s core desires and there must be support that the product will fulfill its promise (20).
In the context of marketing for public health, it is important to understand that individuals are most likely to act in their own self-interest, and are more likely to act in their own interest if “the individual can discern immediate self-interest in the behavior.” A behavior that has no perceived benefit is less likely to occur than one that does (22). In the short term, an individual might see immediate benefits by satiating their appetite with unhealthy foods; the long term benefits of eating fruits and vegetables, like reduced obesity and other improved health factors, are remote and less satisfying. Consequently, the value of health is not a strong enough core value for nutritional marketing to rest on and it must be redefined as fulfilling another interest (21).
Nutritional marketing campaigns fail at the most basic level of marketing theory: it encourages a change in behavior by emphasizing better health when “it is not really health itself that people value most. Rather, it is the freedom, independence, autonomy, and control over their lives that come with being healthy for which people have the most fundamental need and desire” (21). The actual slogan from the campaign “Fruits & Veggies: More Matters,” is meant to market eating more fruits and vegetable by appealing toward the public’s desire for good health. Its website explains that fruits and vegetables provide a “better future” by “reducing your risk of certain chronic disease” (23). But while some people value health more than others, health is not a compelling enough reason for most people to alter their behavior. One study shows that increases in the percentage of adults who consume at least five fruits and vegetables a day were more prominent among people who were initially consuming larger amounts of produce than people who consumed less produce, suggesting that the “5 A Day” campaign had more of an effect on people who were already on the upper end of produce consumption (24). An increase in this group indicates they valued better health and the campaign consequently was less successful in modifying the behavior of those who likely did not hold health as a main desire.
While the imagery of human fat in a glass in the “Are You Pouring on the Pounds?” advertisements is eye-catching and visually disturbing, it is not framed in a way that appeals to human desires of freedom, independence, autonomy, and control. It suggests that an individual who consumes sugary beverages is destined to a predetermined fat future instead of using the campaign as an opportunity to provide an individual with choices so that they can assert their desires for independence and control. The imagery in this aspect of the campaign is compelling, but since it is based on the flawed assumption that the public desires better health, it misses the opportunity to truly resonate with the public.
While the bulletin for the “Are You Pouring on the Pounds?” campaign is also based on the public’s desire for better health, it is made even less compelling by the use of statistics as the support for its health claims. The bulletin informs that, “Teens who consume sugary beverages drink an average of 360 calories per day. Someone would have to walk about 70 city blocks to burn that many calories” (8). This type of support feels arbitrary and statistics are not particularly relatable, especially since the increase in calories does not necessarily have an immediate negative effect. The consequent lack of resonance will not likely alter behavior, especially if a person determines it is more in their self-interest to have a drink they enjoy than a remote future possibility of obesity. Similarly, the “5 A Day” campaign’s suggestion that schools help students learn about food choices by posting “fun facts” on bulletin boards is not compelling and does not appeal to any desires beyond good health (25).
None of the nutritional campaigns package good nutrition as a means to achieve freedom, independence, autonomy, or control and since health is not often perceived to be an immediate self-interest, none of the marketing campaigns will effectively alter behavior.

II. Crunch
In order to address poor nutrition, a new campaign must be devised that accounts for environmental factors affecting affordability and accessibility, utilizes social networks to alter behavior, and bases its marketing on human desires for freedom and control. In order to address environmental factors, government policy will be changed on the basis of Ecological Theory. A campaign called “Crunch,” the noise many fresh fruits and vegetables make when you eat them, would be used to encourage fruit and vegetable consumption among social groups using Social Networks Theory. The use of Marketing Theory would be used to design the campaign so that the “product” of increased fruit and vegetable intake appeals to the desires of the public.

A. Addressing Environmental Factors

The first aspect of the intervention uses the Ecological Theory to address environmental factors of affordability and location that inhibit the consumption of fruits and vegetables in lower-income neighborhoods.
Ecological Theory, developed by Urie Bronfenbrenner, says that a person is at the center of a series of environmental systems stacked on top of each “like a set of Russian dolls.” At the center is the individual, whose immediate surroundings are defined as the microsystem, typically the home, school, work, etc. The mesosystem is the second layer and is defined by the relationship between the environments in the microsystem. Next is the exosystem which consists of external, indirect environments and how they affect an individual: for example, how the workplace of one spouse affects the life of the other spouse. Finally, the outer level is called the macrosystem, which is the overarching environment that involves the culture and government of the society (26).
As addressed in the first critique, large supermarkets offer store brand fruits and vegetables that are more affordable but they tend not to be located in inner-cities or minority neighborhoods. Instead, these communities typically have small grocery stores and convenience stores that are less likely to offer produce, and especially produce at affordable prices (13, 14). To increase the amount of affordable produce options in these areas, an intervention at the macrosystem level is needed to bring fruits and vegetables into the community. Government regulation would give supermarket chains tax breaks for the stores that they open in low-income neighborhoods, these tax breaks would encourage the chains to enter a market they currently do not serve and would provide lower-income residents a place where they can purchase produce at a more affordable price. State governments would also provide schools with funding to hold farmer’s markets on a couple of weeknights and on the weekends. Holding the markets at schools would reduce transportation issues and the varied times for the markets would allow for variances in work schedules.
The lack of affordable produce options in lower income neighborhoods makes it difficult for residents to increase their fruit and vegetable consumption even if they have a desire to do so. Since large, consumer friendly supermarket chains do not exist in these neighborhoods, government intervention is needed.

B. Using Social Networks to Influence Behavior Change
The campaign “Crunch,” would be designed around Social Networks Theory in order to increase the intake of fruits and vegetables among social groups.
Social Networks Theory says that people are influenced most by those in their network and that they are influenced by their social support, social norms, and social engagements (18). To encourage a new social norm of increased fruit and vegetable consumption within social networks, an online community called “Crunching Together” would be developed where friends could connect with each other, mark the progress they make maintaining healthy eating patterns, tell others the methods that work for them, create a platform to share struggles they have in reaching their goals, and provide support for others who are struggling. The site would also post “crunch reminders” that suggest different social activities like meeting at a healthy restaurant, hosting a cooking party, a group outing to a farm or farmer’s market, or another healthy event that the group would be interested in. These “crunch reminders” would provide a link so anyone who wanted to organize such an event could send an invitation to those in their social network on the site. Each individual in the group would have an individual page where they could enter their vegetable and fruit consumption, time they spent exercising, playing sports, or doing other types of physical activity, and other health goals. The site would measure progress individually in “crunch points” and would also measure the progress of the group as a whole, encouraging support and engagement among group members.
“Crunching Together” creates a place where people in a social network can come together to change their social norms by providing each other support and a means to engage with other members of the network.

C. Using Marketing Theory to Promote Change
A marketing campaign would be created to encourage use of the “Crunching Together” site as well as overall good nutrition.
According to Marketing Theory, effective marketing of a product must be based on formative research about what the public wants (21). Good health is generally not one of the public’s main self-interests, so the campaign would instead appeal to two interests the public does hold: control and freedom (22, 21). To do so, a series of advertisements would be created that emphasized taking control over your life by eating fruits and vegetables and breaking free of restrictive food choices by doing the same.
The first advertisement shows a woman weighed down by junk food and soda attached to her body. She holds an apple and with every bite she takes, there is an audible “crunch” and a piece or two of junk food fly off her body. As the ad progresses, she becomes visibly lighter and walks markedly faster until the background scene drops out and she looks triumphant over an unappealing pile of junk food. The advertisement ends with one of the two slogans of the campaign: “Taking Control, One Crunch at a Time.”
The other, similar, slogan: “Freedom, One Crunch at a Time,” is based on a Hot Pockets ad campaign called “EatFreely” that sells itself as a rebellion against the constraints of eating at a table. The ads show people “rebelling” by eating Hot Pockets in a variety of different places: on a tennis court, in a limo, while walking, etc. The “Freedom, One Crunch at a Time” advertisements use similar rebellious images of physically fit people eating carrots one loud crunch at a time at various places like on the top of a mountain, on a bike, or in a library and contrasts these healthy images with images of people eating stereotypically unhealthy foods like pizza and hamburgers while chained to their desk or kitchen table. To tie in with the advertising campaign, the social web site would use the slogans as graphics and also would encourage people to share with their network how they were taking control of their lives and gaining freedom by eating fruits and vegetables.
These ads promise the viewer that eating fruits and vegetables will give them control and freedom over their life. The promise of control is further supported by the images of vanquished junk food at the end of the first commercial. In the second commercial, the promise of freedom is supported by images of the people who are eating fruits and vegetables doing exciting activities compared to the bored and constrained images of people eating the unhealthy food.
Control and freedom are big promises offered in return for eating fruits and vegetables, but it is necessary to frame the product of good nutrition in a manner that convinces people that changing their behavior is in their self-interest.

III. Conclusion
Nutrition campaigns as they are frequently designed fail to address how environment shapes the affordability and accessibility of food choices, especially in lower-income neighborhoods. Use of the Health Belief Model directs these interventions toward individuals and fails to take into account that social networks and social norms affect how a person will behave. Finally, the failure to package nutrition in a way that appeals to the public’s desires results in marketing that does not resonate and will not affect nutritional behavior.
In order for a substantial change in nutritional behavior to occur, government regulation must be used to increase accessibility, social networks must be mobilized to change group behavior, and formative research must be used to create marketing campaigns that appeal to a base desire for control and freedom.

1. United States Department of Agriculture. Increasing Fruit and Vegetable Consumption through the USDA Nutrition Assistance Programs. Alexandria, VA: Food and Nutrition Service, 2008.
2. Centers for Disease Control and Prevention. About the National Fruit & Vegetable Program. Atlanta, GA: Centers for Disease Control and Prevention.
3. Consumers Union. New Report Shows Food Industry Advertising Overwhelms Government’s “5 A Day” Campaign to Fight Obesity and Promote Healthy Eating. San Francisco, CA:Consumer’s Union.
4. King DE, Mainous AG, Carnemolla M, Everett CJ. Adherence to Healthy Lifestyle Habits in US Adults, 1988-2006. The American Journal of Medicine 2009; 122:528-534.
5. Stables GJ, Subar AF, Patterson BH, Dodd K, Heimendinger J, Van Duyn MA, Nebeling L. Changes in vegetable and fruit consumption and awareness among US adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys. Journal of the American Dietetic Association 2002; 102:809-817.
6. 5-A-Day: Working as Well as We Would Like? Nutrition Today 2003; 38:53.
7. New York City Department of Health and Mental Hygiene. New Campaign Asks New Yorkers if They’re “Pouring On the Pounds.” New York, NY: New York City Department of Health and Mental Hygiene.
8. New York City Department of Health and Mental Hygiene. Health Bulletin: Are You Pouring On the Pounds? New York, NY: New York City Department of Health and Mental Hygiene, 2009.
9. Rosenstock IM. Historical origins of the health belief model. Health Education
Monographs 1974; 2:328-335.
10. United States Department of Agriculture. California Children’s 5 a Day-Power Play! Campaign: Fruits and Vegetables. Alexandria, VA: Healthy Meals Resource System, 2005.
11. California Department of Public Health. Network for a Healthy California--Children's Power Play! Campaign. Sacramento, CA: California Department of Public Health, 2007.
12. Blisard N, Stewart H, Joliffe D. Low-Income Households’ Expenditures on Fruits and Vegetables. Washington, DC: United States Department of Agriculture Economic Research Service, 2004.
13. Morland K, Wing S, Roux AD, Poole C. Neighborhood Characteristics Associated with the Location of Food Stores and Food Service Places. American Journal of Preventive Medicine 2002; 22:23-29.
14. Chung C, Myers SL. Do the Poor Pay More for Food? An Analysis of Grocery Store Availability and Food Price Disparities. The Journal of Consumer Affairs 1999; 33:276-296.
15. Centers for Disease Control and Prevention. 30 Ways in 30 Days to Stretch Your Fruit & Vegetable Budget. Atlanta, GA: Centers for Disease Control and Prevention, 2009.
16. Kitchen MS, Ransley JK, Greenwood DC, Clarke GP, Conner MT, Jupp J, Cade JE. Study protocol: a cluster randomised controlled trial of a school based fruit and vegetable intervention - Project Tomato. BMC Health Services Research 2009; 9:101-105.
17. Guthrie JF. Understanding Fruit and Vegetable Choices: Economic and Behavioral Influences. Washington, DC: United States Department of Agriculture Economic Research Service, 2004.
18. Christakis NA, Fowler JH. Social network visualization in epidemiology. Norwegian Journal of Epidemiology 2009; 19:5-16.
19. Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine 2007; 357:370-379.
20. Produce for Better Health Foundation. Fruits & Veggies—More Matters:
T.A.S.T.E. Tips and Information for Moms. Wilmington, DE: Produce for a Better Health Foundation, 2006.
21. Siegel M. Marketing social change: An opportunity for the public health practitioner (pp. 127-152). In: Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change (2nd Edition). Sudbury, MA: Jones and Bartlett Publishers, 2007.
22. Rothschild ML. Carrots, Sticks, and Promises: A Conceptual Framework for the Management of Public Health and Social Issue Behaviors. Journal of Marketing 1999; 63:24-37.
23. Produce for Better Health Foundation. Why Fruits & Veggies. Wilmington, DE: Produce for Better Health Foundation.
24. Ruowei L, Serdula M, Bland S, Mokdad A, Bowman B, Nelson D. Trends in Fruit and Vegetable Consumption Among Adults in 16 US States: Behavioral Risk Factor Surveillance System, 1990–1996. American Journal of Public Health 2000; 90:777-781.
25. Terry S. Eat Your Colors Every Day! Wilmington, DE: Produce for Better Health Foundation, 2005.
26. Bronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press, 1979.

Labels: , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home