Challenging Dogma - Fall 2009

Monday, December 21, 2009

A Critique of Boston University’s Sargent Choice Intervention

– Tina Kapadia

Poor eating habits and sedentary lifestyles have led to an increased prevalence of obesity in Americans, and continues to be one of the main targets of public health interventions. The National Health and Nutrition Examination Survey from 2005 indicated that 32.7% of adults are overweight (1). The obesity epidemic in our country has not only impacted adults, but has also affected younger populations. Research has shown that over two-thirds of college students do not eat five fruits and vegetables each day (2). These unhealthy eating habits combined with the high stress and decreased physical activity representative of college environments have led to increased obesity amongst college students in the United States (16). The National College Health Risk Behavior Survey suggests that 35% of college students may be overweight or obese (3). With obesity and poor nutrition being a risk factor for many associated health problems such as diabetes and heart disease it is important for students to develop healthy eating habits.

In attempt to combat obesity and unhealthy eating habits on their college campus, Boston University (BU) Dining Services and the Sargent College of Health and Rehabilitation Services collaborated on developing a nutrition program entitled Sargent Choice. This program was aimed to try and provide different food options in order to improve the eating habits of the BU community. Sargent Choice started by increasing the availability of fruits and vegetables at different campus retail locations and residence dining halls. In addition, Sargent Choice and BU Dining created new recipes that substitute ingredients to improve the nutritional content and still maintain the same flavor and taste (4). They emphasize the easy identification of the Sargent Choice food options that meet the 2005 Dietary Guidelines for Americans by placing a Sargent Choice logo sign next to the foods that meet the program’s criteria (4). The Sargent Choice program has also developed an interactive website with meal planners, tips, cooking videos, and additional education about eating healthy.

Although the Sargent Choice program was created with good intentions, it is an example of another faulty and ineffective public health intervention. This program has been based upon flawed health theories and beliefs that have led to its inability to improve the eating habits of the BU community. This critique will address three major flaws in the Sargent Choice intervention. The first flaw is the poor advertising and information dissemination techniques used to introduce the program into the BU community and across the campus. Secondly, this program centers its design on the false assumption that people act in a rational manner with regards to their health behaviors. Finally, this intervention is an individual level program that does not address other pertinent contextual and environmental factors outside of the individual that influences students eating habits. These three flaws collectively make the Sargent Choice intervention unable to produce improved dietary habits amongst the BU community.

Poor Advertising

Sargent Choice has been in existence on the Boston University campus since 2005, however, it has not made its presence known to students. The poor use of advertising techniques has rendered this intervention ineffective in its ability to communicate its messages to students. Currently Sargent Choice mainly advertises its program through their online website that provide recipes, healthy eating tips, and cooking videos. The only other source of advertising is the use of their heart shaped logo that is placed in front of food in the dining halls and in the George Sherman Student Union. Sargent Choice has come up with mottos such as “Seize the Cookie” and “Thoughtful Eating,” that create confusion and spark only a little motivation to change dietary habits (4). Lists of “Brain Food” and “Mood Food” provide healthy eating and exercise tips that center on scientific data and statistics (4). As a second year graduate student at BU, I have yet to see any other advertisements or food options other than at the two different campus Starbucks coffee shops I have visited. The only way for students to become aware of what the Sargent Choice program has to offer requires them to visit the website. With little exposure and inspiration provided by the advertising most students are unaware of the program, and do not know how to apply its interventions effectively into their health behaviors. The current advertising does not base its techniques on the successful Advertising and Marketing Theory used by other popular food companies.

Sargent Choice, unlike McDonalds or other fast food chains, has not based its advertising on the basic principles of Advertising and Marketing Theory. Their motto provides no promise or support for choosing their food options, and does not appeal to the core values of college students. McDonald’s, a food competitor for BU Dining services, however, is located near the BU campus and has extremely appealing mottos such as, “I’m loving it” and “We love to see you smile.” These appeal to students by promoting a core value of happiness, and are further supported by the use of smiling children and families in advertisements and commercials (8). Sargent Choice on the other hand, has a simple unmemorable design, mottos that promote health, and no support for their promise. It is evident that the lack of formative research to develop advertising schemes that appeal to Sargent Choice’s target audience has not only limited the dissemination of information, but has rendered incapable of capturing the attention of BU’s students. This has created significant barriers to the involvement of students into the Sargent Choice program, and has led its minimal impact on the eating habits of college students. The ability to properly market health campaigns is crucial for its success, and Sargent Choice has not appropriately marketed their intervention (5).

False Assumption of Rational Behavior

The Sargent Choice program is founded on the basis that people, more specifically college students, act rationally when making choices about health behaviors. This idea of rationality that influences the Sargent Choice program can be explained by its basis on the Heath Belief Model. This traditional health model explains decision-making by assuming that individuals make their choices by carefully balancing the perceived barriers and benefits to performing the health behavior (6). It also suggests that individuals consider their perceived susceptibility and perceived severity when considering the negative health outcome (6). Using this concept Sargent Choice attempted to remove one of the perceived barriers by increasing the availability of healthy food options. Sargent Choice and BU Dining Services provided more fruits and vegetables in residence dining halls and George Sherman Student Union. They created salad bars, fruit salads, and recipes that made the same popular food items that have more whole grains and less saturated fats. If it was true that individuals acted rationally by weighing their benefits and barriers, then students would be choosing the healthier options more often, but instead students act irrationally and continue to eat burgers, pizza, fries, and desserts even with the increased accessibility to healthy foods.

Another example that shows the rational basis and the influence of the Health Belief Model is the Sargent Choice concept of “Thoughtful Eating.” This promotes the idea that healthy eating is a complex decision-making process that can be facilitated by the application of appropriate knowledge and skills provided by the website (4). In addition to this concept Sargent Choice has created a “Personal Meal Planner,” which allows the student to calculate his or her daily energy requirements, and also a “1+2+3 Solutions,” which uses charts and lists to allow you to plan when and what snacks and meals to eat throughout the day. Both of these campaigns use mathematical concepts, formulas, and concepts of planning in order to develop healthy and regular eating habits (4). This concept tries to help students carefully plan and think about theirs meals in advance is wrongfully based on the Transtheoretical Model that suggests in order to change unhealthy behaviors it must occur in stages of contemplation, preparation, action, and maintenance (11, 18). Research has shown that people do not change their behaviors in a logical and rational process of stages as described by the Transtheoretical Model, and because of Sargent Choice’s basis in such principles it has had low yield in changing student diets (11).

However, these programs assume that an individual’s behavior is not spontaneous, but instead that it is static and controlled process. Instead students’ behavior is dynamic, unplanned, and susceptible to visceral influences. Even though there is greater access to health foods and practical individualized programs available online, the fact that individuals do not appraise these options and act upon health-relevant information rationally makes this intervention powerless in its attempt to change dietary behaviors (7).

Individual Based Program

This program is shaped on the concept of health behavior as an individualistic process. The Sargent Choice intervention is rooted in traditionally individual-level models such as The Health Belief Model and Theory of Reasoned Action by assuming that students have individual characteristics such as self-efficacy, positive attitudes, and self-control to make determinations of their choices with regards to health behaviors. Sargent Choice believed that by providing new recipes that are healthier and full of flavor, students would chose these products instead of the unhealthy options. However, this presumes that students already have the self-efficacy to make these decisions, the belief in his or her ability to take action in choosing healthier food options (9). Their assumption that students would pick foods with less fat and more whole grains implies that students have complete and individual self-control that is immune to visceral influences. It also relies on the preconceived notion suggested by these models that individuals have positive attitudes towards these health outcomes, and a high-perceived susceptibility to obesity and other negative health effects associated with poor eating habits. The Personal Meal Planner and 1+2+3 Solutions places all of the control in the individual, and completely disregards the lack of self-control, spontaneity, and irrationality that governs behavioral decisions.

With the entire city of Boston providing a countless array of restaurants at the disposal of students, social clubs, organizations and events, nightlife activities, and influences from friends and family, college students have multiple external factors that play a role in their personal health behaviors. Sargent Choice does not provide individuals with the ability to overcome these external factors that exist outside of the Boston University community. Instead Sargent Choice emphasizes the fact that it is “Exclusively BU,” and does not acknowledge the fact that surrounding social and environmental systems heavily impact an individual’s behaviors (18). They do not address the fact that students of BU do not exist and make decisions within a vacuum. Because of its basis on these models Sargent Choice executes itself on an individual level with no recognition of external factors, and therefore does not provide students with the tools, knowledge, or skills to make healthy eating decisions with regards to these factors.

Reforming Sargent Choice’s Intervention

Sargent Choice, while created with hopeful intentions of reducing obesity and increasing healthy eating amongst college students at BU, has been minimally effective due to its poor execution and flawed design. The Sargent Choice program is inadequately designed because it does not contextualize the risk factors to explain and understand the poor dietary habits of college students. It also does not take into account the social environment, late-night lifestyle, and social norms of college life that influence the eating habits of students. Below I will describe a new intervention that should be implemented, which addresses these flaws, and incorporates group-level principles from the Advertising and Marketing Theory, Diffusions of Innovations, and Social Expectations Theory. This new intervention is based on the assumption that people act irrationally when it comes to making decisions about their health. These significant changes to the BU Sargent Choice intervention will allow for the establishment of a successful intervention that helps the BU community to develop healthier eating habits.

1) Improve Marketing and Advertising

Employing the Advertising and Marketing Theory will allow for an intervention that allows for public health practitioners to appeal to the core values of students, and gives students what they desire out of a health education program. The key to success of this health campaigns is to not to sell health, but instead repackage our product and promote something that appeals to the core values of college students and provides a promise and support for eating healthy (17). One reason the Sargent Choice program is ineffective is because of its failure to consistently and effectively advertise and market itself to students. It is unreasonable to expect students to make use of a health education program if they are unaware of its existence and goals.

For example McDonalds and Burger King each have a symbol or motto that is well known across all populations worldwide. Because advertising and marketing is shaped by the culture in which it is implemented, this intervention should begin its development by conducting formative research amongst students in the BU community (12). Surveying students and asking for their input will allow for the creation of a memorable and catchy logo and slogan that will help students to easily identify food and drink options, flyers, and advertisements. This program also needs to use frequent advertising in order to reach out to all students and maintain awareness of the program. Using advertising such as Facebook, Twitter, the Internet, email, posters, t-shirts, free food, and coupons can all appeal to the cultural norms of college students and act as a frequent reminder to eat healthy (12).

2) Apply Diffusion of Innovations

The next important aspect in implementing an improved intervention that successfully influences eating habits is to integrate concepts from the Diffusion of Innovations Theory. According to Rogers in order for an innovation to successfully diffuse across a social system it needs to initially be adopted by a few key individuals, known as “early adopters.” After this has occurred than the innovation begins to diffuse across the given social system and becomes adopted by more and more people (13). It is important that the most influential students on campus adopt this new intervention; these “opinion leaders” can help to diffuse this intervention and start a new social trend (13). In the beginning stages this intervention should attract leaders of the BU campus such as the BU Hockey team members, other athletic teams, popular campus organizations, Greek community members, dance teams, the student body president, and faculty members that students look up to, such as Dean Elmore. Getting these popular student leaders to adopt these healthy eating habits and use the interventions can help to disseminate the program across the campus allowing it to have more of an­­ impact on students.

3) Accommodate the college student lifestyle

Another flawed aspect of the current Sargent Choice program that needs to be transformed is that is does not address the contextual and external risk factors influence the irrational decisions on health behaviors of students. Conformity, social norms, and herd dynamics are strong contributors to the normal lifestyle of most college students. Social norms have a powerful influence on the way people act because they cause people to overestimate the prevalence of certain behaviors amongst their peers, and because people use the norms of their peers as a standard to compare their own behaviors (14, 19). Social Expectations theory states that people act in groups according to current social norms (15). The current social norms of college students include going out with friends, consuming alcohol, attending parties, and studying late to prepare for exams. Also, based on the Social Network Theory it has been shown that health behaviors are contagious and strongly influenced by an individual’s social networks and ties (20). These late-night lifestyle habits of students contribute to an environment in which unhealthy eating habits flourish. Junk food establishments thrive by accommodating these factors into their businesses. For example, fast food places such as McDonald’s T-Anthonys, U-burger, Beijing Cafe are all restaurants that surround the BU campus and stay open late. Meanwhile BU Dining Services, such as the George Sherman Student Union, closes early most days of the week. Additionally, the only available on campus food places that remain open late at night are Rhett’s diner and BU’s Late Night Café, which both provide unhealthy food options and are only available to students who live on-campus. If fast food establishments can utilize the well-known behaviors of college students to earn profit, why shouldn’t public health also utilize these behaviors to promote healthier eating habits?

Recent research showed that the three biggest factors that influence college students’ decision in choosing where to eat are convenience, taste, and cost (16). With this knowledge of its target audience, the intervention should create a restaurant that is open late all days of the week, have multiple convenient locations on and around campus, and provide affordable and healthy foods. This restaurant should provide food options such as sandwiches, salads, fruits, vegetables, and other healthy snacks. By accepting BU dining points, convenience points, cash, and credit these restaurants will cater to the needs and interests of a low-budget student population. In correspondence with the applications from the Diffusion of Innovations theory, these restaurants will successfully attract more and more students as healthy eating behaviors are diffused and adopted across the campus. Opening restaurants and snack shops that conform to the normative lifestyles of colleges students will help this intervention address this public health issue from a group-level framework that considers social norms and environmental influences that affect eating habits of college students. Combing the use of effective marketing and advertising schemes, strong opinion leaders and early adopters, and opening convenient food locations are crucial aspects of this new and improved intervention that will help to successfully influence eating habits across the BU campus.


Although Sargent Choice was created by Boston University to optimistically address a prevalent health problem amongst its students, it has centered itself on false assumptions that have led to its low rate of success. The poor marketing and advertising employed by the Sargent Choice program have only allowed for minimal dissemination of healthy eating information to its students, and thus has limited its ability to change eating habits of college students. Making the conclusion based on traditional public health models that people act rationally has guided the development of campaigns that have not infiltrated the mindsets of students because of their truly irrational actions towards healthy behaviors. Lastly, the lack of acknowledgement of the influences that herd dynamics and external factors have on students eating behaviors has made a campaign that only considers individualized risk factors. Sargent Choice has committed a common and fallacious mistake that people hold health beliefs to the same high regards that public health educators do. This program addresses a significant public health problem that is widespread amongst American college students; however, this critique has illustrated the impact that multiple flaws have made on this program ineffectiveness.

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. Eating habits frequently become worse during college years so it is imperative to create an intervention that is highly appealing to college students (16). The newly proposed intervention addresses these flaws by creating an approach that is based on Advertising and Marketing Theory, Diffusions of Innovations, and Social Expectation Theory. This program will be based on formative research that helps to develop a creative logo and motto that appeals to core values of BU’s students. It will drastically improve infiltration and diffusion across the campus using of early adopters and opinion leaders in order to effectively disseminate information and awareness of this program. Lastly, this intervention entails creating multiple convenient and affordable food locations that accommodate current social norms and the typical lifestyles of a college student.

The development of this program represents a movement away from traditional public health interventions that typically focuses on individual risk factors and rational behaviors to new public health paradigms that focus on the social and environmental context in which risk factors operate. It is through these creative and innovative interventions that adequately address the underlying social context and mechanisms that the end result will lead to more healthy behaviors. Utilization of new theories and models can result in the design and implementation of more successful public health interventions.


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